Quality Improvement - Amy Boutwell

Reducing Avoidable Re-Hospitalizations: Process Improvements, Policy Challenges Amy Boutwell MD MPP IHI-CMWF Reducing Re-hospitalizations Initiative Institute for Healthcare Improvement

“The Billion Dollar U-Turn” • 17.6% of Medicare admissions are readmissions within 30 days – Accounting for $15 B in spending • Not all re-hospitalizations are potentially preventable, not all avoidable, but many are (accounting for $12B in Medicare spending) – HF, Pna, COPD, AMI lead the medical conditions – CABG, PTCA, other vascular lead surgical conditions • Disparities exist along socio-economic, racial and “burden of illness” lines • Individual delivery systems and health services researchers have demonstrated dramatic (40-85%) reduction of 30-day readmission rates for certain patient populations (esp. CHF)

Prevalence and Drivers of Re-hospitalizations • Preliminary 2007 Medicare data analysis finds: – 20% beneficiaries are re-hospitalized at 30 days – 35% are re-hospitalized at 90 days – 67% are re-hospitalized or deceased at 1 year • Among medical patients re-hospitalized at 30 days: – 50% no bill for MD service between discharge and re-hospitalization • Among surgical patients re-hospitalized at 30 days: – 70% were re-hospitalized with a medical DRG Source: Jencks, Williams, Coleman preliminary data pending peer-review

IHI-CMWF Initiative to Reduce Re-Hospitalizations IHI received a grant from The Commonwealth Fund to lead an initiative to support a multi-state initiative to dramatically reduce re-hospitalizations Context: • Reducing re-hospitalizations is seen by many as an opportunity to simultaneously improve quality and decrease costs • A win for patients, payers, purchasers • Mixed reactions from providers, hospitals Challenge: • Requires working within and between sites of care • Payment, regulatory, professional norms, data are all barriers • Create “system-ness” in fragmented environment

Why Re-hospitalizations? Why Now? • Increasing cost of health care is prompting many to focus on areas of high cost and low quality, or other areas of significant savings – States, purchasers, payers seeking savings • MedPac June 2007 and 2008 reports highlight avoidable hospitalizations as an area of high-cost, low-quality – Some health care systems want to “get out ahead” on this issue • Some commercial payers, integrated systems already track rates • Number of states plan to publically report 30-day readmission rates • CMS Care Transitions focus in the 9th SOW

What can be done, and how? • There exist a wealth of approaches to reduce unnecessary readmissions that have been locally successful Which are high leverage? Which can go to scale? • Success requires engaging clinicians, providers across organizational and service delivery types, patients, payers, and policy makers How to align incentives? How to catalyze coordinated effort?

Key Strategies for Reducing Re-hospitalizations Primary Drivers Secondary Drivers Who ??? Aim: • Multi-stakeholder Coalitions • Hospital Associations To dramatically • Integrated Health Care Systems reduce re- • Payers and Purchasers hospitalizations in • Communities Will • Clinicians / Providers of Care states / regions How ??? • Aligned incentives, Policy Change and Payment Reform • Transparent State-wide Measurement Outcome Measures: • Optimizing the transitions in care after 1.Re-hospitalization hospitalizations rates (Target: reduce • Providing enhancements / supplemental to by 30%) Ideas routine care for patient s at high risk for re-hospitalization 2.Patient and family • Engaging consumers and their family satisfaction with : caregivers in their own care (and medication managment) •transition out of the hospital (Target: • Micro-System Capability 50% increase) • Customized Sequencing of Work Execution •coordination of care • Robust, timely, and actionable measurement that can help to drive Improvement in community (Target: (provides feedback over time) 50% increase) • Learning System o collaborative learning o local support for improvement

Evidence: Reducing Re-hospitalizations • Growing evidence of the effectiveness of following: – High quality in-patient care – Manage medical co-morbidities (in medical and surgical inpatients) – Early assessment of discharge needs – Enhanced patient and caregiver self-management engagement – Early post-acute follow up with MD or RN (home visit, phone call) – Hospital-based post-acute follow-up (phone calls, nurse visit) – Appropriate referral for home care services – Appropriate patient centered end of life/palliative care discussions – Remote monitoring – Improved transfer processes between acute hospitals and post-acute facilities

Improve Existing Processes • 81% of patients requiring assistance with basic functional needs failed to have a home care referral • 64% said no one at the hospital talked to them about managing their care at home Clark PA. Patient Satisfaction and the Discharge Process: Evidence-Based Best Practices. Marblehead, MA: HCPro, Inc.; 2006. 9

Enhance Existing Care or Provide Supplemental Care • Excellent research and experience of innovators highlight the effectiveness of enhanced care delivery during transitions: – Transition coaching (Coleman) – Advanced NP coordination roles (Naylor) – Guided care model (Bolt) – Nurses that “wrap around” primary care for high –risk populations (CMS demonstrations) – Enhanced primary care coordination with home health (NYVNA) – IHI Transforming Care at the Bedside (Ideal Transition Home for HF)

High-Leverage Opportunities for Action 1. Improved Transitions for All Patients a) Transitions “out” of the hospital b) Reception “in” to home (activated home health, office practice) c) Reception “in” to skilled nursing (activated post-acute rehab, NH) 1. Proactively address the needs of “high risk” patients a) Create inventory of evidence-based “wrap around” or enhanced services b) State-specific assessment of plausibility of financing 1. Engage patients and families/caregivers a) Web-based tool, AARP campaign (medications), Partnership for Healthcare Excellence campaign (consumer activation), b) Proactive role in care, especially at times of transitions

Improving the Transition Out of the Hospital Key Recommendations: 1. Enhanced Assessment of Patients 2. Enhanced Teaching and Learning 3. Patient-Centered Communication Handoffs 4. Ensure Timely Post Acute Follow-up 12

HF Readmissions within 30 Days 35 30 29 Aug 06 = Implemented use of new patient education 25 25 materials Percentage Jan 07 = Initiated 20 19 19 complimentary visits 18 16 16 15 14 12 14 12 11 11 9 10 10 8 10 9 9 9.0 8 7 7 5 5 5 4 4 0 0 0 0 0 Jan- 0 6 Jan- 0 7 M ay- 0 5 J u l- 0 5 S ep- 05 N o v- 0 5 M a r- 0 6 S ep- 06 N o v- 0 6 M a r- 0 7 S ep- 07 N o v- 0 7 M ay- 0 6 J u l- 0 6 M ay- 0 7 J u l- 0 7 Rate (%) Median

Reducing Readmissions

Creating Will: Reliable Data 35th

MA rate: 29% Best state: 18% MA rank: 35 MA rate: 20% Best state: 13% MA rank: 41

Creating Will: Align Incentives for System-ness • Create incentives to work across traditional settings of care and between providers (standards, bundled payment, differential payment) • Create incentives to communicate with patients/caregivers (HCAHPS) • Improve outpatient care coordination (Medical Home, ACOs, bundling) • Encourage efficiencies in coordination and communication (electronic records, email and phone interactions, group mgt) • Invest in enhanced services for high risk patients (payment, bundling)  Decrease barriers to change (“carrot,” gain-sharing, reliable data)  Implement catalyst to change (“stick,” data transparency, payment reduction, “bundling”)

Creating Will: Develop Solutions to Policy Challenges • IHI will facilitate targeted technical assistance to state leadership entities working to reduce avoidable re- hospitalization in the following domains: – Financial implications of reducing re-hospitalizations – Payment and other policy reforms – Data and measurement strategies – Collaborations across the continuum of care – Engaging patients and families/caregivers • By working as a multi-state collaborative, hope to facilitate and accelerate adaptation of promising policy/ structural approaches

Quality Improvement - Amy Boutwell

by Massachusetts Health Data Consortium on Feb 10, 2009

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Quality Improvement - Amy Boutwell — Presentation Transcript