Why should you be concerned? We are in the midst of moving from a - - PDF document

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Readmissions

the bottom line

Barry Bittman, MD

Senior Vice President Chief Population Health Officer Highmark Allegheny Health Network Senior Fellow – Estes Park Institute

Why should you be concerned?

• We are in the midst of moving from a

fee‐for‐service model to risk‐based contracts that often prioritize reducing readmission rates.

• Quality achievement now plays a

significant role in reimbursement.

• Excess readmissions may be a sign of

poor quality.

• Potentially preventable readmissions

must be reduced to ensure better patient outcomes and experiences while controlling costs.

• Ignoring potential incentives and

penalties could be devastating.

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Our Hospital

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FY2013 & FY2014 (added algorithm to exclude planned admissions)

• 30 day Readmissions Acute Myocardial Infarction (AMI)
• 30 day Readmissions Heart Failure (HF)
• 30 day Readmissions Pneumonia (PN)

FY 2015 Additions

• 30 day Readmissions chronic obstructive pulmonary disease (COPD)
• 30 day Readmissions elective total hip arthroplasty (THA) and total knee

arthroplasty (TKA) The Excess Readmission Ratio is calculated as the ratio of predicted readmissions to expected readmissions. The 2015 penalty is 3%. A hospital’s excess readmission ratio for each condition is a measure of a hospital’s readmission performance compared to the national average for the hospital’s set of patients with that applicable condition.

CMS Readmissions Reduction Reasons for High Readmission Rates

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Limited clinical coordination within the acute care setting Failure to properly engage clinical documentation specialists and coders with providers Poor communications with physicians and post‐acute care providers. Lack of preparedness for care transitions Maslow’s Hierarchy

• f Needs

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Silo‐based Care Failure to Know the Patient Responsibility Beyond Our Walls Appropriate Follow‐up and Access Medication Errors Medical Literacy Maslow’s Hierarchy of Needs Hunger Financial Impediments

Challenges

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Establishing Balance!

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LOS must be balanced against readmission potential

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Documentation Challenges

1. Documentation Inconsistencies 2. Lack of Communication 3. Discharge Summary Delays 4. Vague Coding Criteria 5. Numerator and Denominator issues

Inpatient Disease‐Based Strategy

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Physician and post‐acute appointments Ancillary care support preparation for care transitions (e.g. respiratory) Medication and DME arrangements Discharge disposition Palliation/Hospice Accountability Sign‐offs MANDATORY TIME OUT!

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What does it take to ensure the well‐being of our patients outside

• ur walls?

Meadville Medical Center Allegheny College

• St. Vincent Hospital

Gannon University Jefferson Hospital Washington & Jefferson College Wooster Community Hospital College Of Wooster Pocono Hospital East Stroudsburg University White River Medical Center Lyon College (Arkansas) Canton-Pottsdam Hospital

• St. Lawrence University

Rochester General Hospital Rochester Institute of Technology Washington Regional Medical Center University of Arkansas Shannon Medical Center University of Texas

A Sample of Health Coach Programs

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AHN Advocate Team

• Definition: A novel patient‐centric integration of

palliative care services within an interdisciplinary care coordination team ensures a successful transition from acute to post‐acute care settings.

• Underlying Premise: Support by an advocate

is a key factor for achieving Triple Aim

• utcomes especially for high risk patients.
• Rationale: Acute high quality care alone is

insufficient to optimize a patient’s overall

• utcome. Silo‐based care results in

poor communications among acute and post‐acute providers and families.

• The term, palliative, often serves as

an obstacle to high quality care. Our approach is to integrate palliative care services through the A Team.

• The care continuum is optimized,

families know what to expect, readmissions are reduced and the cost of care decreases.

AHN Advocate Team

Strategies:

• A coordinated integrated acute and post‐acute

healthcare team led by a palliative care professional is assigned to each high risk‐ stratified patient. A Point Person (Advocate) serves as a liaison, bridging the divide between acute and post‐acute care and the family.

• A care reconciliation plan is developed that

seamlessly aligns acute and post‐acute

• care. The plan is reviewed by the acute

and post‐acute team as well the the patient and family to ensure a smooth transition with clear‐cut expectations based upon a host of identified contingencies.

• Communications are optimized, care

gaps are bridged and a care plan is developed/reviewed. A series of rational expectations facilitate a unique coordination strategy.

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New Data Equation

30 day rolling average

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Denominator Day 1‐30 Numerator Day 31‐60 Day 61‐62 May 13‐June 13 June 14‐July 14 July 16

Care Coordination

New Discharge Standards

(to be applied to all AHN chronic patients) 1. All follow‐up appointments shall be scheduled prior to discharge. 2. No patient shall be discharged with a pharmacological or food‐based care gap. 3. A mandatory time‐out shall occur prior to discharge. 4. Each patient shall be called by a clinician the day after discharge to assess progress, provide support and answer questions. 5. All PAC providers shall be contacted within 72 hours of discharge to review patient status and progress. 6. Every effort shall be addressed to ensure proper coding while the patient is in our hospitals, rather than post‐discharge.

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A Brighter Horizon ACO DREAM Improvement Act of 2014

Key Points

• Beneficiaries can select an ACO physician.
• Regulatory Relief is provided for a two‐sided model:
• 3‐day prior hospitalization waiver for SNFs
• Homebound waiver for Home Health Services
• RAC Audit relief
• Flexibility in Telehealth Services
• Advance Notification of Benchmarks and Past Performance
• Electronic Access to patient claims data
• BENEFICIARY INCENTIVES! Reduce or eliminate cost‐sharing

under Part B

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TO DO List

Re‐evaluate your discharge process from multiple perspectives (patient, family, physician, post‐ acute provider). Build acute‐care programs for chronic disease management (core readmissions) with designated interdisciplinary teams. Establish a comprehensive transitions of care strategy. Develop care coordination within your community to address Maslow’s Hierarchy of Needs. Build a Health Coach program. Track your data closely. Review each core readmission with a root cause analysis. Meet on a weekly basis.

17 AHN PHM Institute 18

When they entrust their lives to us, we owe them more...

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Thank You

For more information: bbittman@iihealthcare.or g