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IHI ExpeditionImproving Care Transitions To Reduce Readmissions

Session 1: Building the Will, Ideas and Execution for Successful Transitions

February 4, 2016

These presenters have

nothing to disclose

Peg Bradke, RN, MA Jill Duncan, RN, MS, MPH

Today’s Host2

Colby Champagne, Project Assistant, Institute

for Healthcare Improvement (IHI), is a co-op

student from Northeastern University. She is a

health science major with a minor in business

administration and hopes to pursue a career in

healthcare management. She is working on the

Passport, Expeditions, and Leadership Alliance

teams.

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Today’s Agenda

• Welcome & Introductions

• Expedition Overview

• Building the Will, Ideas and Execution for

Successful Transitions

• Action Period Assignment

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Where are you joining from?

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Passport to IHI Training Your Entire Staff Benefits

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Contact: [email protected]

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What is an Expedition?

ex•pe•di•tion (noun)

1. an excursion, journey, or voyage made for some

specific purpose

2. the group of persons engaged in such an activity

3. promptness or speed in accomplishing something

Ground Rules12

We learn from one another – “All teach, all learn”

Why reinvent the wheel? – Steal shamelessly

This is a transparent learning environment

All ideas/feedback are welcome and encouraged!

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Expedition Director13

Jill Duncan, RN, Executive Director, IHI, provides

strategic development and programming leadership

for IHI's Quality, Cost, and Value Focus Area;

leadership of IHI's Joint Replacement Learning

Community; program coordination and faculty

leadership for IHI's Leading Quality Improvement:

Essentials for Managers program; and program

development and facilitation for many of IHI's

workforce development initiatives. Her previous IHI

responsibilities include daily operations and

strategic planning for the IHI Open School, and

development and leadership of Impacting Cost +

Quality. Ms. Duncan draws from her learning as a

Clinical Nurse Specialist, quality leader, pediatric

nurse educator, and front-line nurse.

Expedition Sessions

Session 1 Building the Will, Ideas and Execution for Successful Transitions

Session 2 Establish and Implement a Person Centered Transition Plan to meet the

Identified Post-Acute Care Needs

Session 3 Working with Community Partners for Successful Transitions

Session 4 From Prehospital to In-Hospital: The Continuum for Time-Sensitive Care

Session 5 Executing on an Ideal Outcome in the Transition: Right time, Right Place, Right

level of care at the Right Cost

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Faculty15

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.

Expedition Objectives16

At the conclusion of this Expedition, participants will be able to:

• Assess current challenges in reducing care coordination and identify opportunities for improvement in care transitions.

• Build an effective improvement team including patients and families as well as acute, post-acute and community care partners

• Identify successful approaches to engaging staff in all clinical settings to make an ideal individualized person centered transition of care plan.

• Engage participants in sharing strategies and innovative thinking to explore real life issues related to transitions.

• Develop processes with post-acute care providers and community partners to ensure the timely transfer of critical information during transitions.

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Chat

In 5-words or less, describe one of your

current priorities specific to Improving Care

Transitions To Reduce Readmissions

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Expedition Sessions

Session 1 Building the Will, Ideas and Execution for Successful Transitions

Session 2 Establish and Implement a Person Centered Transition Plan to meet the

Identified Post-Acute Care Needs

Session 3 Working with Community Partners for Successful Transitions

Session 4 From Prehospital to In-Hospital: The Continuum for Time-Sensitive Care

Session 5 Executing on an Ideal Outcome in the Transition: Right time, Right Place, Right

level of care at the Right Cost

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Building the Will, Ideas and Execution for Successful TransitionsSession 1

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Achieving Desired Results

“Results”

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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 the idea smooth transition

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

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.” Albert Einstein

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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

What Can Be Done and How?

A growing number of approaches to reduce 30-day readmissions and improving transitions 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?

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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

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

Other penalties coming

SNF – Oct. 2018: 2% payment withhold to fund incentive

pool to reward SNF based on preventable readmissions

– Lower readmissions rates can recoup the 2%+

Home Care – Value Based Purchasing in 9 states

related to measurable performance

– Metrics: Pt. function, ED visits, Hospitalizations during episode

of care, Pt. Satisfaction, Advanced Care Planning

– Payment adjustment begins at 3% increases to 8% in 2022

– MA, MD, NC, FL, WA, AZ, IA, NE, TN

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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.

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

– High Risk clinics

– PACE Program; programs for dual eligibles

– Intensive care management from primary care or health plan

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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

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

Alternative or Supplemental Care for High-Risk Patients

The Transitional Care Model (TCM)

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Target Populations: Each Have Challenges

1. Medicare

2. Medicaid

3. Dual-eligibles

4. Commercial

5. Uninsured

40% of Medicare Discharges Admit to PAC Hospital

≤ Continuing Care Hospital (2%)

≤ 17%

Inpatient Rehabilitation (30%)

≤ 12%

Skilled Nursing Facility (43%)

≤ 22%

Home Health (37%)

≤ 28%

Outpatient Therapies (9%)

≤ 20%

HIGH

LOW

Severity of Illness

PalliativeCare

Source: RTI/Cain Brothers Analysis, Integrating Acute and Post-Acute Care” 2012

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

Cross-Continuum Teams

Comprised of acute and post-acute care partnerships to

co-design care transitions processes

Emphasize that readmissions are not solely a hospital

problem and require a community solution

Have built the foundation for many care settings

participating in ACO development, Patient Centered

Medical homes and the Community-based Care

Transitions Program

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Poll Question

Do you have a Cross-Continuum Team (CCT)?

If so, please chat:

– The people

– The roles

– The organizations engaged in your CCT

Cross-Continuum Team Membership

Recommendations

• Executive Sponsor

• Day-to-Day Leader

• Patients and family caregivers

• Hospital clinicians and staff

• Supporting staff (QI, IT, Finance, etc.)

• Clinical and administrative staff and/or leaders from the community

– Skilled nursing facilities

– Office practice settings

– Home health care agencies

– Community or Public health services

– Outpatient Clinic Centers (Dialysis, Diabetes, Rehabilitation)

• Public and private payers

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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

Fostering Cross-Continuum Collaborations

Start your meetings with a patient story

Before all else, build trust

Convene meetings in various care settings

Do a “deep-dive” into a series of recently readmitted

patients to identify opportunities for improvement across

care settings

Use the power of observation- have members of various

care setting shadow critical processes such as

admission, discharge and patient education

Members from the CCT hear first-hand about the

transitional care problems “through the patients’ eyes

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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

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.

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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

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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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

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”

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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/HowtoGuideImprovingTransitionstoReduceAvoidableRehospitalizations.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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How Might We….

“….gain a deeper understanding of the

comprehensive post-hospital needs of

the patient through an ongoing

dialogue with the patient, family

caregivers, and community providers?”

Key Changes for Enhanced Assessment

Partner with patient and family to determine post-hospital needs:

• Involve the patient, their family, family caregiver(s) and community providers as full partners in completing a needs assessment of the patient’s home-going needs.

• Involve the full care team and be respectful of all that have interactions with the patient/family

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.

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Barriers to a Good Ongoing Assessment

Not addressing the whole patient (e.g., focusing on one condition, missing underlying depression or social needs, etc.)

Looking at only current admission missing the need to look at previous admissions in 30 - 90 days, 12 month

Delayed or absent goals of care discussion

Medication errors, polypharmacy, and incomplete medication reconciliation

Labeling the patient as ‘noncompliant’

Lack of probing around unrealistic patient and family caregivers optimism to manage at home

Partner with Patient and Family to

Determine Post Hospital Needs

‘Enhanced assessment’ goes beyond the nursing

admission assessment

Start on Admission

Establish a relationship – Sit down- be attentive-

LISTEN

Continue ongoing assessments throughout the

hospital stay to reveal new need-to-know details

Share what you learn with the care team

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Open Ended Questions

What are your concerns as you transition?

What matters most to you during these

transitions?

Who do you want involved in your

transitions?

Involve Patient and Family Caregivers

“Family caregivers” are those individuals who

are directly involved in the patient’s care at

home

“Visitors” are not necessarily the persons who

best understand the home environment

limitations/issues and the patient’s home-going

needs

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Assessments are Conversations

Ask open ended questions:

– What do you think may have caused you to come to the hospital?

– Did you call your health care provider( HCP) when you became

concerned?

– What prompted you to call or What kept you from calling?

– When was your last appointment with your HCP?

– Were you able to keep the appointment, if not, why not?

– How do you take your medications at home?

– Describe kind of foods you eat at home

– Do you think there is anything that could have prevented coming

to the hospital?

Assessments > Improving Discharge

Communicate. Communicate. Communicate what is learned in the conversation

Include useful information that might be beneficial but not found on a form, e.g.:– Useful medication lists

– Ability and motivation to provide self care

– Advance directives; Goals of Care conversation was started

– Patient likes to take pills with ice cream

– Patient very concerned about her dog, etc.

– Patient aware that he is getting forgetful and concerned for future

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Questions?

Comments?

Discussion?

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Next Steps

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What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make that

will result in improvement?

Model for Improvement

Act Plan

Study Do

Aim of Improvement

Measurement of

Improvement

Developing a Change

Testing a Change

Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W.,

Norman, C. L., & Provost, L. P. The Improvement Guide:

A Practical Approach to Enhancing Organizational

Performance. San Francisco, CA: Jossey-Bass, 1996.

Why Test?

Increase the belief that the change will result in

improvement

Predict how much improvement can be expected from

the change

Learn how to adapt the change to conditions in the local

environment

Evaluate costs and side-effects of the change

Minimize resistance upon implementation

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Repeated Use of the PDSA Cycle61

Hunches

Theories

Ideas

Changes that Result

in Improvement

A P

S D

A P

S D

Very Small

Scale Test

Follow-up

Tests

Wide-Scale Tests

of Change

Implementation of

Change

Sequential building of knowledge under a wide range

of conditions

Spread

Multiple PDSA Cycle Ramps

Transfusion

Administration

Safety

Communication

and Awareness

Strategies

Engaging with

Leadership

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Implementing

Transfusion

Guidelines

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Action Period Assignment

Action Period Assignment

• Between now and the next session, please

select one of the following activities:

• 1-2 chart reviews using the form, or

• 1-2 patient interviews using the tool, or

• 1 chart review along with a patient interview

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1-2 Volunteers to report back at the start of the next session?

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What did you learn?

Did you have any “a-ha” moments?

What surprised you?

Did you identify any opportunities for

improvement?

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Expedition Communications

• All sessions are recorded

• Materials are sent one day in advance

• Listserv address for session communications:

[email protected]

• To add colleagues, email us at [email protected]

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Session 273

Establish & Implement a Person-Centered

Transition Plan to Meet the Identified Post-

Acute Care Needs

Thursday, February 18th

1:00-2:00 PM ET

Thank You!74

Jill Duncan

[email protected]

Colby Champagne

[email protected]

Please let us know if you have any questions or

feedback following today’s Expedition webinar.