NoCVA Preventing Avoidable Readmissions Collaborative · PDF fileNoCVA Preventing Avoidable...

NoCVA Preventing Avoidable

Readmissions Collaborative

Pre-work: Measurement May 19, 2014

Agenda

• Collaborative context

• What and why? – Measures & details

• How? – Data entry

• Resources? – Introduce data manual & feedback reports

• How do you make your data work for you? – Sample data monitoring plan

• Next steps

Mission

To improve transitions in care and reduce

avoidable hospital readmissions.

Methods

• Pilot Unit / Spread to other units

• Multidisciplinary tiered project team

• Assessment of 5 recent readmissions

• Observations

• Process maps

• Risk assessment

• Follow up appointments and follow up calls or visits

Methods

• Test improvement in 4 key areas:

– Enhanced assessment of patient post-hospital needs

– Effective teaching and enhanced patient learning

– Ensuring post-hospital care follow-up

– Providing real-time handover communications

• Implement and spread improvements

• Community engagement readiness assessment

• Community cross continuum team

How to reduce readmit rates?

Identify high risk patients before

discharge


discharge

Initiate enhanced f/u plan for high risk

patients:

F/u visit with provider within 7 days & phone call/visit within 3 days


patients:


Fewer readmissions

Fewer readmissions

Improve Internal Processes Deepen Community Relationships

What process measures to use?

• % of patients given assessment for high

risk of readmission – Goal: 95%

• % of high-risk patients whose f/u visit is

scheduled within 7 days – Goal: 95%

• % of high risk patients who have a follow-

up phone call within 3 days – Goal: 95%

• % of high-risk patients who cannot be

reached – Goal: <5%

Readmit Rate (hospital-wide)

• Source: claims; hospital does not submit

• Brief definition: All payer, all-cause readmission rate—every patient, every reason, every time

• Not the same as the Medicare readmit rates

• Not risk-adjusted

• Observation patients not included

• Data available roughly 6 months after close of quarter

Unit/Population Readmit Rate

• Each hospital should calculate a readmit rate for the unit/population it is working with

– Work with your hospital resources—are there available reports which (roughly) track this population?

• Each hospital will define its readmit measure slightly differently

– Data will be used to track progress relative to your baseline, but not to compare hospitals

Considerations for unit/population

readmit rates

• Include readmits back to any part of the hospital, not just back to your unit, if possible.

• Ideally, include readmits back to other hospitals (e.g., in your system).

• Talk to your hospital about how to handle same day ‘readmits’.

• Ideally, NoCVA suggests including observation patients.

Timeframes?

• It is likely most hospitals will not have

good historical data on their

unit/population.

• If you have historical data, you have option

of entering back to 2010Q4.

– Allows better trending

Readmit rates for unit/population (cont.)

• Big picture:

– Use available hospital resources

– It’s okay if your internal readmit report doesn’t perfectly capture your specific unit/population

– Don’t get bogged down in readmit details—key question is whether your hospital can build/track a measure which will show movement in response to the work you do with this population/unit. You want feedback for your PI work!

Process Measures


discharge


discharge


patients:



patients:


Fewer readmissions

Fewer readmissions

Improve Internal Processes Deepen Community Relationships

% of patients given assessment for

high risk of readmission

• Numerator: # of patients discharged from

pilot unit or population who have been

given assessment for high risk

• Denominator: All patients discharged from

pilot unit/population

Goal: 95% of patients will be assessed

Measure details

• Sampling is permitted, but discouraged

– If sampling: Report on 25 pts per month or

10% of patients on unit/population, whichever

is greater

• Include observation patients, if they are

seen on your unit or part of your

population

% of high risk patients whose f/u visit is

scheduled within 7 days

• Numerator: Patients in pilot unit/population

who are at high risk and are scheduled for

a f/u physician visit within 7 days of

discharge

• Denominator: Number of patients who are

at high risk in pilot unit/population

Measure details

• 7 days = 7 calendar days

• Patients who die in hospital may be

excluded from this measure

• Hospice, transfer, and AMA patients

should be included if they are assessed at

high risk

Measure details

• What if next site of care is responsible for making f/u appointment?

• Hospital can count patient as having f/u visit scheduled if:

– Hospital tells the next site of care that pt is high risk for readmitting

– Hospital tells next site of care that patient needs f/u within 7 days

– Hospital reasonably believes next site of care will act on this recommendation

Follow-Up Phone Call within 3 days

• Numerator: # of high risk patients who

receive a follow-up phone call (or home

visit) within 3 days of discharge

• Denominator: Number of high risk patients

on pilot unit/population

Measure details

• Patients who die while in hospital can be excluded

• 3 days = 3 business days

• If patient is discharged to next site of care, they can be counted as receiving a phone call—provided next site of care is informed the patient is at high risk of readmission

• In some cases, a party other than the hospital may be responsible for making these calls. In this case, the hospital can count the call as having been made—provided the hospital has done some due diligence to verify that the third party is actually conducting these calls.

Measure details

• Ideally, use best practices for phone calls,

e.g. ask patient when is best time to call.

Patients Who Cannot Be Reached

• Numerator: # of high risk patients who

were called two or more times, but could

not be reached for f/u phone call or home

visit within 3 days of discharge

• Denominator: Number of high-risk patients

on the unit/population

Measure details

• Patients who die in hospital can be

excluded from this measure

• This measure is designed to help your

hospital evaluate success of your efforts to

reach patients by phone

– Are there challenges to get phone calls made

reliably?

– Are staff making the calls, but just not

reaching patients?

Collaborative Measures

Questions? Comments?

• Some of these measures are new—there are things we haven’t thought of.

– Your feedback makes these better and more meaningful!

• It is good to have questions—but we want them before the June 18th in-person meeting.

– Your first data is due July 20th, so you will be data-collecting during June.

• Questions can go to coaches, Dean, Laura or myself: Erica Preston-Roedder [email protected]

mailto:[email protected]

Data Submission Timeline

• Process measures

– First submission July 20th (June data)

– Subsequent submissions monthly

• Readmit rate by unit/population

– First submission on August 20 (April, May, and June data)

– Okay to submit historical data back to 2010, if desired

– Subsequent submissions monthly if possible, quarterly if necessary

Note: readmit rates & 30 day look-forward

• For process measures, June data is due July 20th.

• But for readmit rate, June data is due August 20th.

• Why?

– Readmit requires 30-day look-forward, i.e. June discharges may readmit in July. You will not have full readmit data until July 31, so NoCVA does not ask for submission until Aug 20.

Data Entry

• Data entry is via the “Quality Data System”

(QDS), a secure, web-based portal:

QDS: data.ncqualitycenter.org

– Data is numerator/denominator only

Choose: “Readmissions Collab 2014”

What resources does NoCVA provide?

• Data manual will be on website next week

& emailed to teams

34

Data Manual (cont.)

What resources does NoCVA provide?

• Data manual

• Word of mouth

– Use your coach/NoCVA: ask us questions!

– Use each other—if you build a report in EPIC to get some of this data, send a note to the list-serve letting others know they can contact you to share ideas.

• Monthly feedback reports, starting July 30th.

Example of run chart on monthly

feedback report

How do you make your data work for you?

You have two jobs…

• How can I collect &

report meaningful data

to NoCVA?

• What is my team

actually going to do

make this data

meaningful to our PI

efforts?

Making use of your data

• Collection: Who will collect it & how?

• Make use of data:

– Where/how report? To the staff, to senior leaders, etc.?

– Who is responsible for investigating any process or outcome measure gaps, e.g. who will find out WHY telephone calls aren’t being made? (Or, who is responsible for reviewing reports and identifying gaps for PI?)

– What are our internal team targets? Which measures are we focused on first?

Summary

• Process/Outcome measures look at whether

care is transformed for high risk patients.

– 2 outcome measures; 4 process measures

• Make your to-do list

– Can you get unit/population readmit rates?

– What questions do you have on process measure

definition?

– Who will collect process measures?

– How will our team use the data?

Prework

Complete leadership assessment and review on leadership 1:1 call

By May 19

Recruit and convene multidisciplinary, tiered, cross continuum project team

By May 5

Develop or review risk assessment; plan piloting or spread of risk assessment

By May 5

Review prework webinars on NCQC website

By June 18

Complete IHI Diagnostic Assessment of 5 recent readmissions

By June 18

Develop process map of patient discharge By June 18

Develop plan to collect, submit and use your data

By June 18

In-person Learning Session June 18

Timeline

Complete leadership assessment and review on leadership 1:1 call

By May 19

Recruit and convene multidisciplinary, tiered, cross continuum project team

By May 5

Develop or review risk assessment; plan piloting or spread of risk assessment

By May 5

Complete IHI Diagnostic Assessment of 5 recent readmissions

By June 18

Develop process map of patient discharge By June 18

Develop plan to collect, submit and use your data

By June 18

In-person Learning Session June 18

https://www.ncha.org/meetings/registration_index.lasso?e=1323

Type to enter text

PREVENTING AVOIDABLE READMISSIONS COLLABORATIVE

LEARNING SESSION June 18, 2014

DoubleTree Raleigh-Durham Airport at Research Triangle Park

Learning Session Overview

This day of learning and sharing will bring together teams wrapping up cohort 2 as well as those just starting out in

cohort 3. The content outlined below, led by faculty from the NC Quality Center and The Carolinas Center for

Medical Excellence, will make for an exciting, interactive day. The event will focus on sharing of accomplishments

and learnings, teaching of key strategies and interventions, and facilitation of team action planning. It is essential

for all teams, continuing and new, to participate in order to lay a solid foundation for success moving forward.

Learning Objectives

• Explain the overall strategy for the 2014-2015 collaborative

• Describe the process for testing and implementing key changes to

reduce readmissions

• Create a detailed action plan to guide the work of the impr ovement team

Registration Information

Register at: https://www.ncha.org/meetings/registration_index.lasso?e=1323(Don’t know your hospital login info? Choose Register as a "Non Member" to get to the appr opriate registration page)

No registration cost. (Due to restrictions on federal funds covering this event, lunch will not be provided by the

event sponsors)

Registration Deadline: June 11, 2014

WHO SHOULD ATTEND

All members of your project team including:

• Team Leads

• Unit Leaders

• Executive Sponsor

• Physician Champions

• Nursing Champions

• Pharmacy Champions

• Patient Safety or Quality Rep

• Clinical Educator

• Community Partners

• Patient Advisors

• Other key team members

Content 9:00am-4:30pm (8:30am 9:00am check-in. Lunch not pr ovided)

• Keynote: Michael E. Frisina, PhD, MA, Founder and Pr esident, The Frisina

Group- Dr Frisina will focus on the combination of technical and behavioral

based strategies needed to reduce readmissions and will teach behavior

based tools proven to be effective.

• Networking session on best practices and innovative appr oaches

• Working session with teams and coaches covering: r eview of pre work data,

developing project aims, project management support, and team action

planning using data and key collaborative interventions.

Meeting Location

DoubleTree by Hilton Raleigh-Durham AirportResearch Triangle Park

4810 Page Creek Lane

Durham, NC 27703

Directions

For more information, contact James Hayes, Pr oject Coordinator, at [email protected] or 919-677-4140

or Laura Maynard, Director, Collaborative Learning, at [email protected] or 919-677-4121

Continuing Education Credits

.5 CEU’s from Wake Forest School of Medicine5.5 Contact Hours from Northwest AHECNurses: This educational activity (5.5 contact hours) can be applied toward your continuing competence plan for maintaining your current licensure with the North Carolina Board of Nursing.

Northwest Area Health Education Center (AHEC) of Wake Forest School of Medicine and a part of the North Carolina AHEC Program

!

Contact

For more information, contact:

Laura Maynard, Director of Collaborative Learning, [email protected] 919-677-4121

Erica Preston-Roedder, Director of Quality Measurement, [email protected] 919-677-4125

Dean Higgins, Project Manager, [email protected]




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