Webinar presented by VITAS Healthcare on May 11, 2017. Presented by Christine Mlot

1. Reducing Readmissions and
Lengths of Stay
Developed by:
Dr. Joseph Shega
Regional Medical Director

2. Objectives
• Discuss the intent of the Hospital
Readmission Reduction Program
• Identify three components of readmission
measures
• Verbalize an understanding of preventable
hospital readmissions
• Appreciate the role of hospice in reducing
hospital readmissions

3. How People Die
• <10% die suddenly of an unexpected event:
MI, accident, etc.
• >90% die of a life-limiting condition, typically
over a 5-15 year period
– Predictable steady decline with a relatively
short “terminal” phase (cancer)
– Slow decline punctuated by periodic crises
(CHF, COPD, dementia)

4. What Do Patients With
Serious Illnesses Want?
• Pain and symptom control
• Avoid inappropriate prolongation of the dying process
• Achieve a sense of control
• Relieve burdens on family
• Strengthen relationships with loved ones
Singer et al, JAMA 1999

5. Outcome Hospice Nursing
Home
Home
Health
Hospital
Not Enough Help with
Pain, %
18.3 31.8 42.6 19.3
Not Enough Help
Emotional Support, %
34.6 56.2 70 51.7
Not always Treated
with Respect, %
3.8 31.8 15.5 20.4
Enough Information
Dying, %
29.2 44.3 31.5 50
Quality Care
Excellent, %
70.7 41.6 46.5 46.8
Last Place of Care Experience
Teno et al. Family Perspectives on End of Life Care. JAMA 2004

6. Where do patients spend their
last days?
Without Hospice
Hospital
Home
Nursing Facility
7
56
19
16
20
With Hospice
Hospital
Home
Nursing Facility
Hospice Unit
Residential Care Facility

7. Medicare Hospice Utilization
NHPCO Facts and Figures: Hospice Care in America. Alexandria, VA:
National Hospice and Palliative Care Organization, October, 2012.

8. Healthcare Spending in the U.S.
• Continues to far exceed other industrialized countries
• Accounts for $2.64 trillion ($8,650 per person a year)
– 17.7% of the nation’s total economic output and
nearly twice that of 34 countries
• It is estimated by 2020, that will increase
to $13,710 or $4.6 trillion

9. International Comparison of Spending on Health, 1980–2009
* PPP=Purchasing Power Parity.
Data: OECD Health Data 2011 (database), version 6/2011.
Average spending on health
per capita ($US PPP*)
Total expenditures on health
as percent of GDP
9
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
United States
Canada
Germany
France
Australia
United Kingdom
0
2
4
6
8
10
12
14
16
18
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
United States
France
Germany
Canada
United Kingdom
Australia
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
EFFICIENCY

10. Sun Sentinel
(Broward County edition)
Tuesday, August 9, 2011

11. Impact of Baby Boomers
• 2.8 million boomers qualified for Medicare in 2011
• Through 2030, about 10,000 Baby Boomers a day
will reach the age of 65
• Medicare beneficiaries: 47 million today; 80 million
by 2030
– Patient access will become an issue
– Hospitals will need to address chronic
care needs

12. Readmission Patient Profile
• 1 in 5 Medicare patients re-admit within 30 days
• 1 in 3 Medicare patients re-admit within 90 days
• 30 day re-admissions cost Medicare $12-$15 billion
– 3/4 would not return to the hospital if they had a
follow-up plan
– 1/3 of patients can not explain their medications
– 1/2 cannot state their diagnosis

13. Re-Hospitalization Rate
by State 2011

14. Lack of Care Coordination
Contributing To Waste
• $25-$50 billion annually
• Eliminating estimated avoidable emergency
department visits—$21.4 billion annually
• Cost for “avoidable” hospitalizations of nursing
home residents—$7.5 billion annually
• Cost of Medicare unplanned readmissions—
$17.4 billion
IOM Report

15. Costs at the End of Life
• Last two years of life, patients with chronic illness
account for approximately 32% of total healthcare
spending
• Sickest 5% of population accounts for almost half
of all health care expenses
• Hospital & physician bills during last two months
of patients’ lives cost Medicare $50 billion
• Hospitals have long argued ALOS figures are
skewed by patients no longer responsive to
curative treatments

16. Readmission Patient Profile
• Hospital death rates are 2-10 times higher for
re-admitted patients
• Re-admitted patients frequently require ICU
admission
• Re-admitted ICU patients length of stay (LOS)
is twice as long as non-readmitted patients
• ICU re-admits are associated with dramatically
higher hospital mortality

17. Changing Healthcare
Environment

18. With Passage of Health Care
Reform, CMS is Advancing
Value of Medicare

19. Where We Are – Where
We’re Going

20. How They Think About it in
Washington: The Value
Equation
Value of health care = Quality
Cost
Numerator problems
– 100,000 deaths/year from medical errors
– Millions more harmed by overuse, underuse and misuse
– Fragmentation
– Medical practice based on evidence <50% of the time
– U.S. ranks 40th in quality worldwide

21. How They Think About it in
Washington: The Value
Equation (Cont.)
Value of health care = Quality
Cost
Denominator problems
• Insurance premiums increased by >200% in the
last 10 years.
• U.S. spending 17% GDP, >$8400/person/year
• Nearing 35% of total state spending
• Health care spending is the #1 threat to the
American economy and way of life.

23. Hospital Readmission
Reduction Program (HRRP)
• Part of the Affordable Care Act (ACA)
• Intended to drive meaningful reductions in all-cause
readmissions by aligning payment with outcome
• Outcome measure: Hospital specific, risk standardized,
all cause 30-day excess readmission ratio following index
hospitalizations for AMI, heart failure or pneumonia
• 2013: 1% reduction in Medicare base reimbursement for
inpatient services for all DRGs
• 2014: 2% and 2015: 3%
Source: Kocher R, Adashi E. Hospital readmissions and the affordable care
act. Paying for coordinated quality care. JAMA 306:1794-1795, 2011.

24. Conditions for FY 2013 and
Expansion in FY 2015

25. Components of Readmission
Measures

26. Components of Readmission
Measures (Cont.)

27. Hospital Compare National
Readmissions Rate
Source: U.S. Department of Health and Human Services – January 2012

28. Change in Re-admission Rates
2011 to 2012

29. What is Counted as a
Readmission?

30. Reasons for Readmission
• Failure in discharge planning
• Insufficient outpatient and community care
• Severe progressive illness
Source: Jencks S, et al: Rehospitalizations among patients in the
Medicare fee-for-service program. NEJM 360:1418-1428, 2009.

31. Provider Visit after Discharge

32. Coordinated Approach
Hospitalist
• Communicate PCP on
admission
• Involve PCP early in
discharge planning
• Notification of discharge
• Discharge summary
• Follow-up appointments
• Prescriptions at pharmacy
• Self-management
Primary Care
• Call within 72 hours D/C
• Ensure follow-up
• Coordinate care
• Repeat until stable
• Access for patients with new
symptoms
• Track readmission rates
• Track and review frequently
admitted patients
Teng N. Jour Gen Hosp Med 2013

33. Readmission Impacts
on Hospitals
• Adversely affects hospital LOS and mortality rates
– Stay longer
– More likely to die
• Negatively impacts hospital “Core Measure” outcomes
• Utilization challenges for managing LOS and DRGs
• Increased ED volume and extended patient wait times
• Reduced patient and family satisfaction
• Hospice appropriate patients occupy hospital beds

34. Hospice/Palliative Care
Interface
Integrating Palliative Care and Hospice
Modified From Emanuel, von Gunten, Ferris. Plenary 3:EPEC series and reproduced in
Kinzbrunner. Palliative Care Perspectives, Chapter 1 in Kuebler, Davis, Moore Palliative
Practices, An Interdisciplinary Approach, 2005, p. 22.
Hospice
Curative / disease modifying
therapy
Time course of illness Last months
of life
Palliative care
Family
Bereavemen
t care

35. Hospice Care
• Interdisciplinary team-oriented
approach to end-of-life (EOL) care
– Patient-family center of care
– Goals of care/shared
decision making
• Aggressive care at the EOL—
medical care, pain and symptom
management and emotional and
spiritual support
• Provided in any setting

36. Medicare Hospice Benefit
Basic Hospice Benefit
• Prognosis of six months or less if the terminal illness
runs its normal course as determined by the patient’s
attending physician and the hospice medical director
• Patients elect hospice via informed consent
• Hospice reimbursed a flat per diem based on one of
four levels of care:
1. Routine home care
• Includes patients living in LTC or ALF
2. Continuous home care
3. General inpatient care
4. Respite inpatient care

37. Readmission: Hospice
Can Help
Medicare Hospice Benefit
• Comprehensive Part A benefit
• Focus is on care in the patient’s primary place of
residence
– Private home, ALF, nursing home
• “General inpatient” level of care for patients who
require “hospitalization” or “readmission”
• “Continuous care” enables patients who would
otherwise “require” an acute care (re)admission to
remain at home

38. VITAS Care Transition Pathway 2012
Hospital
(ED/CC/Telemetry/Med-Surg)
IPU GIP or Home
ICC ICC
Home Home
Visit VisitICC ICCTelecare Telecare
Visit
Frequenc
y
Virtual
ED
Mobile
Intensive
Palliative
Care
Visit
Frequenc
y
Virtual
ED
Mobile
Intensive
Palliative
Care
Patient
ED

39. Readmission: Hospice
Can Help (Cont.)
Kelly, A. Hospice enrollment saves money and
improves quality. Health Affairs 2013

40. Readmission: Hospice
Can Help (Cont.)
• Nursing home residents on hospice were less likely
to be hospitalized than residents not on hospice (OR
0.47; 95% CI: 0.45-0.5) 1
• Nursing home residents who had a “hospice
informational visit” had fewer acute care admissions
(mean 0.28 vs. 0.49; p = .03) and fewer acute care
days (mean 1.2 vs. 3.0; p = .03) than those who
did not 2
1Gozalo P, Miller S. Hospice enrollment and evaluation of the
causal effect on hospitalization of dying nursing home patients.
Health Svcs Res 42:587-610, 2007.
2Casarett D, et al. Improving the use of hospice services in
nursing homes. A randomized trial. JAMA 294:211-217, 2005.

41. Readmission: Hospice
Can Help (Cont.)
• University of Iowa, Retrospective Chart Review
• Penultimate admission within 12 months of death
– 60% (125/209) of patients met NHPCO guidelines
for hospice
– 84% (175/209) of patients were within six mo. of their
actual deaths
– Only 59% (103/175) of patients who died within six mo.
of the admission met NHPCO guidelines
• Documentation of hospice discussion
– Terminal admission: 23%
– Penultimate admission: 14%
Source: K Freund et al. Hospice eligibility in patients who died
in a tertiary care center. J of Hospital Med 7:218-223, 2012.

42. Case of AF
• 84 y/o with six-year history of CHF; relatively stable
until past six months
– Presents to ED with third exacerbation in three
months
– Recent EF 55% with diastolic dysfunction
– Long-standing ace inhibitor, b-blocker
and diuretic
– Dopplers negative DVT, CXR CHF
– PMH- s/p CVA, HTN, DJD, hard of hearing
• Admitted to hospital with CHF exacerbation
unclear reason

43. Case of AF (Cont.)
• Admitted to hospitalist service
– IV diuresis
– Optimization of BP medications
– Education about CHF
• Patient had cut back on diuretics due to
functional urinary incontinence
• Start consideration of discharge process
• Prior to admission ambulates with assistance,
shortness of breath minimal exertion

44. Hospice Guidelines
• NYHA Class IV : Symptomatic at rest
– Despite maximal therapies and/or therapies are
not tolerated or refused
• NYHA Class III : Symptoms with minimal exertion
– multiple co-morbidities, renal disease, pulmonary
disease, syncope, arrhythmia

45. CHF Outcomes by Type
Gotsman I et al. Plos One 2012

46. Hospice Triggers
• Frequent readmissions to the hospital
• Ongoing symptoms despite optimal treatment
• Declining functional status
• Use of ionotropes
• Declining renal function
• ICD fires despite medical therapies
• Patient goals focus on quality of life
• Would we be surprised if this patient died in
the next 6-12 months?
HFSA 2010 Guideline Executive Summary.
Journal of Cardiac Failure 2010; 16 (6)

47. Elements Important To Goals
of Care Conversations
Shared Decision-Making
Allen L A et al. Circulation 2012;125:1928-1952
• No more hospitals
• Minimal tests
• Improve shortness
of breath
• Continue to live
at home
• Keep alive as long
as possible

48. Readmission: Hospice Can
Help–Cost Savings and
Hospital Days Avoided

49. Burden Heart Failure
–Symptoms
Outcome Heart Failure
EF< or = 30%
Heart Failure
>30%
Advanced
Cancer
Number of physical
symptoms
9.4 (1.1) 8.7 (1.2) 8.7 (1.5)
Depression score 3.6 (0.6) 4.3 (0.6) 3.2 (0.8)
Spiritual well-being 35.2 (1.8) 36.3 (1.9) 39.1 (2.3)
No significant difference between any of the groups
Bekelman DB et al Journal of General
Internal Medicine 2009

50. Burden Heart Failure
—Symptoms (Cont.)
Heart Failure Most Common Symptoms (>50%)
Bekelman DB et al Journal of General
Internal Medicine 2009
• Lack of energy
• Pain
• Feeling drowsy
• Dry mouth
• Shortness of breath
• Depression

51. Comprehensive Services
Service VITAS Home Health
Nurse 24 hours day Yes Variable
Nurse frequency of visits Unlimited Diagnosis
Driven
Palliative Care Physician Support Yes No
Medications Included Yes No
Equipment Included Yes No
Levels of Care Home
Inpatient
Respite
Continuous
Home
Home
Bereavement Support Yes No
Primary Care/Specialty visits Yes Yes
Targeted CHF program Yes Variable
Care Plan Review Weekly Variable

52. Prolonged Survival
Connor SR et al, JPSM 2007; 33: 238-45

53. Case of AF (Cont.)
• Family meeting with patient and daughter. They
want to try skilled rehabilitation to get stronger
• Open conversation with patient and daughter
– Overall poor prognosis
– Recommend hospice services to best meet
patient goals
– Continue to provide state-of-art CHF care
– Open to informational visit prior to transfer

54. Case of AF (Cont.)
• At NH patient participates in PT/OT and builds
up some strength and endurance
– Ambulate with quad cane
• Still short of breath minimal exertion
• Approaching end of stay and develops acute
shortness of breath and back to the hospital
– Cut back on diuretic dose due to ongoing
functional urinary incontinence

55. Re-Hospitalization Rates from
Skilled Rehabilitation

56. Reason for Hospital Admission
from Nursing Home
Krueger K et al. Nursing Research and Proactive 2011

57. Case of AF (Cont.)
• Admitted to the hospital with CHF
• Diuresis
• Goals of care conversation and amenable
to hospice
• Elects hospice benefit

58. Case of AF (Cont.)
• At home on hospice and remains
relatively stable for two months
• Middle of night patient develops
acute shortness of breath
• Calls hospice—nurse to arrive in
1-2 hours
• Daughter brings mom to ED

59. Readmission Rate

60. VITAS Care Transition Pathway 2012
Hospital
(ED/CC/Telemetry/Med-Surg)
IPU GIP or Home
ICC ICC
Home Home
Visit VisitICC ICCTelecare Telecare
Visit
Frequenc
y
Virtual
ED
Mobile
Intensive
Palliative
Care
Visit
Frequenc
y
Virtual
ED
Mobile
Intensive
Palliative
Care
Patient
ED

61. Case AF (Cont.)
• Elects to go home with continuous care
• Sub Q furosemide initiated for fluid overload
• Overall stabilization within five days
• Routine home level of care re-initiated

62. AF Visit Summary
Patient Profile
• 84 y/o female w/heart
disease unspecified
(ICD-9 429.9)
• Home hospice elected
• LOS 92 days
VITAS Services Received
• Seven Physician Visits
• 42 RN Visits
• Two Social Worker Visits
• 35 CNA Visits
• Continuous Care:
Five days
• HME-Elect bedzO2,
w/C, etc.

63. “Whenever I walk in the room,
everyone ignores me.”

64. References
• Casserett D, et al. (2005) Improving the use of hospice services in
nursing homes. A randomized trial. JAMA 294:211-217.
• Freund, K. et al. (2012) Hospice eligibility in patients who died in a
tertiary care center. J of Hospital Med 7:218-223.
• Gade G, et al. (2008) Impact of an inpatient palliative care team: A
randomized control trial. J Pall Med 11(2):180-190.
• Gozalo P, & Miller S. (2007) Hospice enrollment and evaluation of the
causal effect on hospitalization of dying nursing home patients. Health
Svcs Res 42:587-610.
• Jencks S, et al: (2009) Rehospitalizations among patients in the
Medicare fee-for-service program. NEJM 360:1418-1428.

65. References (Cont.)
• Kocher R, & Adashi E. (2011) Hospital readmissions and the
affordable care act. Paying for coordinated quality care. JAMA
306:1794-1795.
• Nelson C, et al. (2011) Inpatient palliative care consults and the
probability of hospital readmission. Permanente J 15:48-51.
• Pantilat: Role of Palliative Care in Readmission Reduction. (2012)
Retrieved from:
http://www.avoidreadmissions.com/wwwroot/userfiles/documents/76/pr
esentation-3.pdf.
• U.S. Department of Health and Human Services – January 2012
• Wright JB, & Kinzbrunner B. (2011): How to assist patients and
families in accessing end-of life care. Chapter 2 in Kinzbrunner BM,
Policzer JS (eds): End-of-Life Care: A Practical Guide. New York:
McGraw Hill, p. 37.