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  • 1.
    • Provider Implementation of PPRs --
      • Florida Public Reporting of PPRs
    © 3M 2007. All rights reserved. Keith Mitchell PhD and Caroline Piselli, RN, MBA; 3M Health Information Systems
  • 2. Agenda
    • Pay for Performance and Potentially Preventable Readmissions (PPRs)
    • Florida Provider Proactive Approach to PPR Public Reporting
    © 3M 2007. All rights reserved.
  • 3. Pay for Performance © 3M 2007. All rights reserved.
  • 4. Readmissions beyond Florida
    • … situations in which patients return to the hospital within days or months of their initial hospitalization
    • Cause may be related to a patient’s treatment during the first hospitalization, or it may be the result of a secondary condition, suggesting possible quality problems in the hospital care receive during the initial visit or problematic transitions between hospital and the outpatient care setting
    © 3M 2007. All rights reserved.
      • (Quality Matters: Hospital Readmissions: March/April 2008)
  • 5. Readmissions in the News beyond Florida
    • 17.6% of Medicare patients were readmitted to the hospital within 30 days of discharge, accounting for $15 Billion in spending in 2005
      • (MedPac Report to Congress, Promoting Greater Efficiency in Medicare, June 2007)
    • Study of patients admitted to hospital with preventable admissions: 19.4% = at least 1 preventable readmission within 6 months
      • (Agency for Healthcare Research and Quality Study: B Friedman and J Basu (2004) The Rate and Cost of Hospital Readmissions for Preventable Conditions, Medical Care Research and Review 61, 225-240)
    • Commercial Population Example
      • PacifiCare Health Systems Inc review in 2005-2006
      • Readmission rates at hospitals ranged from 0-44% (avg. 10%)
      • (Quality Matters: Hospital Readmissions: March/April 2008)
    © 3M 2007. All rights reserved.
  • 6. Potentially Preventable Hospital Readmission Rates (MedPAC 2007) © 3M 2007. All rights reserved.
  • 7. Florida: 1 st PPR Public Reporting!
    • Opportunity for collaborations/ partnerships to:
      • Understand the data/ reports and impact
      • Determine potential reasons for PPRs
      • Drill down to root cause analyses
      • Create innovative approaches to improve outcomes together
      • Provide ‘lessons learned’ for the other 49 States…
    © 3M 2007. All rights reserved.
  • 8. So, What Should Florida Hospitals Do Now?
    • Reports will be public soon…
    © 3M 2007. All rights reserved.
  • 9. State Adoption Process/ Opportunity © 3M 2007. All rights reserved. Today Soon 1. Replicate Reports 2. Understand where you stand and potential opportunities.
  • 10. Recommended Provider Proactive Approach to PPR Public Reporting © 3M 2007. All rights reserved. Appoint Interdisciplinary Leaders- “ Change Agents” Educate Organization Understand Public Reports (Peer Comparisons) Analyze Impact/ Gaps Communicate Offensively Documentation/ Coding Service Lines Reasons PPRs Internal Stakeholders External Constituents Initiate Focused Quality Improvement Clinical Operations Track, Monitor, Continue Focused Improvement Approach
  • 11. Recommended Provider Proactive Approach to PPR Public Reporting © 3M 2007. All rights reserved. Appoint Interdisciplinary Leaders- “ Change Agents” Educate Organization Understand Public Reports (Peer Comparisons) Analyze Impact/ Gaps Communicate Offensively Documentation/ Coding Service Lines Reasons PPRs Internal Stakeholders External Constituents Initiate Focused Quality Improvement Clinical Operations Track, Monitor, Continue Focused Improvement Approach
  • 12.
    • Include functional integration of
      • Clinical Care
      • Documentation & Coding
      • Decision Support
      • IT
      • Operations
      • Quality/ Case Management
      • Discharge Planning FOCUS
    • Delegate responsibility and accountability for:
      • Coordination of organization-wide goals
      • Tracking and execution of control plan in conjunction w/ ancillary accountability
    • Gain insights into public perception of your hospital
      • Where does my hospital stand?
      • How do I compare to others?
    • Emphasize internal and external importance/ implications
      • Clinical Quality
      • Market Share
    • Focus upon opportunities for improvement and integration
      • Pre-admission and Discharge planning
      • Cross functional/ specialty coordination
    © 3M 2007. All rights reserved. Appoint Interdisciplinary Leads- “ Change Agents” Educate Organization Understand Public Reports
  • 13. Recommended Provider Proactive Approach to PPR Public Reporting © 3M 2007. All rights reserved. Appoint Interdisciplinary Leaders- “ Change Agents” Educate Organization Understand Public Reports (Peer Comparisons) Analyze Impact/ Gaps Communicate Offensively Documentation/ Coding Service Lines Reasons PPRs Internal Stakeholders External Constituents Initiate Focused Quality Improvement Clinical Operations Track, Monitor, Continue Focused Improvement Approach
  • 14.
    • Validate accurate documentation/coding within key areas
    • Implement improvement programs as needed
    • Emphasize – complete and accurate codified data provides the foundation from which public data is reported and improvement decisions are made
    • Consider a concurrent model
    © 3M 2007. All rights reserved. Analyze Impact/ Gaps Documentation/ Coding
    • Analyze service lines and sub-service lines –e.g:
      • Rates
      • Intervals
      • #’s of chains
      • PPRs % of discharges
      • Top 10 Medical, Surgical, other
      • Top Reasons for Readmits
      • Severity Adjustments
      • Linkage to financial indicators (cost, charges)
    • Analyze reasons for PPRs
    • Determine potential areas of improvement
    • Focus on measurable indicators
    • Track reasons over time
    • “ Repeaters”
    Service Lines Reasons for PPRs
  • 15. FloridaHealthFinder.gov  New PPR Reports soon © 3M 2007. All rights reserved.
  • 16. General Guidelines for PPRs © 3M 2007. All rights reserved.
  • 17. PPR Reason Codes: Medical Readmission
    • A Medical readmission is considered clinically related to the initial admission if the reason for the readmission falls into the following categories:
    • Medical readmission for
      • Continuation or recurrence of the reason for the initial admission, or for a condition closely related to the reason for the initial admission
        • e.g. a readmission for diabetes following an initial admission for diabetes
      • Acute decompensation of a chronic problem that was not the reason for the initial admission but was plausibly the result of inadequate care during the initial admission or inadequate outpatient follow-up care
        • e.g. a readmission for diabetes in a patient whose initial admission was for an acute MI
      • Acute medical complication plausibly related to care during the initial admission. A readmission for an acute medical problem was not considered clinically related unless it could have been a consequence of care provided in the initial admission.
        • e.g. Patient readmitted for a UTI infection ten days after a hernia repair, the infection was likely related to the use of a foley catheter during the initial admission.
    © 3M 2007. All rights reserved.
  • 18. PPR Reason Codes: Surgical Readmissions
    • A Surgical readmission is generally preventable unless they meet 1 of 2 criteria for a clinical relationship to the initial admission:
    • A readmission for a surgical procedure to address a:
      • Continuation or a recurrence of the problem causing the initial admission
        • e.g. a patient readmitted for an appendectomy following an initial admission for abdominal pain and fever
      • Complication resulting from care during the initial admission
        • e.g. a readmission for drainage of a post- operative wound abscess following an initial admission for a bowel resection
    © 3M 2007. All rights reserved.
  • 19. Example: Surgical Initial Admission with Surgical PPR © 3M 2007. All rights reserved. Only Admission- 25 days post admission: APR DRG 460- Renal Failure Procedure - Acute renal failure with lesion of tubular necrosis Readmission- 9 days post admission: APR DRG 791- O.R. procedure for other complications of treatment Procedure - Disruption of external operation wound Initial Admission: APR DRG 173- Other Vascular Procedures Procedure - Atherosclerosis of native arteries of the extremities, unspecified
      • Reason #5
      • Complication resulting from care during the initial admission
      • Reason
      • Clinically relevant but outside readmission window
  • 20. Example: Medical Admission with Medical PPR © 3M 2007. All rights reserved. Readmission 8 days post admission: APR DRG 133 Pulmonary edema & respiratory failure w/ acute respiratory failure
      • Reason #1
      • Continuation or recurrence of the reason for the initial admission, or for a condition closely related to the reason for the initial admission
    Only Admission 27 days post admission: APR DRG 133 Pulmonary edema & respiratory failure w/ acute respiratory failure
      • Reason
      • Clinically relevant but outside readmission window
    Initial Admission: APR DRG 194- Heart Failure w/ CHF followed by Readmission 10 days post admission: APR DRG 1940 Heart Failure w/ CHF
      • Reason #1
      • Continuation or recurrence of the reason for the initial admission, or for a condition closely related to the reason for the initial admission
    Only Admission 22 days post admission: Pulmonary edema & respiratory failure w/ acute respiratory failure
      • Reason
      • Clinically relevant but outside readmission window
    Initial Admission: APR DRG 139 Other pneumonia w/ pneumonia, organism unspecified followed by Readmission 7 days post admission: APR DRG 194 Heart failure w/ CHF
      • Reason #2
      • Acute decompensation of a chronic problem that was not the reason for the initial admission but was plausibly the result of inadequate care during the initial admission or inadequate outpatient follow-up care
  • 21. Example: Admission Procedure with Medical PPR © 3M 2007. All rights reserved. Readmission 10 days post admission APR DRG 221 Major small & large bowel procedures w/ digestive system complications, not elsewhere
      • Reason #1
      • Continuation or recurrence of the reason for the initial admission, or for a condition closely related to the reason for the initial admission
    Patient 2- Hospital A Initial Admission: APR DRG 221- Major small & large bowel procedures w/ malignant neoplasm of rectum followed by Readmission 0 days post admission: APR DRG 721 Post-operative, post-traumatic, other device infections w/ other postoperative infection followed by Readmission 7 days post admission: APR DRG 252 Malfunction, reaction & complication of GI device or procedure w/ mechanical complication of colostomy and enterostomy
      • Reason #3
      • Acute medical complication plausibly related to care during the initial admission. A readmission for an acute medical problem was not considered clinically related unless it could have been a consequence of care provided in the initial admission.
  • 22. Example: Medical Initial Admission with Surgical PPR © 3M 2007. All rights reserved.
  • 23. Report #1: Overall Rates of Potentially Preventable Readmission ( PPRs ) © 3M 2007. All rights reserved.
  • 24. Report #2: PPRs Admissions by Service Line © 3M 2007. All rights reserved.
  • 25. Report #3: Admission Reasons by Service Line © 3M 2007. All rights reserved.
  • 26. Report #4: PPRs Admissions by Service Line © 3M 2007. All rights reserved.
  • 27. Report #5: PPRs Patient-level Details © 3M 2007. All rights reserved.
  • 28. Recommended Provider Proactive Approach to PPR Public Reporting © 3M 2007. All rights reserved. Appoint Interdisciplinary Leaders- “ Change Agents” Educate Organization Understand Public Reports (Peer Comparisons) Analyze Impact/ Gaps Communicate Offensively Documentation/ Coding Service Lines Reasons PPRs Internal Stakeholders External Constituents Initiate Focused Quality Improvement Clinical Operations Track, Monitor, Continue Focused Improvement Approach
  • 29. How Will You Proactively Understand PPRs? …eventually prevent PPRs?
    • http://student.bmj.com/issues/99/11/education/images/oliver_howes.gif
    © 3M 2007. All rights reserved.
  • 30. Use of Information on Potentially Preventable Readmissions
    • Readmissions rates – can be used to
      • Compare hospital performance
      • Select areas for quality improvement efforts
    • Individual patients with a PPR
      • identify patients who may be good candidates for improved discharge planning and care management after hospital discharge
    © 3M 2007. All rights reserved.
  • 31.
    • Carefully examine areas in need of improvement
      • Pre-admit process details (e.g. elective admits)
      • Clinical Practice
      • Discharge & Post-discharge
        • Multi-faceted
    • Implement ‘readmission mitigation’ strategies for key areas
    • Include multi-disciplinary clinical team
    • Focus and build
    • Avoid ‘boiling the ocean’
    © 3M 2007. All rights reserved. Initiate Focused Quality Improvement Clinical
    • Collect data once and repurpose it many times
    • Prioritize most important – focused operational improvements
    • Cost/benefit analysis
    Operations
  • 32. Example: NQF National Priorities Survey- January 2008 © 3M 2007. All rights reserved. Top 3 Conditions- Lead to most sizeable gains in improvement -- Diabetes -- Healthcare Acquired Infections -- End of Life Care NQF Survey : National Priorities Partners Survey Council Data, Jan 10, 2008; Karen Adams, PhD Councils representing Consumers, Health Plans, Health Professionals, Provider Organizations, Public/Community Health Agencies, Purchasers, QMRI, Supplier,Industry &Other Top 3 Cross-Cutting Strategies: -- Care Coordination -- Health Information Technology -- Medication Reconciliation Top Recommendations: Stakeholders: Broad range across the continuum Implementation : Concrete goals within a roadmap Burden: Include administrative/ documentation Systems Approach : Process/Outcomes coupled w/ human capacity IT: EHRs w/ registries, interoperability, reporting Health Lifestyle/Prevention: Value/reward for early detection/ prevention Episodes of Care: measure across Efficiency: Incorporate w/ effectiveness
  • 33. P4P- A Provider Proactive Approach (Hypothesis) © 3M 2007. All rights reserved. Success in payment reform …will require unprecedented levels of collaboration across the entire system of care. “Hospitals and physicians have a substantial obligation… to knock down barriers to improving quality and effectiveness. Modern Healthcare, 3/3/08 issue: “A Quality incentive at a crossroads- P4P summit features debate on limits, potential of bonus pay for meeting benchmarks- quote from Tom Priselac, president and CEO of Cedars-Sinai Medical Center, LA, CAL
  • 34. Example: The Virtuous Circle of Hospital Admissions © 3M 2007. All rights reserved. “ Shifting the focus of services Tackling some typical scenarios Authorities can find themselves trapped in 'vicious circles' of providing crisis-driven services which are neither effective for the service users and carers concerned nor an effective use of their resources. In these circumstances, authorities have to identify how they can inject a different dynamic into the system of care to turn 'vicious' into 'virtuous' circles of activity. “ Source: Improvement and Development Agency: makingendsmeet.idea.gov.uk/idk/aio/5221438, makingendsmeet.idea.gov.uk/idk/core/page.do?p...
  • 35. Some Additional Challenges © 3M 2007. All rights reserved. **Used with Permission by George Isham, Health Partners Hypothesis: Improvement of Outcomes Measures may positively impact performance across hospitals, physicians, health plans, states, etc……
  • 36. Recommended Provider Proactive Approach to PPR Public Reporting © 3M 2007. All rights reserved. Appoint Interdisciplinary Leaders- “ Change Agents” Educate Organization Understand Public Reports (Peer Comparisons) Analyze Impact/ Gaps Communicate Offensively Documentation/ Coding Service Lines Reasons PPRs Internal Stakeholders External Constituents Initiate Focused Quality Improvement Clinical Operations Track, Monitor, Continue Focused Improvement Approach
  • 37.
    • Continually educate and update key stakeholders
    • Gain insights
    © 3M 2007. All rights reserved. Communicate Offensively Internal Stakeholders
    • Communicate hospital accomplishments and expertise
      • Multi-venue
      • Integrated approach
    External Constituents
  • 38. Recommended Provider Proactive Approach to PPR Public Reporting © 3M 2007. All rights reserved. Appoint Interdisciplinary Leaders- “ Change Agents” Educate Organization Understand Public Reports (Peer Comparisons) Analyze Impact/ Gaps Communicate Offensively Documentation/ Coding Service Lines Reasons PPRs Internal Stakeholders External Constituents Initiate Focused Quality Improvement Clinical Operations Track, Monitor, Continue Focused Improvement Approach
  • 39.
    • Establish baseline information, reports, data
    • Continually track and communicate to interdisciplinary teams
    • Understand outcomes data and potential relationships
    • Focus and continue learning…
    © 3M 2007. All rights reserved. Track, Monitor, Continue Focused Improvement Approach
  • 40. Questions? © 3M 2007. All rights reserved.

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