5/28/2014

Preventing Readmissions: Working Together Across the Continuum of Care Richard Fraioli, MD, John Muir Health System Tory Starr Starr, MSN MSN, PHN PHN, Sutter Health System Cassidy Tsay, MD, Newport IPA

Preventing Readmissions: Working Together Across the Continuum of Care

Agenda of Presentation 1. Introduction, Background, Current and Target States : Tory Starr 2 Risk 2. Ri k A Assessment: t Richard Ri h d F Fraioli i li 3. Experience From Field: Cassidy Tsay

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OVERVIEW

Why is CMS Focusing on Readmissions? • Indicator of the (or lack of ) care coordination • Hospitals = Costs & Risk • Stimulates growth of collaborative relationships. • Stimulates development of integrated care systems. • Precursor to bundled payments & shared risk models of reimbursement.

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Why is CMS Focusing on Readmissions?

 19% readmission t rate

 1.9 million readmits



$17.5 billion

CMS Readmissions Reduction Efforts: STICK Medicare Readmission Reduction Program • CMS will reduce payments  1% penalty yr/1 (2012)  2% penalty yr/2 ( 2013)  3% penalty yr/3 (2014) T t DX: DX Target 2013: AMI, HF, Pneumonia 2014: COPD, THA ,TKA

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CMS Readmissions Reduction Efforts: CARROT Medicare Payment Incentives • Transitions of Care (2014)

• Chronic Care

(2015)

Readmission Prevention Program

Hospital Admission: A Patient Perspective

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Hospital Admission Experience Bundle elements 1. Risk Assessment 2. Post D/C provider (MD, NP, clinic, etc.) 3. Medication management ( includes but not    limited to medication reconciliation) 4. Self management competency  5. Care plan coordination ( bridging with the  ambulatory setting) b l i ) 6. Tailored intervention and support for at least 30  days post discharge.

Hospital Admission Experience

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Hospital Admission Experience

Hospital Discharge Experience

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Readmission Causes 1. Medication Reconciliation/Management Challenges 2. Inadequate Transitions of Care Planning 3. Delayed / Absent Follow Up with Primary Care 4. Lack of Knowledge re Disease Process “Red Flags” 5. Lack of Follow up on Tests & Treatments 6. Lack of Communication between Providers and/or Family/Caregivers 13

Care Coordination and Population Risk Complexity

10% of the Population Utilizes 60% of the Resources

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Who Is High Risk? –

High risk defined as having at least one: Unplanned readmissions within 30 days. Two or more admissions in 12 months. Two or more ED visits in 12 months. One or more SNF admissions in 12 months Patients on 7 or more medications. Patients with 3 or more chronic conditions. conditions Patients of “non-aligned” physicians or nophysician.  Lives Alone & Age > 75 years old       

Influencing Factors

 Social Determinants of Health 1. 1 Behaviors 2. Physical Environment 3. Social & Economic 4. Clinical Care

Noncompliance = Provider Failure 16

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California County Health Rankings

Yolo=5 Sacto=30 Solano=31 Amador= 33

California County Health Rankings

Orange = 7 Contra Costa = 19 Sacramento = 30

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Care Coordination • All Complex Patients need follow up care! • Safe and effective care transitions involve conforming each transition to the involved patient, not attempting to fit the patient into the existing transfer process. • Patient-centered care: 1. Patient/family ownership & empowerment 2. Clinical and psychosocial information travels with the patient rather than remaining anchored at individual sites of care. 19

The Original Care Coordinator

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Target State Where to we want to be? • Understanding that every readmission is important to try to prevent. • Focusing on all patients or specific target g groups g p

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Care Coordination: Continuum of Care Strategy  Admission  Management

Admission  Prevention

Home  Health

Ambulatory  Complex C l

Transition Inpatient  Status

Care  Coordination

Complex  High Risk  Patient Outpatient  Service  Coordination                 & 

ED Care Coordination

Observation  Status : 

Primary  Care

HOSPICE

Specialized  Care 

Zone

Unit

Expansion

Disease  Mngmnt

Robust Services & Support

SNF Care  Coord.

Rigorous Management

Physician Leadership and Communication

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Models of Care 1. Matching resources to specific pt need 2. Patient Centered, team based care 3. Distributive versus intensive » PCMH » MD practice imbedded CM, SW, Pharmacist » Virtual Support

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What Is Working: Lessons From the Field • Readmission bundles • Patient identification & risk stratification matching resources to specific need –Population management • Reimbursement/ payment and incentives –CMS support with new codes for »Transitions of Care (2014) and » Care Coordination (2015) 24

• Coordination with Post Acute Providers

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What Is Working: Lessons From the Field

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What Is Working: Lessons From the Field

See Appendix for List of Programs in place at Presenters Organizations 26

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John Muir Health • 700+ beds • 2 Acute Care Hospitals • 1 Behavioral Health Hospital • ~ 70 Case Managers (Inpatient and Outpatient) • Foundation Model o IPA – 800+ MDs care and MD ((primary i d specialists) i li t ) o 165 member primary care group o Hospitalists

Readmission Risk Identification • Intense inpatient concurrent review o Identify Id tif expected t d GMLOS per DRG o Identify risk for readmission (LACE Score) o Notify Hospitalists of expected LOS and readmission risk o Place patient at appropriate level of care (inpatient vs. observation)

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Lace Score • LACE scores for every patient on admission and discharge on the following parameters: o Length of stay o Acuity of the admission o Co-morbidities o Emergency Department visits in the previous 6 months • LACE scores range from 1 1-19 19 and predict the rate of readmission or death within 30 days • Calculated by the concurrent review RN/case manger o Entered into patient’s chart with high visibility

From Canadian Medical Association Journal *April 6, 2010*182(6)

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LACE Index for the quantification of risk of death or unplanned readmission within 30 days of discharge* Attribute

Value

Length of Stay ("L)

Points*

10 at discharge identifies patients with high probability of readmission • With an admission LACE score of >10, the inpatient case management team, with the attending physician, begins the discharge planning process early • JMPN developed graduated protocols for post-discharge case management depending on the discharge LACE score oStrong correlation between the admission and discharge LACE scores

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Lace Score • Patients with a LACE score > 13 (predicted readmission rate 19-43%) received the above plus enrollment ll t iin llonger tterm complex l case management, t Patient Centered Medical Home, and other individualized programs. o CHF + COPD Tele-monitoring o Heart Failure Clinic o Diabetes Clinic o Behavioral Health • Primary Care Physician Notification o Notification of all HMO patients admitted with a LACE score >10

Lace Score • Control Group oSome patients, for various reasons, did not receive the interventions, and they served as an internal control group.

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Lace Score Readmissions within 30 Days of Discharge Lace Active Group vs. Control Group November 12 – December 13 40% 35% 30%

Rate

25% 20% 15% 10% 5% 0% 10 to 12

13 to 16 LACE Range

Active Group Total n 1145

17 to 19

Control Group Total n 585

Lace Score Readmissions within 30 Days of Discharge Lace Active Group vs. Control by Payor Type November 12 – December 13 Lace Score > 9 35% 30% 25%

Rate

20% 15% 10% 5% 0% Commercial

Active Group Total n 962

Medicare Advantage

Control Group Total n 503

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Lessons Learned • Avoiding unnecessary readmissions requires oAttending physician awareness of LACE score oCoordinated plan for discharge transition oWarm patient hand-offs and ambulatory case management oTimely follow-up by Primary Care Physicians post discharge oCoordination with skilled nursing facilities oPatient acceptance of and compliance with post-discharge transition plans

Greater Newport Physicians, IPA • • • •

Independent Physician Association (IPA) 100,000 Patients 170+ Primary Care Physicians 4 Hospital Network – – – –

Hoag Presbyterian Long Beach Memorial Orange Coast Memorial Saddleback Memorial

• Mantras! – High Quality Care High Cost Care – Right Patient - Right Place - Right Time

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GNP/SNF Joint Operating Committee • SNF Training Workshop • Scheduled Quarterly Meetings with frequently used SNFs • Attendances: – SNF staff: Administrator, Director of Nursing and PT, Case Manager – GNP staff: Associate Medical Director, Supervisor of Case Management, SNF Case Managers, Quality Supervisor, Manager of Inpatient Case Management – GeriNet: SNF physicians and/or Nurse Practitioner

• Agenda – – – –

Updates in current healthcare environment Changes in any processes or staff on both sides Active issues or complaints Review of the dashboard

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What is Palliative Care? • It focuses to relieve and prevent suffering by ffi i lif – affirming life – promoting quality of life – treating the patient – supporting the family • It is a spectrum

Impact 1 year before the program

With the program

Differences

ER Volume patients who had ER visit  # of p  Total # of visits

63 113

27 35

57% ↓ 69% ↓

Inpatient Volume  # Patient Hospitalized  ALOS  Readmission rates

82 4.3 40%

33 5 30%

60% ↓ 16% ↑ 25% ↓

150 100 before

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after 0 ER patient volume

ER visits

Inpatient patient  volume

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Failures/Learning

• Inpatient Team Rounding Approach • Hire the right people for the job

Where Do We Go From Here?  Opportunities: • Creating C ti motivation ti ti and d iincentives ti along the continuum • Emergency Department Case Management • Managed Medicare/ MediCal 46

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Where Do We Go Form Here?  Challenges:

• Increasing complexity and volumes • Resources • Reimbursement 47

Making A Difference What We Need From You • Understanding that every readmission is important to try to prevent. • Limit unnecessary visits to the ER as 90% end up as admissions. • Discussions regarding end of life/ goals of care 48

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Questions

APPENDIX OF PROGRAMS

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JMH The Transitions of Care Program Care Transitions Intervention

Criteria    

   

Discharged following inpatient admission with 1 or more “disease states” Lives within John Muir Health service area Is followed by a Primary Care Physician and/or specialist Is able to be taught selfmanagement skills or has consistent caregiver who can assist patient Primary diagnosis not mental health No active substance abuse HMO and non-HMO patients LACE readmission risk score ≥10

Disease States               

Frail Elderly CHF COPD Diabetes Total joint replacements Hip fractures Amputations Cellulitis New anticoagulation therapy More than 6 medications Multiple ER visits Multiple inpatient admissions Chronic illness & lives alone Confusion about treatment plan Lack of knowledge of resources

Description  o o o o   

Home visit w/in 72 hrs. of discharge Med Reconciliation Create Personal Health Record Coaching for MD f/u visit Identify “red flags” 7-day f/u call 14-day f/u call Assessment/referral to case management

JMH The Transitions of Care Program Tel‐Assurance

Criteria      o o



 Diagnosis of CHF or COPD  Is able to call toll‐free  number or lives with  someone who can h Is followed by Primary Care  Physician and/or specialist Has scale at home or can  purchase one; has  touchtone phone Does not have exceptions: Currently undergoing  hemodialysis Resides in Skilled Nursing  Facility, Assisted Living  Facility or Long Term Care  p where patient is not  independent in Activities of  Daily Living Include both HMO and non‐ HMO patients

Disease States CHF COPD

Description 





Pt calls toll‐free number to  enter daily wt and take  survey indicating status of  symptoms t If abnormal wt (> 3 lbs/day  or 5 lbs/week) or abnormal  answer to survey, clinical  variance will alert Case  Manager who will call  patient and MD if needed. No call variance will trigger  alert when patient has not  completed survey in > 2  days.  Nurse will call patient  to determine health status

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JMH The Transitions of Care Program Complex Case   Management 

Criteria

Disease States

HMO patients, complex conditions,  multiple co‐morbidities, needing  assistance in navigating the health  system.  Referrals may come from  s stem Referrals ma come from Primary Care Physicians, health  plans, specialists, Home Health,  Senior Services, or patients may  self‐refer.

Chronic or complex, multiple diagnoses   such as:  Transplants  Congenital anomalies Congenital anomalies  Paraplegia, CVA  Neurological disorders   Complex oncology  Uncontrolled diabetes or CHF  Self‐reported health status of fair  to poor  Multiple hospitalizations or  frequent ED visits  Polypharmacy with knowledge  deficit regarding meds  Complicated socio‐economic  issues  Complex care coordination  needs/treatment plans  Frail Elderly

Description      



Patients contacted to  participate in Case Manager Development of Care Plan  with Primary Care Physician  ith Primar Care Ph sician and patient or caregiver Self‐management support,  education Care coordination with  interdisciplinary care team Frequent contact as needed  with patient to assess  compliance with Care Plan Assistance in connecting with  Community Resources as  needed (Meals‐On‐Wheels,  transportation, Peer Group  p , p counseling, placement in  Assisted Living Facility or Long  Term Care as needed,  referrals to Senior Services,  HF Resource Center, or HH as  needed) Act as patient advocate  improve quality of life 

JMH The Transitions of Care Program

Criteria

Disease Management  HMO patients with specific disease   states. Newly diagnosed or   challenges with self‐management   and achieving goals of treatment,  multiple ED visits or admissions.

Disease States Diabetes CHF COPD

Description Patients with specific disease states  are identified and contacted as  often as necessary to improve and  maintain health status.  Phone calls  Home or office visits, if  needed  Group educational events for  teaching self‐management  principles.

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JMH The Transitions of Care Program

Criteria

Practice Based Patient  All patients (regardless of payer)  Centered who are under the care of the  Medical Home physicians within the practice are  eligible for  eligible for Complex Case  Complex Case Management & Disease  Management.  Multiple chronic  conditions, co‐morbidities, acute  illness requiring support, referral,  education, multiple ED visits or  admissions, need for complex care  coordination services.

Disease States All patients with chronic diseases, the  complex patient with multiple co‐ morbidities or medications, or by  physician request. physician request  Neurological disorders  Complex oncology  Newly diagnosed, or uncontrolled: o diabetes o heart Failure o coronary artery disease o pulmonary disease o other chronic, complex  Self reported health status of fair  to poor  Multiple hospitalizations or  frequent ED visits  Polypharmacy with knowledge  deficit regarding meds  Complicated socio‐economic  issues  Complex care coordination  needs/treatment plans  Frail Elderly 

Description 



 

Case Manager meets with  patients referred by MD who  are in acute state –when  stable transferred to stable, transferred to  Healthcare Coordinator Healthcare Coordinator  contacts patient or meets  face‐to‐face to assist with  education to chronic disease  state Assists practice with health  plan programs preventive and  chronic disease measures Post discharges and post ED  follow‐up calls

JMH The Transitions of Care Program

Criteria

Disease States

Central Based Patient  Patients of Primary Care Physicians  All patients with chronic diseases, the  complex patient with multiple co‐ Centered Medical  participation in the Medicare  Home Accountable Care Organization and  morbidities or medications, or by  HMOs are eligible for Complex Case  physician request. HMO li ibl f C l C h i i t Management & Disease   Neurological disorders Management.  Multiple chronic   Complex oncology conditions, co‐morbidities, acute   Newly diagnosed, or uncontrolled: illness requiring support, referral,  o diabetes education, multiple ED visits or  o heart Failure admissions, need for complex care  o coronary artery disease coordination services. o pulmonary disease o other chronic, complex  Self reported health status or fair  to poor  Multiple hospitalizations or freq  ED visits  Poly‐pharmacy with knowledge  deficit regarding meds  Complicated socio‐economic  issues  Complex care coordination  needs/treatment plans  Frail Elderly

Description       



Close management of all  patients with chronic diseases Disease Management to assist  with treatment plan  ith t t t l compliance Post‐discharge and post ED  follow up calls  Post discharge follow‐up Close coordination of care  with specialists Referrals to other JM entities  or community resources Close management of  compliance with preventative  services (immunizations,  p , g , colonoscopies, mammograms,  etc) Creation of patient‐centered  care plan to meet identified  health goals

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The Transitions of Care Program

Criteria

Disease States

Skilled Nursing Facility  Patients transitioned from acute All patients with chronic diseases,  Care Management  inpatient stay, qualifying for skilled  complex multiple co‐morbidities or  (SNF) nursing services,  rehabilitation.   medications, post surgical, stroke,   rehabilitation needs, rehabilitation needs frailty, etc.   frailty etc

Description  

 





Nurse Care Managers round at SNFs for review of assigned  HMO members. Collaboration with identified Collaboration with identified  SNFs, based on the INTERACT  II Collaborative Quality  Improvement Project model. PN and SNFs participated in  leadership, staff education  sessions. Implementation of transition  communication tools, early  warning assessments, SBAR  communication, change in  condition enhanced  assessment guidelines.   Nurse Care Managers  reinforcement of enhanced  assessments, use of tools,  improved communication  with SNF clinical staff. Nurse Care Managers partner  with LCSW for discharge  planning, and hand‐off to  Medical Home at discharge. 

The Transitions of Care Program

Criteria

Home Health Services Patients discharged to home from  acute inpatient or SNF stay,  qualifying for skilled nursing  services, rehabilitation, who are  services rehabilitation who are home bound.  

Disease States Various conditions, medical or surgical  events, requiring skilled observation,  assessment, nursing services, wound  care, rehabilitation services.  care rehabilitation services

Description Patients are managed for a defined  period of skilled need.  At the end  of the episode of skilled care,  patients are assessed for ongoing  patients are assessed for ongoing care coordination needs, referred  to Medical Home program and  assessed for ambulatory case  management, care coordination,  tele‐monitoring services, disease  management support.

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GNP Outpatient Programs Programs

Descriptions/Indications

Anticoagulation Center

Outpatient management of patients on anticoagulation: on‐site fingerstick INR as well as  phone management and Lovenox bridging program

ACTIVE Diabetes Program

Team approach with a Nurse practitioner, Pharmacist, Social Worker,  and Nutritionist to  develop and manage patients with Hemoglobin A1C > 8%‐ concentrating on identifying  and addressing barriers and empowering patients with their care

GeriNet NP or MD Home Program Services need to be evaluated by GNP CM

Patient who will need a Nurse Practitioner or Gerontologist to evaluate, treat, and  manage the patient in the home setting when patient could not be seen in the PCP or  specialist offices. 

GNP Bridging Program patients not going to the SCC

GNP inpatient case managers calling patients 1‐2 days after discharge to make sure  patients have received all their discharge needs: DME, home health, medical  reconciliation, PCP and specialist appointments scheduled

Home Health health plan dependent Hospice

Home bound patients who will need nursing care (i.e. wound care), PT, social services, teaching (i.e. lovenox) Patient who meets the guidelines for hospice care- not managed by GNP- care managed by the hospice agencies. Please inform GNP if a patient is referred. Program in which a nurse case manager communicates with the patient, family and physicians to help coordinate care, understand of disease, encourage dietary modification and lifestyle changes. This is done via scheduled telephonic communications as well as face-to-face meetings when they are hospitalized in the acute setting.

Not managed by GNP

CHF Case Manager CHF and post-AMI patients

GNP Outpatient Programs Programs

Descriptions/Indications

Care Coordination Team

Referred by PCP and/or patients and their families to have one person as the point person for management of their complicated medical needs- to help them coordinate the care and be a resource. You can also contact the team through Access Express email addressed to GNP Care Coordination Team.

Palliative Care Program

Patients (cancer, COPD, CHF, CAD, dementia, frequent ER visits or hospitalization due to medical problem, etc.) - to provide services commonly seen under hospice care to patients and family members who may not be emotionally ready or meet the guidelines for hospice- to provide relief from distressing symptoms such as pain, shortness of breath, fatigue, constipation, nausea, decreased appetite, sleep problems and more- 24/7 availability by phone for patients and family members

Evaluated by CM for appropriateness

SNF Bridging Program patients not going to the SCC Social Worker Program

Special Care Center (SCC)

SNF case managers calling patients 1-2 days after discharge to make sure patients received all their discharge needs: DME, home health, medication reconciliation, PCP and specialist appointments scheduled Available for questions, guidance, and management of patients with social needs such as accessing community resources, helping family with placements, understanding the complexities of healthcare system, guiding patients and families to other resources outside of their healthcare coverage plan, etc. Outpatient post-discharge follow-up appointment for patients discharged from the hospital, long-term care facility or SNF: to have the hospitalist go over the patient’s discharge medical needs; pharmacist to do medication reconciliation; and case manager to insure discharge needs are met.

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Sutter Readmission Prevention Programs Focus Area/ Program Leadership Care Coordination Leadership Team: System, Regional & Medical Group System Complex Case Management Development Team Regional Readmission Prevention Leadership Team Regional Hospitalist & Care Coordination Leadership team Measurement Care Coordination (readmission) Dashboards: System & Regional Inpatient Standardized Case Management Functions, Processes and Training Integrated Clinical Social Work and Case Management Team Standardized Risk Assessment Process ED Case Management

Description Implemented system and regional level executive leadership positions to oversee development and implementation of care coordination efforts System level coordination of regional activates focused on complex care coordination model development and implementation.. Cross continuum leadership team focused on readmission prevention. Physician and support services leadership focusing on care coordination operational activities.

Regular reporting of established care coordination activities including readmission rates.

System wide support for the establishment and maintenance of standardized case management functions, processes and training of staff. Social Work services are clinical focused provided by LCSW level of practitioners who work as an integrated team with case management.

The 4 largest hospitals have 24/7 RNCM services. Pilot process underway for expansion of services to include SW and navigator support. g Risk Care Transitions Team One hospital p has a CT Team utilizing g the CTI model of intervention. High Dialysis Patient Management Services Contracted CM services for high , risk dialysis patients. Palliative Care Services To provide care coordination and expert consultation for distressing symptoms for patients and support for family members. Collaborates with inpatient CM to coordinate with home health, hospice and AIM service for post discharge care Heart Failure Clinic Specialized follow up clinic services. Cardiac Rehab Specialized follow up clinic services. A variety of targeted programs developed in partnership with FQHC network and funded through Underinsured Patient Programs: ICP community benefit program to focus on underfunded, high risk patient receiving services in the (Intensive Care Program), T3 (Triage, ED and inpatient settings. Transportation, & Treatment), ED Navigators & Inpatient Navigators Post Discharge Phone Call Program GNP inpatient case managers calling patients 1-2 days after discharge to make sure patients have received all their discharge needs: DME, home health, medical reconciliation, PCP and 61 specialist appointments scheduled.

Sutter Readmission Prevention Programs Focus Area/ Program Ambulatory Anticoagulation Management Program Disease Management Program: Heart Failure, Diabetes & COPD Post Acute/ Skilled Nursing Case Management  Post Acute/ Skilled Nursing Case Management Program Sutter Care Coordination Program (Physician Office  Based Case Management) Home Health/ Integrated Care Management Hospice AIM (Advanced Illness Management) Program Sutter Senior Care Program (PACE)

Description Outpatient management of patients on anticoagulation. Protocol driven. Nurse managed. Program in which a nurse case manager communicates with the patient, family and physicians to help  coordinate care, understand of disease, encourage dietary modification and lifestyle changes.  This is  done via scheduled telephonic communications. SNF case managers working with a physician specialist group and SNF provider network to make manage  SNF case managers working with a physician specialist group and SNF provider network to make manage patient through post acute care and into the ambulatory network .Complex case management team (RNCM, LCSW, Pharmacists and health care coordinator) focusing on  longitudinal management of patients with complex needs and at the top of the population risk pyramid. Home bound patients who will need skilled services. Patient who meets the guidelines for hospice care‐ not managed by GNP‐ care managed by the hospice  agencies‐ close relationship with 3 agencies. CMS innovation grant program focusing on outpatient palliative care services for patients with 12‐18  month life expectancy. All inclusive program of care for the population at risk for SNF placement.

Complex Ambulatory Care Pilots: PCMH,  Ambulatory  System level coordination of multiple regional efforts focused on developing models for primary care  ICU, & IOCP (CMS Grant) management of complex patients. Patient Health Literacy Program Expert in‐house consultation for program and process alignment with health literacy principles Practice Improvement: LEAN Support Performance improvement efforts directed at the individual group practice level focusing on access,  affordability, variation reduction, population management. ff d bilit i ti d ti l ti t Physicians Communication Across the Continuum of Care Ongoing facilitated efforts to develop models for  improved physician communication across the  continuum of care. Quality Improvement Plan  Contractual incentives focused on readmission prevention.

Sutter Medical Network

Medical group Consolidation

Integration of numerous  smaller medical groups into a larger regional group with consolidated  leadership. System wide  focused on practice improvement including variation reduction, affordability and quality.

EHR 

Ambulatory electronic record implementation.

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