Strategies for Reducing Avoidable Readmissions Kim Werkmeister, BA, RN, CPHQ, CPPS Cynosure Health
Strategies for Reducing Avoidable Readmissions
Kim Werkmeister, BA, RN, CPHQ, CPPS
Cynosure Health
What Drives Improvement in Readmissions?
The Readmissions Puzzle
Improvement?
▪ Where did you start?
▪ Where are you now?
▪ What’s working?
▪ What’s not working?
▪ How far to you need to drive?
▪ Which road(s) should you take?
A Few Things We Know
▪ There is no one thing
▪ There is no one person
▪ Interventions are both easy and amazingly difficult at the same time
Many Resources Available to Guide Improvement
Drivers for Improvement in Readmissions
Reduce Readmissions
Use data to inform improvement activities
Improve standard hospital transitions of care
Deliver enhanced services based on need
Collaborate with providers and services across the continuum
Driver #1: Use Data to Inform Improvement Activities
Use data to inform improvement activities
Analyze data to inform your targeting approach
Understand root causes of readmissions; elicit the patient, caregiver and provider perspectives
Periodically update your approach based on findings; articulate your readmission reduction
strategies
Develop a performance measurement dashboard to use data to drive improvement
Big Data, Little Data
Big Data – What Coded Data Tells UsData Drill Down Tool
Readmission by rate
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Understand: Who, What, Where, When, Why
▪Who is being readmitted?
▪What medical conditions are contributing to the most readmissions?
▪Where are the majority of readmissions coming from?
▪How long after discharge are they returning?
▪Why are patients returning? Determine the root cause of the unfulfilled need.
Your Turn
▪Using data provided to you, identify the following:
▪ Top diagnosis codes for your readmission population
▪ Top discharge disposition for your readmission population
▪ Any other important information about your readmission population
What Did You Find Out?
Trends?
Were you able to determine WHY they came back?
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Little Data: Why Did They Return? Really?
Little Data – What Our Patients Tell Us (The REAL Story)
Readmission Discovery Tool
Driver of Utilization Tool
Patient Interviews
Your Turn
▪At your tables, choose two participants to be the “patients” –patients will each receive a brief description about their history to use when being interviewed
▪Choose two participants to be “interviewers” using the ASPIRE interview guide to conduct two mock patient interviews
▪Conduct one interview at a time so the table can listen and take notes
▪As a group, discuss your findings from the mock interviews and identify a few “root causes” for the readmissions
Pulling Big Data and Little Data Together
As a group, based on the sample data and patient interviews, how might this organization prioritize their readmissions reduction efforts?
▪ Is there a population that needs focus?
▪ Is there an underlying root cause that needs to be addressed?
Driver #2: Improve Hospital Care Transitions Processes
Improve hospital care transitions processes
Engage patients and their families to identify the learner, understand care preferences and assess risk for readmission
Facilitate interdisciplinary collaboration on readmission risks and mitigation strategies
Develop a customized care transitions plan that includes patient preferences, risk factors and post discharge contact info
Use teachback and other health literacy tactics to optimize patient/caregiver understanding
Timely post-discharge follow up with patient and/or caregiver
Engage Patients and Families
▪Who is the caregiver?
▪Do we have a standard method for gathering this info?
Assessing Risk for Readmission
Teachback
Stop, Slow Down and Show Me
▪ Ask the patient (or family member) how they learn best.
▪ Provide instruction in plain talk
▪ Assess activation
▪ Ability to manage meds
▪ Understanding red flags
▪ Medical Follow up Plan
▪ Personal Health Record
How Do We Provide Information To Our Patients?
▪ Handing someone a stack of papers and going over a set of instructions won’t guarantee a successful transition from the hospital to home.
▪ People need more.
▪ They need a human touch, emotional recognition, and a sense that they’re not going to be left on their own as they try to recover from the setback that brought them to the hospital.
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We Can Do Better
What was communicated: ▪ Here is a prescription for pain medication. Don’t drive if you take it. Call your surgeon if you
have a temperature or are worried about anything. Go see your doctor in two weeks. Do you want a flu shot? I can give you one before you leave. If you need a wheel chair to take you to the door, I’ll call for one. If not, you can go home. Take care of yourself. You are going to do great!
What wasn’t communicated: ▪ Here’s a number to call if you have any questions. Here’s the medical expert who’s in charge of
your follow-up care and how to reach him or her. Here’s the plan for your care over the next month, and here’s the plan for the next six months.
▪ Or this: You’re going to experience a lot of challenges when you get home. Here are the three or four concerns that should be your priorities. Here’s what your caregiver needs to know to help you most effectively. Here are resources in the community that might be of assistance.
Teach-back Resources
USE TEACH BACK www.teachbacktraining.org
• Training videos
• Conviction & confidence scales
• Tips on making standard work
How Do We Prepare Our Patients For Discharge?
DISCHARGE PAPERWORK/INSTRUCTIONS
DISCHARGE PHONE CALLS MAKE FOLLOW UP APPOINTMENTS
DISEASE SPECIFIC CLINICS
Driver #4: Collaborate with Providers and Agencies Across the Continuum
Collaborate with providers and agencies across the continuum
Identify clinical, behavioral, social and community based support organizations that share the care of your high risk
patients
Convene a cross continuum of providers and agencies that share the care of your high risk patients
Improve referral processes to make linking to social, behavioral and community-based services more effective
and efficient
Finding Agencies for Collaboration
▪Highest utilization for your population
▪Referral sources
▪Community agencies
Working With Partners
Hospitals, Pharmacies
Patients and Caregivers
Skilled Nursing Facilities, Long Term Care
Medical Home
Home Care Agencies, Palliative Care
Board and Care Organizations
Simple But Effective
▪ Get people in the same room
▪ Learn what everyone has to offer
▪ Learn what everyone's frustrations are
▪ Start with one issue and go from there
Hospital and Skilled Nursing 3 C’s Strategy
“3Cs”: COLLABORATION
SNF monthly meetings
SNF administrators and directors of nursing (DONs) invited
Development of mutual goals that are patient-centered
Dialogue opened and issues addressed
Case reviews of all 7-day readmissions - trends & action items identified
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ACH
“3Cs”: COMMUNICATION
Standardized Hospital to SNF Checklist
Standardized SNF to Hospital Checklist
Verbal handoff by nurse practitioner (NP) for high risk patients
Follow-up phone call by NP within 24-48 hours of discharge
Telepresence follow-up on high risk patients
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“3Cs”: COMPETENCY
Provided SNF RNs and LVNs education on specific topics (i.e. COPD, HF, Aspiration Pneumonia)
Needs assessment performed for future topics
Provided education at SNF meeting on special topics (i.e. Palliative Care and Conservatorship Process)
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Your Turn
▪Discuss with your table:
▪Who should we be partnering with in our organization?
▪What kind of collaboration is already occurring in our organization?
▪Where should we be meeting? (Is an opportunity already in existence that we can leverage?)
Driver #3: Deliver Enhanced Services Based on Needs
Deliver enhanced services based on
assessed needs of the patient
Palliative care
Condition specific programs
Pharmacy interventions
Complex care management
Emergency Department pause
Bright Spots in the Room
How are you approaching certain higher need populations in your organization?
How did you find out this population needed assistance/focus?
▪ Which patients will probably do well with “normal discharge”?
▪ Which patients need something more?
▪ Which patients need far more?
▪ How do you know?
▪ What do you do?
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Match needs with resources
Inventory Community Resources
https://www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/index.html
www.AuntBertha.com
Palliative Care▪ What are the challenges?
▪ Bright spots?
Emergency Department
Efforts
• Process to inform ED staff that this person had a prior admission
• Pause to interact in-person or on the phone with a care transitions team member
• Decision
• Admit
• Observation
• Home with follow up
What are you doing in your ED?
Highest Utilizer Strategies
▪ Identify highest utilizers▪ How many of your patients are admitted to the hospital 4 or greater
times in any calendar year?
▪ Learn what drives their utilization▪ More than chart audits
▪ Meet the needs of those patients▪ These changes will have far reaching effects for other patients
What are you doing for your highest utilizers?
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Highest Utilizer Strategies: Plan For Their Return
Little Data – What Our Patients Tell Us (The REAL Story)
Readmission Discovery Tool
Driver of Utilization Tool
Many Of These Patients Have, In Combination
• Acute clinical:• Sepsis, UTI
• Chronic clinical:• HF, COPD
• Behavioral health• Mood disorders• Substance use disorder
• Social issues
Methods of Identification
• Goal is real time identification when the patient arrives
• Flags
• Alerts
• Banners
• Lists
• Ideally automated
Some Drivers of Utilization
• Basic needs
• Unstable
• Isolation, anxiety
• Sent by someone else
• End-of-life
Do Something Different
Otherwise it’s groundhog day all over again
What Are The Drivers Of
Utilization?
Match the DOU(s) with the plan
If/Then
If DOU is
•Anxiety
• Isolation
Then
•Reassure
•Build trust
•Frequent contact
•High touch
If/Then
If DOU is
•Lack of advance care planning
•End-of-life
Then
•Determine goals of care
•Palliative care referral
If/Then
If DOU is
•Sent by someone else
Then
•Work with sender
If/Then
If DOU is• Need for food, shelter, etc.
Then• Address basic needs
• Locate community services outreach in ED
• Aunt Bertha
If/Then
If DOU is• Chronic instability
Then• Work to stabilize• Patient goal setting• ED care alert
Plan for Their Return
“If you fail to plan, you are planning to fail!”
Benjamin Franklin
Increase Stability Over Time
What does “Planning for their return” look like?
▪ “When they come back three days later it’s not, ‘Oh it’s you again,’ it’s, ‘How did that work out with that organization I put you in touch with? It didn’t work out? OK, let’s try something else.’”
▪ “You don’t take someone coming to the hospital 27 times in one month and expect them not to come to the hospital at all,” she said. “We take someone coming into the hospital 27 times in one month and try to fix a couple little things so maybe they’re only coming in 17 times next month.”
Expand time between episodes of care
Planning the plan?
What’s in it?
▪ You decide
▪ Balance brevity with depth of information
▪ Key elements to think about:
▪ Demographic information, care plan date or origin and most recent update, reason e.g. >4 hospitalizations in past 12 months, brief hx and DOUs, recent tests/results, clinical and support resources, key contacts, recommendations
Who completes it?
▪ You decide
▪ Establish accountability for creation, review and upkeep
Where is it?
▪ You decide
▪ Best practice alert, Note
What are we trying to
accomplish?
▪ Improve outcomes
▪ Decrease utilization
▪ by
▪ Identifying people with >4 hospitalizations in the past 12 months
▪ Finding out their drivers of utilization (DOU)
▪ Actively work to mitigate these DOU
▪ by
▪ Increasing connectivity between providers
▪ Tailoring clinical and non-clinical interventions
▪ Coordinating care
▪ Integrating disparate systems
▪ And addressing the social determinants of health
What does something different look like?
▪ Extensive outreach and engagement;
▪ Initial whole person assessment;
▪ Goal setting (What matters to you?)
▪ Care plan development;
▪ Health education/coaching;
▪ Frequent care team contact;
▪ Follow-up with patients after discharge;
▪ Direct linkages to housing, substance use disorder services, and other community resources
▪ Encouraging self-advocacy and personal accountability
http://www.chcs.org/media/HNHC_CHCS_LitReview_Final.pdf
What’s can we try?
▪ Patient engagement and activation▪ Are new skills and processes needed?▪ Building trust
▪ Cross continuum team/relationships▪ Who are we working with?▪ How do we link?▪ What do we need that isn’t currently available?
▪ Co-developed cross continuum plan▪ Do we have a template?▪ Who will complete/update it?▪ Where will it reside?
▪ People▪ Do we need non-traditional healthcare workers?
Your Turn
At your tables use the sample patient scenarios and the results of the patient interviews from this morning
Develop a personalized care plan for this patient that “plans for their return” but with a goal to increase the amount of time between visits
Patient engagement and activation
Attributes of Person-Centered Care
▪ Individualized, goal-oriented care plan based on person’s preferences.
▪ Ongoing review of person’s goals and care plan preferences.
▪ Care supported by interprofessional team in which person is integral team member.
▪ One primary or lead point of contact on health care team.
▪ Active coordination among all health care and supportive service providers.
▪ Continual information sharing and integrated communication.
▪ Education and training for providers and, when appropriate, for person receiving services and those important to that person.
▪ Performance measurement and quality improvement using feedback from person receiving services and caregivers.
https://interactives.commonwealthfund.org/2016/modelsgrid/table1.pdf
Motivational Interviewing –OARS
• Ask OPEN ended questions
• Offer AFFIRMING statements
• REFLECT patient’s ideas and feelings
• SUMMARIZE the patient’s perspective
https://motivationalinterviewing.org/
How Activated is Your
Patient?
• What’s the PAM?
• An evidence based tool
• 13 questions
• 4 levels of activation
• Improve activation = better outcomes
Patient Activation Measures
PAM Levels
How to Improve Activation
Patient Activation
Assessment
Maslow’s Hierarchy
Creating trusting relationships
• Engage with the patient in a sensitive, respectful, and strengths-based way
• Sit down
• Make eye contact
• Ask “What matters to you”?
• Ask “How do you think that could be accomplished?
• Request permission to offer suggestions
• Single point of contact
• Be there
• Follow up
It takes a village – Who is on your team?
Integrated Care Team
▪ IT/data
▪ Executive sponsor
▪ Clinical champion
▪ Project manager
▪ Dir. case management/social work
▪ Social worker/care transitions staff
▪ Emergency department champion
▪ Cross-continuum partners
▪Meets frequently to address the DOU
▪Think of them as a DOU pit crew
Informed Improvement Activities - What are you learning?
It takes a plan
Brief Action Planning
▪ The overall goal of BAP is to assist an individual to create an action plan for a self-management behavior that they feel confident that they can achieve.
▪ 3 Questions:▪ Q1:"Is there anything you would like to do for your health in the next
week or two?“
▪ Q2:"How confident or sure do you feel about carrying out your plan (on a scale of 0 to 10)?
▪ Q3: "Would you like to set a specific time to check in about your plan to see how things have been going?"
https://old.centrecmi.ca/wp-content/uploads/2013/08/Gutnick2014BAPevidenceJCOM.pdf
Do you have who you need?
Non-traditional healthcare
workers
▪ Provide cultural mediation;
▪ Deliver appropriate education;
▪ Ensure connections to needed services;
▪ Offering informal counseling and social support;
▪ Advocating;
▪ Providing direct services;
▪ Building capacity
Your Turn
▪Who in your organization should be on your team?
▪ Is there already something like this in place?
▪Discuss at tables
Bringing It Home
Bright Spots
Bright Spots
▪ Use of data to select target populations and priorities
▪ Interdisciplinary collaboration / Improved educational practices
▪ Condition specific programs / Complex care management
▪ Pharmacy involvement in care transitions
▪ Stronger collaborations with SNF & HH
Opportunities
Opportunities
▪ Learning from and engaging with patients
▪ Learning what matters most to patients
▪ Improved health literacy / validating understanding through effective teachback
▪ Use of an ED pause / mechanism to discuss complex patients prior to admit
▪ Discussion about/referrals to Palliative Care
▪ Collaboration with Behavioral Health, Social/Community Resources
What Are YOUR Bright Spots and Opportunities?
Readmissions Prevention Top 10
1. Enhanced patient assessment of discharge needs at time of admission
2. Assess risks for readmission and align interventions to needs
3. Accurate medication rec at admission, transfers, and discharge
4. Customized, literacy & culturally appropriate patient education
5. Identify primary caregiver & include in planning and education
6. Use teach back
7. Send discharge summary to PCP <48h of discharge
8. Build a cross-continuum team to collaborate across providers in region
9. Schedule appointments prior to d/c; work to find unassigned pts a PCP
10. Conduct post discharge phone calls <48h of discharge
Get Started
▪ Identify YOUR Readmission reduction goal
▪ Identify YOUR target population
▪Apply population-specific strategies
▪Choose one new idea to test
Readmissions Resources
▪ Readmissions Change Package
▪ ASPIRE Guide
▪ Trail Guide
▪ Readmissions Top Ten Checklist
▪ Readmissions Whiteboard Video Series
▪ HRET-HIIN Hospital Wide Topics LISTSERV
▪ Huddle for Care Discussion Forum
▪ Discovery Tool, Driver of Utilization Tool, Data Drill Down Tool, ASPIRE Interview Guide
Thank You!
Kim Werkmeister, BA, RN, CPHQ, CPPS
Cynosure Health