Partnership for Patients: Reducing Readmissions and Hospital Acquired Conditions

Dennis Wagner & Paul McGann, MDCo-Directors, Partnership for Patients

US Department of Health & Human Services and Centers for Medicare & Medicaid Services

AHRQ Annual ConferenceSeptember 10, 2012

Questions to Run On

• Why is the Partnership for Patients Different and How will it Make a Difference?

• How can you benefit from the Partnership? • What actions and contributions might you, your

organization, AHRQ’s network make?• What are your insights and advice about how CMS

and AHRQ can be most helpful in achieving these bold aims?

…we want your answers too

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Breakthrough Aims of the Partnership for Patients

40% Reduction in Preventable Hospital Acquired Conditions– 1.8 Million Fewer Injuries– 60,000 Lives Saved

20% Reduction in 30-Day Readmissions– 1.6 Million Patients Recover Without Readmission

Up to $35 Billion Dollars Saved

3 Partnership for Patients Engines to Generate Better Health & Better Care at Lower Cost

1. CMS Innovation Center Investments, up to $1 billion– Technical Assistance to Hospitals (Hospital

Engagement Networks)– Community Based Care Transitions Program

2. Programs and platforms of the Department of Health & Human Services – AHRQ, CDC, ACL, HRSA, CMS, ONC, OASH, IHS – VA and DoD

3. Programs and platforms of Partners: AMA, ABMS, AFL-CIO, AHA, NAPH, ANA, N4A, many more

If we always do what we’ve always done, we’ll always get what we’ve always got.

• Partnership for Patients is About All of Us Doing Things Differently

• We have unprecedented Federal action and coordination.

• We have an unprecedented CMMI Investment in taking proven practices to scale.

• We are calling for continued unprecedented action and alignment by CBOs, hospitals, clinicians, private partners and others.

26 Hospital Engagement Networks (HENs)Achieving Results through 3,700+ Hospitals

• American Hospital Association• Premier Healthcare Alliance• VHA• NC Hospital Assoc• Intermountain HealthCare • GA Hospital Assoc• TX Hospital Assoc• MN Hospital Assoc• Healthcare Assoc of NY State• IA Healthcare Collaborative• PA Hospital Assoc• WA Hospital Assoc• DFWHC Foundation

• OH Hospital Assoc• NJ Hospital Assoc• Ascension Health• TN Hospital Assoc• MI Health & Hospital Assoc• National Public Hospital & Health

Institute• LifePoint Hospitals, Inc• Joint Commission Resources• OCHSPS National Children’s Network• Dignity Healthcare• NV Hospital Assoc• Carolinas Health Care• UHC

Joint Commission Resources Reduces Heart Failure Readmissions: 3-Hospital System Pilot

Readmissions/total casesPrior to Intervention: 159/515Post Without Intervention :165/558Post With Intervention: 36/184

Baseline, Prior Year: Oct. 2009 – May 2010

NO interventionOct. 2010 – May 2011

Intervention Oct. 2010 – May 2011

Hosp A Hosp B Hosp C System

AHA/HRET HEN First Focus Results: Early Elective Delivery (EED)

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0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Baseline Jan-Feb 2012 Mar-Apr 2012 May-Jun 2012

AHA/HRET Early Elective Delivery Rate (TJC PC-1) (N = 77)

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Baseline Jan-Feb 2012 Mar-Apr 2012 May-Jun 2012

Florida Early Elective Delivery Rate (TJC PC-1) (N = 10)

0.00%5.00%

10.00%15.00%

20.00%25.00%30.00%

Baseline Jan-Feb 2012 Mar-Apr 2012 May-Jun 2012

Louisiana Early Elective Delivery Rate (TJC PC-1) (N = 8)

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Baseline Jan-Feb 2012 Mar-Apr 2012 May-Jun 2012

Oklahoma Early Elective Delivery Rate (TJC PC-1) (N = 20)

AHA/HRET EED Reduction Initiatives

• In May 2012, the AHA Board of Trustees approved the position of supporting policies to eliminate early-term non medically necessary deliveries.

• Physician engagement• Patient education• March of Dimes toolkit implementation• Implementation of hard stop policies. • Hospitals submitted Early Elective Delivery baseline

and monitoring data to the HRET Comprehensive Data System.

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AHA/HRET Reducing EED:State Activities

Oklahoma• Partnered with the Oklahoma State Department of Health-Maternal Services, University of

Oklahoma Health Sciences Center Office of Perinatal Quality Improvement, Oklahoma March of Dimes, and the Oklahoma Health Care Authority to implement an approach to institute scheduling process changes in birthing hospitals for scheduled cesareans and inductions, asking OB providers to distribute March of Dimes patient education materials and broadcasting a public service announcement on the risks of scheduling a baby’s birth before 39 weeks gestation.

Florida • Worked with the Florida Perinatal Quality Collaborative (FPQC) and the Lawton and Rhea Chiles

Center for Healthy Mothers and Babies at the University of South Florida. Hosted an EED kick-off webinar in July that provided the MoD toolkit, tips for engaging a hospital team, and resources available from the FPQC and FHA. FHA is promoting data submission to the HRET CDS, one-on-one coaching with OB hospitals, and development of OB/EED grand rounds.

Louisiana • LHA partnered with the Louisiana Department of Health and Hospitals (LDHH) in a comprehensive

birth outcomes initiative. Every birthing hospital, in 2011, pledged to adopt a comprehensive 39-week gestation delivery prohibition policy by the end of 2012. Partnered with the IHI Perinatal Collaborative efforts in which 22 hospital are enrolled and actively participating in the second phase of the collaborative.

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The Community-Based Care Transitions Program (CCTP, ACA Section 3026)

GOALS:• Improve transitions of beneficiaries from the inpatient

hospital setting to home or other care settings

• Improve quality of care

• Reduce readmissions for high risk beneficiaries

• Document measureable savings to the Medicare program

For more information, visit: http://innovations.cms.gov/initiatives/Partnership-for-Patients/CCTP

2010 Readmission Rates by Payer

PAYERPAYER-

SPECIFIC RATE

TOTAL INDEX ADMISSIONS (2009

FOR MEDICAID; 2010 FOR ALL OTHERS)

TOTAL READMISSIONS

NUMBER OF READMISSIONS TO PREVENT TO

REACH 20% REDUCTION,

BASED ON 32.85 MILLION

ADMISSIONSMEDICARE 18.7% 14,672,303 2,742,187 548,437MEDICAID 14.0% 6,004,407 838,412 167,682PRIVATE INSURERS

8.6% 8,527,941 731,101 146,220

UNINSURED POPULATION

10.3% 1,650,410 170,518 34,104

ALL OTHER 12.7% 1,996,018 253,315 50,663

TOTAL 14.4% 32,851,079 4,735,532 947,106

The Community-Based Care Transitions Program (CCTP, ACA Section 3026)

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Now 47 Sites: CBOs with 200+ hospitals serving 185,500 beneficiaries in 21 states

Quality Improvement Organizations (QIOs) Work and Results on Partnership for Patients

• 202 Communities Recruited• 179 Community Coalition Charters Signed• 89 Communities Submitting Applications to Care

Transitions Funded Programs• 32 Communities Accepted into Funded Care Transitions

Programs• Recruited communities across the country include 661

Hospitals, 1584 Skilled Nursing Homes, 532 Home Health Agencies, 118 Dialysis Facilities, and 273 Hospices

PfP Readmissions Aim: A Network of Networks for Nationwide Results

QIO-Recruited Communities, CCTP Sites, & ADRC Option D Grantees (as of July 31, 2012)

CCTP Sites, QIO-Recruited Communities, ADRC GranteesZIP Code Level Readmissions per 1000 Medicare Beneficiaries

(January 1, 2011 – December 31, 2011)

30-day Readmissions per

1000 beneficiaries

CCTP and QIO Care Transitions: The Approach

• Convene community partners to improve transitions across the continuum of care, including social and HCBS providers, hospitals, pharmacy, nursing homes, home health, primary care, other post-acute care providers

• Identify major drivers of readmissions and ideal target population through community-specific Root Cause Analysis

• Select interventions best suited to address those drivers and implement for target population identified as at high risk of readmission (in CCTP, with monthly payment for services)

• Use PDSA, rapid-cycle measurement for improvement (e.g., run charts), learning collaboratives and change packages to share successful practices, other continuous improvement tools to adjust target population and/or intervention strategy and improve along the way

• Partner with multiple payers if possible, to serve more patients and reduce more readmissions

Community-Based Care Transitions - Your QIO Can Help!

• Community Coalition Formation

• Community-specific Root Cause Analysis

• Intervention Selection and Implementation

• Assist with an Application for a Formal Care Transitions Program

Access a comprehensive Toolkit, Learning Sessions, and locate your QIO care transitions contact at: http://cfmc.org/integratingcare under “Contact Us”

Readmissions ReductionKeys to Success

• Build on and spread success within and across networks, including CCTP, QIO, HEN, private efforts, and so on

• Hospitals team with the larger community• Work closely with QIOs and align with state/local efforts• Target patient-level interventions to highest risk patients• Conduct a thorough Root Cause Analysis (RCA) to determine

major readmissions drivers, not just top diagnoses• Make greater patient engagement and enhanced role of family

caregivers a core focus• Choose your interventions based RCA findings• Target High-Risk but Measure All-Cause Readmissions

Federal Partners and Programs Are Aligned & Generating Results on Partnership for

Patients

AHRQ Alignment and Action on Partnership Aims

• Led team that established the “Science Base” for PFP and developed national goals for reducing HACs and readmissions.

• Worked with other agencies to establish methods and national baselines for the measured 2010 rates for HACs and readmissions that will be tracked through 2013.

• Currently providing healthcare organizations with opportunities to implement proven tools and programs (e.g., CUSP for CLABSI, TeamSTEPPS® in partnership with DoD) and to join new projects (e.g., CUSP for CAUTI, for Safe Surgery and for Perinatal Safety).

• A source for no-cost, stand-alone toolkits and guides, Webinars on available resources and implementation research findings, and related patient safety and quality improvement expertise.

AHRQ “CUSP for CLABSI” Project: Central Line-Associated Bloodstream Infections Reduced in Adult ICUs

Baseline Year

Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q80

0.5

1

1.5

2CLABSI Rate*

40% Reduction

(1.91 CLABSIs per 1,000 line-days to 1.13)

* CLABSI rate calculated as sum of infections divided by sum of line-days for all reporting ICUs

Notes:1. Data are for six cohorts that started collecting baseline data from May 2008 to April 2009. Q1 varies from May-Jul

2009 to Apr-Jun 2010. Q1 to Q4 covers all six cohorts; Q5 to Q8 covers three to five cohorts. 2. Data are from 44 States, DC and PR; with a total of 1142 participating ICUs. 3. We estimate that 27 percent of hospitals with an adult ICU in the nation are participating in CUSP for CLABSI. See:

www.onthecuspstophai.org. 4. The project is led by HRET, Johns Hopkins’ Armstrong Institute, and Michigan’s Keystone Center.

AHRQ-CMS Collaboration on PfP National Results Scorecard

Aim Baseline 2013 Target

40% Reduction in Preventable HACs

145 HACs per 1,000 discharges (2010 est.)

119 HACs per 1,000 discharges

20% Reduction in 30-day Readmissions

14.4 %, based on 32.9 million admissions (2010 est.)

11.5%, based on 32.9 million admissions (or approx. 947,106 readmissions averted, 548,437 of which are Medicare)

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PFP-Measured HACs (2010)

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PFP-Measured HACs (2010)

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Adverse Drug Events Measured in the PFP HACs

The 1.621M and 34 percent of HACs measured in the PFP 2010 totals are as follows:– ADE Associated with Digoxin (12,000)– ADE Associated with Insulin and Hypoglycemic Agents (930,000)– ADE Associated with IV Heparin (170,000)– ADE Associated with LMW Heparin and Factor Xa Inhibitor (340,000)– ADE Associated with Warfarin (170,000)

These ADE HACs are 57 percent hypoglycemic agents, 42 percent anticoagulants, and 1 percent Digoxin. – The most important missing ADE-type is probably opiate-related ADEs.

Not counted in the ADE category, but related to ADEs and counted in the “all-other” HACs category:– Contrast Nephropathy Associated with Catheter Angiography (230,000)

– C. difficile Infection after Inpatient Antibiotics (87,000)

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Counting the “40% of Preventable (44% of) HACs” Nationwide Goals for 2013

Health Resources and Services Administration (HRSA)

• HRSA’s Patient Safety & Clinical Pharmacy Collaborative (PSPC) and CMS’s QIOs partnered to have teams in all 50 states working on preventing medication errors and facilitating care transitions

• Outreach to small rural hospitals for their participation in PfP, with over 900 CAHs now engaged by the HENs.

• Providing leadership to the Rural Affinity group with 20 of the HENs participating.

• Convened representatives of rural hospitals and PfP HENs in a special 2-day working event for the HEN Rural Affinity Group.

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ADRCs are implementing a variety of evidence based models:• Care Transitions Intervention®• Transitional Care Model• Project BOOST• Bridge• GRACE• Guided Care®

Current Status: • 93 ADRCs are partnering with 242 hospitals in 27 states

• 30 ADRCs are partnering with QIO’s

• 74 ADRCs supported the transition of 10,314 consumers

Source: ACL Semi Annual Report Data October 2010- March 2012

ADRC Evidence Based Care Transition Program

• Partnership between Delaware County ADRC and Crozer Keystone Health System

• Mary Naylor Transitional Care Model– Partnership designed a team based approach: Hospital provides Nurse

Assessor, ADRC provides Options Counselor– Original 2 year goal was to serve 235 participants

• Served 355 participants within 13 months

• ADRC Care Transition Program Readmission Rate = 7%* – 47% reduction from baseline

• ACL investment of $400,000 yielded $3 Million in Savings*

• State provided special funding to purchase supplies, equipment, and services for participants not covered by existing programs– Examples: Talking scale for a consumer with a visual impairment and CHF

to monitor weight; Air Conditioner; Stair Rides

• ADRC CT data was cited in successful CCTP application

Success Story: Pennsylvania

*Data provided by Crozer Keystone Health System

ACL Work on ACA Care Transitions

• AoA (now ACL) National and Regional Leadership Engagement• Technical assistance to Aging Network on evidence-based care

transitions interventions. – 12 webinars on practical implications for the Aging Network; 10,000+ Attended /

100,000+ Downloaded– Care Transitions Online Toolkit

• CMS Community Based Care Transition Program (Section 3026/CCTP)– 47 CCTP sites

• 86% lead CBO is in the Aging Network• 92% have at least one Aging Network Partner

Care Transitions Resource Development

• Resource Development– Care Transitions Toolkit (41,000+ downloads from the AoA website) http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/Toolkit/index.aspx

– ACL 2010 Evidence Based Care Transitions Program Webpage

http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/index.aspx

– ACL Affordable Care Act: Opportunities for the Aging Network Webpage http://www.aoa.gov/Aging_Statistics/Health_care_reform.aspx

– ADRC Care Transition Technical Assistance Exchange Webpagehttp://www.adrc-tae.org/tiki-index.php?page=CareTransitions

• National Quality Strategy• Assistant Secretary for Health – Office of Healthcare Quality

– HAI Action Plan, State-Based Partner Meeting, Data Summit, Partnering to Heal Computer-based Simulation, Do the WAVE Consumer Campaign

• Centers for Medicare and Medicaid Services– Medicare and Medicaid EHR Incentive Programs (with ONC)– ACA Sec. 3008 - Payment Adjustment for Hospital Acquired Conditions – ACA Sec. 3025 - Hospital Readmissions Reduction Program– QIO work to reduce readmissions, ADEs, HAIs– Medicare Hospital Inpatient Value-Based Purchasing Program– CMS Innovation Center Models, including ACOs and Bundled Payment

Other Examples of Federal Alignment on Partnership Aims

• Centers for Disease Control and Prevention– NHSN Measurement System, State HAI Coordinators, Healthcare

Infection Control Practices Advisory Committee

• Department of Defense– TeamSTEPPS, Patient Safety Research Center

• Office of the National Coordinator for HIT– Beacon Communities, Improving Care Transitions Through HIT Meaningful

Use, Innovator Challenges

Other Examples of Federal Alignment on Partnership Aims

Partners Are Contributing to PfPin Major Ways

• “Buying Value” initiative to align purchasing with PfP Aims by large employers, unions, NBGH and many others.

• Johnson & Johnson incentives to employees discharged from hospitals who call for guidance on health care follow up.

• Joint Commission is educating surveyors through a video and at the annual training course on the goals of the PfP

• NAPH push to get public hospitals teaming with CBOs on Care Transitions to reduce 30 day readmissions.

• AHA has launched a Readmissions Race across 1600 hospitals within 31 states to achieve significant reductions in 30 day readmissions by 12/31/2012.

• Be a part of the largest public or private sector investment in patient safety & readmissions reduction

• Access to real-time data and cutting-edge discoveries from hospitals and communities participating in the work of improvement

• Opportunity to see your research used in real-time to influence community –based care and/or drive patient and family engagement

• Become an important coordinator of care beyond hospital walls by establishing new cross-setting collaborations

• Ease the burden of HACs and re-hospitalization on patients and the community

• Build “communities of scale” by tapping into efforts already going on right in your backyard

• Other ways?

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How Can You Benefit?

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Take 1 Minute

Talk to Your Neighbor

What are your answers?

How Can You Benefit?

• Make sure your hospital or other care setting is a part of thisimportant initiative

•Connect with leaders in your hospital to be part of improvement work

•Make HACs and readmissions your area of focus

•Connect with the Partnership’s Network of Networks, starting withefforts already going on in your own backyard

•Show us what works. We want to spread your proven practices!

• What HIT tools better enable good patient safety and care transitions?

• What gaps are there, and how can you help to fill them?

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How Can You Contribute?

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Make a note….30 Seconds

What is your answer to this question?

How Can You Contribute?

How Can CMS and AHRQ Help?

• Work aggressively to bring proven practices to scale• Help to facilitate the connections among Partnership networks

and results-getters• We want to broadcast your successes and results!

– Have you submitted your QualityNet abstract?– Are you our next webinar keynote?

• What more can CMS and AHRQ do to team with you and your networks and link you to other partners in the Partnership for Patients?

• Other ways?

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Sharing Insight, Possibility and ActionAHRQ Annual Meeting

My biggest insight about how my organization can benefit from the Partnership for Patients initiative is: _____________________________________________________________________________________________________.

The possibilities I see for our organization to act on or contribute to the Partnership for Patients are:1.2.3.

My main advice to CMS and AHRQ about how they can be most helpful in achieving the bold aims of the Partnership:______________________________________________________________________________________________.

Name, Organization, Email:_______________________________________