2016 IHI Webinar Series - Tennessee Center for Patient Safety · 2016-12-15 · 2016 IHI Webinar Series Rhonda Dickman, RN, MSN, CPHQ Rhonda Dickman is a Quality Improvement Specialist

Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar

8/31/2015

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2016 IHI Webinar Series

Rhonda Dickman, RN, MSN, CPHQ

Rhonda Dickman is a Quality Improvement Specialist with

the Tennessee Hospital Association’s Tennessee Center

for Patient Safety, supporting hospitals in their quality

improvement work, particularly in the area of

readmissions. She is also the clinical manager of the

Tennessee Center for Patient Safety’s PSO (patient

safety organization).

Rhonda has worked in the field of hospital quality

management since 2006 and has a clinical background in

trauma, critical care, oncology, and organ donation.

[email protected]

615-401-7404

mailto:[email protected]


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Introduction to Webinar Series

• Exclusive program for clinical leaders in hospitals that are part of the Tennessee Hospital Association Hospital Engagement Network (HEN)

• Focused on supporting clinical leaders who supervise front-line staff

• 18 webinars in total

• 1.5 contact hours for each webinar

• Transitioning to new webinar platform

Kathy Duncan, RN Kathy D. Duncan, RN, Director, Institute for Healthcare Improvement (IHI), oversees multiple areas of content, directs multiple virtual multiple learning webinar series. Currently she serves as Faculty for the AHA/HRET Hospital Engagement Network (HEN) 2.0 Improvement Leadership Fellowship

Ms. Duncan also directed content development and spread expertise for IHI’s Project JOINTS, an initiative funded by the Federal Government to study adoption of evidenced-based practices. In 10 US States, Project JOINTS spread three evidence-based pre-and perioperative practices to reduce the risk of surgical site infections in patients undergoing total hip or knee replacement.

Previously, she co-led the 5 Million Lives Campaign National Field Team and was faculty for the Improving Outcomes for High Risk and Critically Ill Patients Innovation Community. She has also served as a member of the Scientific Advisory Board for the American Heart Association’s Get with the Guidelines Resuscitation, NQF’s Coordination of Care Advisory Panel and NDNQI’s Pressure Ulcer Advisory Committee.

Prior to joining IHI, Ms. Duncan led initiatives to decrease ICU mortality and morbidity as the Director of Critical Care, Orthopedics and Neuro for a large community hospital.


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Peg Bradke, RN, MA

Peg M. Bradke, RN, MA, has held various administrative positions in her 25-year career in heart care services. Currently she is Vice President of Post-Acute Care at St. Luke's Hospital in Cedar Rapids, Iowa, where she oversees a long-term acute care hospital and two skilled nursing and intermediate care facilities, with responsibility for home care, hospice, palliative care, and home medical equipment. In her previous role as Director of Heart Care Services at St. Luke's, she managed two intensive care units, two step-down telemetry units, several cardiac-related labs, and heart failure and Coumadin clinics. Ms. Bradke also serves as faculty for the Institute for Healthcare Improvement on the Transforming Care at the Bedside (TCAB) initiative and the STAAR (STate Action on Avoidable Rehospitalizations) initiative.

Gail A. Nielson, BSHCA, RT(R), FAHRA Fellow and Faculty of the Institute for Healthcare Improvement (IHI).

Nielsen is the former system-wide Director of Learning and Innovation for UnityPoint Health (formerly Iowa Health System). Her current work as faculty for IHI includes reducing avoidable readmissions and improving transitions in care, leading 2-day Reducing Readmissions seminars, improving the quality of care in nursing facilities, and other assignments.

Nielsen’s ten years of experience in improving care transitions and reducing avoidable readmissions began during her 1-year IHI Fellowship. Her most recent experience includes system-wide work in Iowa; four years in the STAAR initiative across three states: Massachusetts, Michigan, and Washington; and support to Hospital Engagement Networks in multiple states.

Additional past areas of expertise and work with IHI includes six years on the Patient Safety faculty; four years on the faculty for Transforming Care at the Bedside; engagement and patient-centered care; reducing falls and related injuries; spread and scale-up of innovations; and ACOs-Post Acute Care.


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THA Readmissions Review

State of the State

• State of the Region

• Look at readmissions data from three perspectives:

– CMS readmissions penalty

– Statewide data from claims

– HEN data


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CMS Penalty Data – Year 4

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

1.40%

0 10 20 30 40 50 60

Penalty P

erc

ent

States

Average Penalty by State (FY2016)

Vermont - Lowest Average Penalty - 0.08%

Kentucky - Highest Average Penalty - 1.19%

Tennessee Average Penalty - 0.64%

National Avg: 0.61% Mississippi Average Penalty - 0.61%

Virginia Average Penalty – 1.01%

Arkansas Average Penalty – 0.83%

Year 4 - Comparison to National Average

Hawaii & Alaska are

below national average


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CMS Penalty Trend - Arkansas

37 41

1.02%

0.83%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

0

10

20

30

40

50

60

70

80

90

100

FY2015 FY2016

Change in Arkansas Penalty Statistics

# of hospitals penalized average penalty

CMS Penalty Trend - Mississippi

55 54

0.70% 0.61%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

0

10

20

30

40

50

60

70

80

90

100

FY2015 FY2016

Change in Mississippi Penalty Statistics



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CMS Penalty Trend - Virginia

66 68

0.97% 1.01%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

0

10

20

30

40

50

60

70

80

90

100

FY2015 FY2016

Change in Virginia Penalty Statistics


CMS Penalty Trend - Tennessee

86 78

0.75% 0.64%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

0

10

20

30

40

50

60

70

80

90

100

FY2015 FY2016

Tennessee Penalty Statistics



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Tennessee All-Payor Data

11.25%

11.09% 11.08%

10.40%

10.50%

10.60%

10.70%

10.80%

10.90%

11.00%

11.10%

11.20%

11.30%

11.40%

0

100000

200000

300000

400000

500000

600000

700000

800000

900000

1000000

2012 2013 2014

Admissions Readmissions Readmission Rate

Tennessee – First Six Months Trend

11.72 11.6

11.45 11.31

11.13

11.36

10.6

10.8

11

11.2

11.4

11.6

11.8

12

12.2

12.4

12.6

H1-2010 H1-2011 H1-2012 H1-2013 H1-2014 H1-2015


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Performance of HEN Hospitals

11.20%

10.82%

11.24%

11.04%

11.14%

10.61%

10.97%

10.62%

10.42%

10.20%

10.40%

10.60%

10.80%

11.00%

11.20%

11.40%

11.60%

2010H1 2010H2 2011H1 2011H2 2012H1 2012H2 2013H1 2013H2 2014H1

Tennessee Hospital Association HEN Readmissions Outcome Measure

Aggregate Rate per 100 Discharges (Jan 2010-June 2014)

This information is prepared and protected in accordance with the Tennessee Patient Safety and Quality Improvement Act of 2011. T.C.A. 68-11-

272.

This information is prepared and protected in accordance with the Tennessee Patient Safety and Quality Improvement Act of 2011. T.C.A. 68-11-

272.

The Impact of Patient Volume

• HEN 2.0 hospitals:

– Compared H1- 2010 to H1-2015

– Patient admissions were 1.42% lower

– All-payor readmissions were 1.95% lower

• HEN 2.0 Goal – 20% reduction in readmissions


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New Model! Kathy D. Duncan, IHI Director

“Flipped Classroom Model”

• Coaching on project selection and completion

• Examples for learning from participants and CMS topics

– Learners view didactic lectures and readings prior to session—videos, readings or Open School courses

– Faculty use “in-class time” for discussion and exercises

– Interactive, 60-minute live sessions will include report-back from learning, didactic discussion, assignments

– “Assignments” practical steps to take between sessions


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Learning Lab

• Discussion and

collaboration – Go

THA!

• Resources

• Articles

• Short videos

• You may customize

how much and how

deep you go!

Discussion – Your Turn

• What has been your greatest success?

• Chat in your thoughts


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• What has been your biggest barrier?

• Chat in your thoughts

Roadmap for Improving Transitions and

Reducing Avoidable Rehospitalizations


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The Major Challenges

• Potentially preventable rehospitalizations are prevalent,

costly, burdensome for patients and families and

frustrating for providers

• No one provider or patient can “just work harder” to

address unplanned rehospitalization

• Our delivery system is highly fragmented - providers

often act in isolation and patients are usually responsible

for their own care coordination

• Most payment systems reward maximizing units of care

delivered rather than quality care over time

Opportunities

• Many re-hospitalizations are avoidable

• Nationally we are making progress

• Keys to reducing re-admissions include:

– Not focusing on the hospital alone

– Aligning financial incentives

– Addressing systematic barriers

– Fostering leadership at the multiple levels


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What Can Be Done and How?

A growing number of approaches to reduce 30-day readmissions have been successful locally

Which are high leverage?

Which are scalable?

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?

Determinants of Preventable Readmissions • Preventable readmissions have hallmark characteristics of

healthcare events prime for intervention and reform

• Patients with generally worse health and greater frailty are

more likely to be readmitted

• Identification of determinants does not provide a single

intervention or clear direction for how to reduce their

occurrence

• There is a need to:

– Address the tremendous complexity of contributing variables

– Identify modifiable risk factors (patient characteristics and health care

system opportunities)

Determinants of preventable readmissions in United States: a systematic review.

Implementation Science 2010, 5:88


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The Good News: There Are Promising

Approaches to Reduce Rehospitalizations

• Improved transitions out of the hospital

– Project RED, BOOST

– IHI’s Transforming Care at the Bedside and STAAR Initiative

• Reliable, evidence-based care in all care settings

– PCMH, INTERACT, VNSNY Home Care Model

• Supplemental transitional care after discharge from the

hospital

– Care Transitions Intervention (Coleman)

– Transitional Care Intervention (Naylor)

• Alternative or intensive care management for high risk patients

– Proactive palliative care for patients with advanced illness

– Evercare Model (APNs)

– High Risk clinics

– PACE Program; programs for dual eligibles

– Intensive care management from primary care or health plan

Loehrer S, McCarthy D, Coleman, EA Population Health Management DOI: 10.1089/pop.2015.0005


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Effective collaboration among health

care providers requires:

• Trusted convener (individual or organization)

• Cultivation of trust (common goals)

• Shared understanding of the challenges faced by each

participant (site visits and shadowing)

• Starting small and building on early progress

• Expand type of participants as needs arise

• Data to identify opportunities for improvement

• Focusing on patients’ needs and experiences

Loehrer S, McCarthy D, Coleman, EA Population Health Management DOI: 10.1089/pop.2015.0005

Target Populations: Each Have Challenges

1. Medicare

2. Medicaid

3. Dual-eligibles

4. Commercial

5. Uninsured


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Medicare & Medicaid Top 10 Readmit Dx

AHRQ H-CUP STATISTICAL BRIEF 172

CMS Incentives for Reducing Readmissions

1) Risk Adjusted 30 day all cause

Readmission Rate

2) Readmission Penalty in the Quality

measures of VBP

3) Bundling payment across continuum of

care


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The Bad News:

There are No “Silver or Magic Bullets”!

….no straightforward solution perceived to

have extreme effectiveness

Conclusion: “No single intervention implemented

alone was regularly associated with reduced risk

for 30-day rehospitalization.”

Hansen, Lo, Young, RS, Keiki, h, Leung, A and William, MV,

Interventions to Reduce 30-Day Rehospitalizations: A

Systematic Review, Ann Int Medicine 2011; 155:520-528.

Hospital Readmission Program

• 2016 Readmission penalties are estimated at $420 million – average 0.61%

• 2592 Hospitals received lower Medicare payments for all Medicare patients

• Just slightly less than last year

• 6 million more that FY 2015 – 22% -- no penalties

– 63% -- 1% or below

– 11% -- 2% or below

– 4% -- 3% or below (38 hospitals got max. 3%)

• FY 2016 penalties were just announced, but 2017 penalties are already set


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Selected Index Admission Diagnoses

Medicare Focused Diagnoses –affects payment

adjusted for Age, Sex, Acuity and recent diagnosis

• Acute MI

• COPD

• Heart Failure

• Pneumonia

• Stroke

• Total Hip Replacement

• Total Knee Replacement

– Coming CAB will be factored in during 2017

Two New Codes TCM –Transitional Code Management

• Designed to promote greater support through both face-to-face and non face-to-face encounters

• New CPT codes (99495 and 99496) to pay physicians (and NPs & PAs) for post-hospital discharge (30 days) care coordination provided to FFS Medicare beneficiaries

Complex Codes for Ambulatory Care

• Compensates physicians for non-face-to-face time:

– regular development and revision of a plan of care

– communication with other treating health professionals

– medication management (total 20 minutes over 30 days)

• Medicare patients with 2+ significant chronic conditions

38


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Medicare Post-Acute Care

Transformation Act of 2014 (IMPACT)

• Signed into law October 6, 2014

• By 2022, payment rates will be tied to “individual

characteristics instead of settings where the patient is treated

• Intended to streamline PAC sector by standardizing

assessments - Continuity Assessment Record and Evaluation

Item Set (CARE)

• Affects skilled nursing facilities (SNF), home health agencies,

inpatient rehabilitation facilities (IRF), and long-term care

hospitals (LTCH).

• Financial penalties for failing to report quality measures

beginning 2019.

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Changing Paradigms

Traditional Focus Transformational Focus

Immediate clinical needs Whole person needs

Patients Patient & family members

LOS & timely discharge Post-acute care plan for

comprehensive needs

Handoffs Co-design of “handovers”

Clinician teaching Patient & family learning

Location teams Cross-continuum team

“We can’t solve problems by using the same kind of

thinking we used when we created them.” A. Einstein


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Did you meet Rebecca?

What can Rebecca Teach us?

Rebecca Bryson lives in Whatcom County, WA and she suffers

from diabetes, cardiomyopathy, congestive heart failure, and a

number of other significant complications; during the worst of her

health crises, she saw 14 doctors and took 42 medications. In

addition to the challenges of understanding her conditions and the

treatments they required, she was burdened by the job of

coordinating communication among all her providers, passing

information to each one after every admission, appointment, and

medication change.

http://www.ihi.org/offerings/Initiatives/STAAR/Page

s/Materials.aspx#videos

Rebecca’s Story


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Rebecca said if she were to dream up a tool that would be

truly helpful, it would be something that would help her

keep her care team all on the same page. Bryson described

typical medical records as being “location or process

centered, not patient-centered.” She also describes how

difficult it can be for patients to navigate a large health care

system. Rebecca summarizes her experience in this way –

“Patients are in the worst kind of maze, one filled with

hazards, barriers, and burdens.”

http://www.ihi.org/offerings/Initiatives/STAAR/Page

s/Materials.aspx#videos

Rebecca’s Story

IHI’s approach to reducing

avoidable readmissions


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IHI Four Key Changes

1. Perform an Enhanced Assessment of Post-

Hospital Needs

2. Provide Effective Teaching and Facilitate

Enhanced Learning

3. Ensure Post-Hospital Care Follow-up

4. Provide Real-Time Handover Communications

Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide:

Improving Transitions from the Hospital to Community Settings to Reduce

Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare

Improvement; June 2013. Available at www.IHI.org.

Patient and Family Engagement

Cross-Continuum Team Collaboration

Health Information Exchange and Shared Care Plans

Transition from Hospital

to Home or other Care

Setting

Transition to Community

Care Settings and Better

Models of Care

Supplemental Care for

High-Risk Patients

The Transitional Care

Model (TCM)

IHI’s Framework:

Improving Care

Transitions


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Hospital

Skilled Nursing Care Centers

Primary & Specialty Care

Home Health Care

Home (Patient & Family

Caregivers)

Improving Transitions Processes

Cross-continuum

Teams are Core to

the Work

Core

Processes

Co-Design of Handover Communications


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Lessons Learned

• Cross-continuum team partnerships transform

care processes together

• “Senders” and “receivers” partnerships agree upon

and design the needed local changes

– Vital few critical elements of patient information that

should be available at the time of discharge to

community providers

– Written handover communication for high risk patients is

insufficient; direct verbal communication allows for

inquiry and clarification

Cross Continuum Teams

A team of hospital and community-based clinicians

along with patients and family members:

• Provide oversight and guidance

• Help to connect improvement efforts across all care

settings

– Identify improvement opportunities

– Facilitate collaboration to test changes

– Facilitate learning across care settings

• Provide oversight for the initial pilot unit work and

establish a dissemination and scale-up strategy


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Cross Continuum Teams

CCTs: • Are one of the most transformational changes in IHI’s work to

improve care transitions

• Reinforce the idea that readmissions are not solely a hospital

problem

• Need engagement at two levels:

1) Executives remove barriers and develop overall strategies for

ensuring care coordination

2) Front-line leverages the power of “senders” and “receivers”

co-designing processes to improve transitions of care

Collaboration across care settings is a great foundation for integrated

care delivery models (e.g. bundled payment models, ACOs)

• Reducing readmissions is dependent on highly

functional cross-continuum teams and a focus on

the patient’s journey over time

• Providing intensive care management services for

targeted high risk patients is critical

Lessons Learned


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Diagnostic Case Reviews

• Provide opportunities for learning from reviewing a small sampling of patient experiences

• Engage the “hearts and minds” of clinicians and catalyze action toward problem-solving:

– Teams complete a formal review of the last five readmissions every 6 months (chart review and interviews)

– Members from the cross-continuum team hear first-hand about the transitional care problems “through the patients’ eyes”

Lessons Learned

• There are no universally agreed upon risk

assessment tools

– We need a much deeper understanding of how best

to meet the needs of high-risk patients

– Use practical methods to identify modifiable risks

• Written handover communication for high-risk

patients is insufficient


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Four Guides on Transitions

• Senders:

– From Hospital to SNF or Home

• Receivers:

– Office Practice

– Home Care

– Skilled Nursing Care Facilities

• How-to Methods

http://www.ihi.org/resources/Pages/Tools/HowtoGuideI

mprovingTransitionstoReduceAvoidableRehospitalizati

ons.aspx

Summary

• Rehospitalizations are frequent, costly, and actionable for improvement

• The IHI approach acts on multiple levels – engaging hospitals and community providers, communities, and state leaders in pursuit of a common aim to reduce avoidable rehospitalizations

• Working to reduce rehospitalizations focuses on improved communication and coordination over time and across settings – With patients and family caregivers; – Between clinical providers; – Between the medical and social services (e.g. aging services, etc.)

• Working to reduce rehospitalizations is one part of a comprehensive strategy to promote patient-centered care and appropriate utilization of health care resources


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Questions and Wrap up

Questions?

Chat in your thoughts


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• What do you hope to get out of this

web series?

Action Period Assignment

Develop an Aim: – What do you want to improve?

– How much?

– By When?

– (video on Model for Improvement) http://www.ihi.org/education/WebTraining/OnDemand/ImprovementModelIntro/Pages/default.aspx

Complete an Observation – Purpose: Learning to “see” the real processes before we attempt to

change therm.

– Process of Observation and Diagnostic worksheet will be sent to you via email this evening.

– Please send a note or some learnings to Kathy [email protected] and be prepared to discuss on our February call.

http://www.ihi.org/education/WebTraining/OnDemand/ImprovementModelIntro/Pages/default.aspx





mailto:[email protected]


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Resources

STAAR issue Brief

http://www.ihi.org/resources/Pages/Publications/STAARIssueBriefE

ffectofMedicareReadmissionsPenalties.aspx

15 promising interventions link below

– http://www.ihi.org/resources/Pages/Changes/EffectiveInterventio

nstoReduceRehospitalizationsCompendium15PromisingInterven

tions.aspx

Healthcare Executive blog post

– http://healthaffairs.org/blog/2013/09/06/measuring-

readmissions-for-improvement-accountability-and-patients/

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Next Webinar

Wednesday, February 3rd, 12:00p – 1:30pm Central Time

• Watch your email for: – Invitation to webinar series in new platform

– Materials for action period assignment

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http://www.ihi.org/resources/Pages/Publications/STAARIssueBriefEffectofMedicareReadmissionsPenalties.aspx

http://www.ihi.org/resources/Pages/Publications/STAARIssueBriefEffectofMedicareReadmissionsPenalties.aspx

http://www.ihi.org/resources/Pages/Changes/EffectiveInterventionstoReduceRehospitalizationsCompendium15PromisingInterventions.aspx



http://healthaffairs.org/blog/2013/09/06/measuring-readmissions-for-improvement-accountability-and-patients/














2016 IHI Webinar Series - Tennessee Center for Patient Safety · 2016-12-15 · 2016 IHI Webinar Series Rhonda Dickman, RN, MSN, CPHQ Rhonda Dickman is a Quality Improvement Specialist

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