Collaborative Approach to Improving Care and Reducing Readmissions - - PowerPoint PPT Presentation

Collaborative Approach to Improving Care and Reducing Readmissions

Edna Clifton, MBA, BSN, RN

Associate Director, Care Coordination Health Services Advisory Group (HSAG)

March 14, 2017

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Presentation Objectives

Define the focus of Quality Innovation Network’s (QIN’s) work. Recognize where Florida’s readmission rates rank with the nation’s rates. Identify the Centers for Medicare & Medicaid Services (CMS) strategy goals. Examine the goals of community coalitions. Identify projects that have successfully reduced readmission rates.

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CMS Quality Strategy Goals

Better Care, Healthier People, Healthier Communities, Smarter Spending

Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/QualityInitiativesGenInfo/Downloads/CMS-Quality-Strategy-Goal-Card.pdf

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Health and Human Services’ (HHS) Efforts to Improve Healthcare

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Source: Burwell, Sylvia M. Setting Value-Based Payment Goals- HHS Efforts to Improve US Healthcare, New England Journal of Medicine, January 26, 2015.

30% 50%

85% 90%

Tying payment to value through alternative payment models

• f all Medicare fee-for-service (FFS)

payments tied to quality or value by 2016

through alternative payment models by the end of 2016

• f all FFS payments tied

to quality or value by 2018

through alternative payment models by the end of 2018

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Policy Development

Comprehensive Care for Joint Replacement, Coronary Bypass Grafts, Acute Myocardial Infarction, and Cardiac Rehabilitation Proposed Rule for Discharge Planning

Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) and Value-Based Purchasing

(VBP) for Skilled Nursing Facilities (SNFs)

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Medicare’s Call for Action to Communities

Build and sustain community coalitions focused on improving coordination of care between settings. Strengthen communication with community coalition partners in an open, non-competitive forum. Reduce hospital readmission rates for Medicare FFS patients by 20% by 2019. Improve medication safety to prevent adverse drug events that contribute to significant patient harm.

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QIN-QIO Areas of Focus

Cardiac Health Disparities in Diabetes

Support of Clinicians in the Quality Payment Programs

Antibiotic Stewardship in Communities Coordination of Care Value-Based Purchasing Program Healthcare Acquired Conditions in Nursing Homes Patient is at the center of care

What are the Readmission Rates?

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Readmission Definition

“We define a readmission as a subsequent inpatient admission to any acute-care facility which occurs within 30 days of the discharge date of an eligible index admission.”

Source: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/MMS/downloads/MMSHospital-WideAll-ConditionReadmissionRate.pdf

Florida State 30-Day Readmissions Ranking January 1–December 31, 2015

Source: This material prepared by Telligen, the Quality Innovation Network National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. (11SOW-QINNC-00794-05/13/16)

We are here 

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Why All the Talk About Readmissions?

• Poor care coordination and use of

evidence-based approaches

• Large number of readmissions are

preventable

Quality

• Institute of Medicine (IOM) reports made

clear the consequences of poor transitions management

Safety

• Centers for Medicare & Medicaid Services

(CMS) indicate $13B* in savings or $25B across all U.S. payers

Cost

*MedPac 2007 Report to Congress; Promoting Greater Efficiency in Medicare; Chapter 5: Payment Policy for Inpatient Readmissions Source: Riddle, S. M.. What Works for Preventing Hospital Readmissions? [PowerPoint]. http://www.wapatientsafety.org/downloads/Riddle_Readmissions_Programs_WPSC_2012-Final.pdf

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How Can We Reduce Readmissions?

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The Care Coordination Solution

Define the Problem Discharge Process Mapping Cause & Effect Diagram (Fishbone) Data Driven Root-Cause Analysis Evidenced- Based Solutions Cost-Benefit Analysis Action Plan for Improvement Measure Intervention Results Sustain or Modify the Plan

Hospice Home Health Skilled Nursing Hospitals Physicians Patients

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Care Coordination Coalitions

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The Building Blocks of a Community Coalition

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Community Essentials

Developed around collaborative care delivery

Shared vision Sharedmission Shared resources Shared decision making Environment of trust

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Care Coordination

Establish coalitions

to bring providers together to coordinate efforts to support the CMS call to action measures

Assist coalitions

to identify the root cause of their readmissions

Analyze processes

to identify gaps which cause the failure to achieve a smooth transition from one level of care to the other

Develop interventions to correct the issues Measure effectiveness of the intervention Modify processes Re-measure

Best Practices

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Best Practices: Program to Enhance Communication to Avoid Readmissions

Osceola Community

Issue: Patients were being sent from the skilled nursing facility (SNF) to the emergency department (ED) for an issue and it was not clearly communicated to the ED why the patient was sent there. Dilemma: With incomplete information, the ED treated the patient based on diagnosis and emergency medical services (EMS) information. Solution: The SNF community collaborated with local ED physicians to identify critical information needed to appropriately treat the patient for that episode.

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SNF to ED Transfer Communication Sheet

Best Practices: Programs to Divert Readmissions to Appropriate Providers

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Jacksonville Community

Issue: Dialysis patients were presenting in the ED with fluid

• verload because of missed treatments.

Dilemma: Hospitals cannot dialyze patients on an outpatient basis. Solution: The hospital reached out to a nearby dialysis center to negotiate chair times for these patients and averting a readmission.

Best Practices: Programs to Divert Readmissions to Appropriate Providers (cont.)

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Brevard Community

Issue: Patients discharged to home often become overwhelmed with changes in treatments and medications and tend to return to the ED for assistance. Dilemma: The patients are often readmitted because of adverse drug events and/or changes in their condition due to failure to follow treatment plans. Solution: Patients who had been transported by emergency medical services (EMS) to the hospital for their initial admission had follow-up visits from EMS within 8–24 hours of their discharge. Treatment and medications were reviewed and the patients’ living conditions were assessed for community services. Providing this support reduced hospital readmission.

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Top 10 Evidence-Based Interventions

• 1. Enhanced admission assessment

– Begin discharge planning on admission

• 2. Formal assessment of risk of readmission

– Align interventions to patient’s needs

• 3. Accurate medication reconciliation at:

– Admission – Any change of level of care – Discharge

• 4. Patient education

– Assess health literacy

Source: www.hret-hen.org/topics/readmissions/13-14/2014-READSChecklist.pdf

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Top 10 Evidence-Based Interventions (cont.)

• 5. Identify primary caregiver
• 6. Use teach-back to validate understanding
• 7. Send discharge summary within 24–48 hours
• 8. Collaborate with post-acute care and community
• 9. Schedule follow-up appointments before discharge

10.Conduct post-discharge follow-up calls within 48 hours of discharge

Source: www.hret-hen.org/topics/readmissions/13-14/2014-READSChecklist.pdf

Coming together is a beginning. Keeping together is progress. Working together is success.

–Henry Ford

Thank you!

Edna Clifton

EClifton@hsag.com Office: 813.865.3579 Cell: 813.753.5379

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This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency

• f the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS
• policy. Publication No. FL-11SOW-C.3-02282017-01

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