Preventable Hospital Readmissions and the Bottom … Hospital Readmissions and the Bottom Line Using...
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Preventable Hospital Readmissions and the Bottom Line Using Technology to Address the Growing Financial Risk
Transcript of Preventable Hospital Readmissions and the Bottom … Hospital Readmissions and the Bottom Line Using...
Preventable Hospital Readmissions
and the Bottom LineUsing Technology to Address the Growing Financial Risk
Mary Kay Thalken
• 25+ years in healthcare leadership
• Clinical expertise with prior roles as CNO and COO in Nebraska & Iowa healthcare systems
• Passionate about improving care transition processes that impact patient outcomes and organizational financial performance
Mary Kay Thalken, RN, MBAChief Clinical Officer - Ensocare
Today’s Agenda
The Reality of Reform
What are Preventable
Readmissions?
Care Coordination and the
Discharge Challenge
The Technology Solution
Case Studies and ROI
Questions and discussion
Hospital Readmissions Reduction Program
• The Readmissions Reduction Program (HRRP)
– Section 3025 of the Affordable Care Act
– Requires CMS to reduce payments to IPPS hospitals with
excess preventable readmissions
• 1% penalty year 1
• 2% penalty year 2
• 3% penalty year 3
The Reality of Reform
2%• 2,592 hospitals penalized
• $420 million dollars lostto readmission penalties
2015
What is a Preventable Readmission?
A readmission is considered to be clinically related to a prior admission and potentially preventable if there was a reasonable
expectation that it could have been prevented by one or more of the following:
1. The provision of quality care in the initial hospitalization;2. Adequate discharge planning;3. Adequate post discharge follow-up; or 4. Improved coordination between inpatient and outpatient health care
teams.
A readmission is defined as a return hospitalization to an acute care
hospital that follows a prior acute care admission within a specified time interval, called the readmission time interval.
DAYS
Source: CMS, 2016
Sources of Readmissions
Source: Jencks SF, et al., “Rehospitalizations among Patients in the Medicare Fee-for-Service Program,” New England Journal of Medicine, 2009, 360: 1418-1428; Nursing Executive Center interviews and analysis.
75%
25%
System Issues
Patient Noncompliance
About one in five Medicare patients discharged from a hospital are readmitted within 30 days.
-Centers for Medicaid and Medicare Services
48%
Sources of Readmissions
64%
20%
11%
5%
Rehab/Psychiatric Hospitals, LTC2
Discharged with Home Health
Skilled Nursing FacilityHome, No
Post-Acute Care
Avoidable Hospital Readmissions Originating from SNFs
Source: Jencks SF, et al., “Rehospitalizations among Patients in the Medicare Fee-for-Service Program,” New England Journal of Medicine, 2009, 360: 1418-1428; Nursing Executive Center interviews and analysis.
The Right Thing For Patients
"Readmissions is a barometer of how a hospital is doing, but we also want to make sure we're doing what needs to be done to
help our community partners. And of course we're reducing readmissions because it's the
right thing to do for our patients.”
Josh Brewster, LISW, FACHE, Director of Social Services
The Issues Behind the Struggle
The discharge process is fragmented and complex, creating upstream delays in patient flow.
Jeopardizes quality outcomes
and patient safety
Decreased hospital
capacity
Financial performance
at risk
Multiple stakeholder involvement
(patient/family, hospital, post-acute
facilities, nurses, planners, etc.)
Patients with complex clinical
needs or poor financial status
are difficult to place
Time consuming, manual
process takes time away
from patient
The Discharge Challenge
Hospitals are being held more & more accountable for the outcome their patients experience AFTER the patient leaves
• Readmissions – up to 3% of a hospital’s Medicare revenue at risk with a total penalty this year of $428M
• Value Based Purchasing – up to 2% of a hospital’s Medicare revenue at risk from Outcomes and HCAHPS measures
• Private or Medicare Shared Savings – arrangements that focus on the best outcomes from the lowest appropriate cost of care; goal is to avoid costly events such as complications and readmissions
Penalties continue to grow through a series of private and government pay-for-performance programs
• Provide better communication and coordination with numerous disparate providers and facilities
• Accurately determine the level of risk of a patient as well as specific areas of concern
• Move patients as quickly as clinically appropriate to lower cost of care sites
• Maintain communication and patient status at the patient’s care facility, home, or other location
• Provide both clinical and non-clinical services to keep the patient well
New CMS Discharge Planning Regulations 11/3/2015 - Hospitals are faced with the need to:
• Too many manual processes
• Too small of a provider network
• Not enough time to assess and address patient needs while tracking patients after discharge
Most discharge planners today don’t have the time, technology, or relationships to achieve these goals
Economic Vulnerabilities from Poor Referrals
• Patient Experience• Care Coordinator Efficiency• Data Integration
• Operating Costs for Facilities • Costs to Payers• Patient Clinical Risk
Five Care Coordination Trends Guiding our Future
• Phenomenon #1: Growing Burden of Older, Sicker Patients
• Phenomenon #2: Proliferation of Programs to Improve Care Transitions
• Phenomenon #3: Focus Beyond Traditional Clinical Services
• Phenomenon #4: Investment in Predictive Risk Modeling and Analytics
• Phenomenon #5: Expansion of IT Connectivity Across the Continuum
*Source: Clinical Advisory Board interviews and analysis, The Advisory Board Company, 2011
Perception vs. Reality
Hospital Leaders Give High Marks to Care Coordination Consumer View Less Rosy
Very Strong/Strong
64%
Neutral22%
Weak/Very Weak14%
n=487
Very Strong/Strong Neutral Weak/Very Weak
Major Problem17%
Minor Problem27%
Not a Problem at All53%
Don't Know/Refused
3%
n=1,238
Major Problem Minor Problem
Not a Problem at All Don't Know/Refused
*Source: HealthLeaders Media Industry Survey 2011
Bounce Backs Caused by Hospitals and PAC Providers
SubstandardQuality of Care
Discontinuityof Care
Communication Gaps Between Settings
HospitalDrivers
• Hospital inpatient team missed some aspect of patient care during index stay
• Hospitalists, inpatient team is unavailable to answer questions, inform PAC providers of individual patient nuances
• Incomplete medical information shared from hospital to PAC provider during transfer
PACDrivers
• Nursing staff not trained to care for high-risk patients
• Home health, SNFs not meeting minimum quality standards (such as medication reconciliation)
• Lack of physician oversight in SNFs
• Staff do not have time, incentives to communicate with inpatient team
• Lack of IT connectivity• Do not resuscitate (DNR)
forms and/or advanced directives not transmitted between settings
*Source: Clinical Advisory Board interviews and analysis, The Advisory Board Company, 2011
Forced to Manage an Increasingly Complex Population
*Source: Thorpe, K., Howard D., “The Rise in Spending Among Medicare Beneficiaries: The Role of Chronic Disease Prevalence and Changes in Treatment Intensity,” Health Affairs, Sept-Octd. 2006, w378-w388; Innovations Center Futures Database; Clinical Advisory Board Interviews and analysis.
EMR Alone is Not a Silver Bullet
Representative Scenario
“Garbage In”
Clinician entersincomplete or inaccurate information into the EMR
A+“Perfect IT System”
Top-of-the-line EMR and supporting IT infrastructure; all technical aspects of system working as intended
?
*Source: Clinical Advisory Board interviews and analysis, The Advisory Board Company, 2011
Struggling to Access “Need-to-Know” Information
Two Key Challenges
Information is Buried
Patient record contains large amount of patient information; clinicians struggle to find most critical information in the moment
Information is Missing
Patient record is missing key pieces of information (e.g., details about patient’s home environment)
*Source: Nursing Executive Center Interview and analysis.
Poor Coordination Costing Us Billions Nationally
Difference Between “Loosely-Managed” and “Well-Managed” PMPM1 Spending2
Medicaid Commercial Medicare
Loosely Managed
Well Managed
Loosely Managed
Well Managed
Loosely Managed
Well Managed
$100.48 $131.84 $449.79
$12BEstimated annual cost of preventable30-day hospital readmissions
$25 - $45BEstimated annual amount of wasteful spending resulting from inadequate coordination2
Source: Milliman: Health Affairs, “Health Policy Brief: Care Transitions,” 2012.1) Per member per month2) 2011
Huge Opportunity for Improvement
71%
Percentage of ED Visits thatare Avoidable in the US1
18%
30-day all-causereadmission rate2
4.4M
Estimated number ofpreventable trips to US
hospitals each year
1) Truven Health Analytics2) CMS, 2012
Source: Truven Health Analytics, “Avoidable Emergency Department Usage Analysis,” 2013.
Where We Are Today
Specialist
Medical Home
Community Agency
LTACHomeHealth
PrimaryCare
Pharmacy
ED
Home
SNF
Hospital
Source: The Advisory Board
Where We Need to Be
Care Coordination Solution
• Social factors, family support and transportation needs are some non-clinical factors that drive high probability for readmission
• Risk stratification
Clinical & Non-Clinical Needs Assessment
• Co-developed with care team and family
• All-way communication through recovery, not just at transition points
Care Planning and Communication
• Patient and family engagement• Monitor post discharge, track progress, initiate interventions
Facilitating Care Transitions
• Include non-medical resources in the network: social services, home-care, transportation, homeless shelter
• Allow provider community to push its own educational content
Connecting with Community Resources
Source: Massachusetts Child Health Quality Coalition Care Coordination Task Force
Communicate and Automate
In fact, the results indicate that a hospital
would, on average, reduce its readmission
rate by 5% if it were to prioritize
communication with the patients in addition
to complying with evidence-based
standards of care.”
Healthcare Financial Review
“It is the communication between caregivers and patients that has the largest impact on reducing readmissions.
How Enabling Technology Impacts Care Coordination
Less time on clerical tasks means more time
communicating personally with patients and families
Using technology to automate redundant tasks ensures
greater accuracy and creates fail-proof measures to
ensure essential steps are not missed
Technology helps monitor patients AFTER they exit the
hospital’s doors.
Technology enables patient and family engagement,
found to be essential for positive patient outcomes
Typical Discharge Planning Workflow
Referral Workflow Enabled by Technology
An ROI Scenario
• A 260 bed, regional medical center
• 22,628 annual discharges
• 14 full -time employees managing
discharge activities
The Case for Post-Acute Referral Automation
▶ 260 bed hospital ▶ 22,628 annual discharges ▶ 14 Discharge Planning FTEs Typical Regional Hospital
Calculations are based on data obtained from the American Hospital Directory as well as 2015 ACMA Survey benchmarks. Hospital data is hypothetical, but represent characteristics of a typical regional hospital.
Another Case for Post-Acute Referral Automation
▶ 436 bed hospital ▶ 21,500 annual discharges ▶ 35 Discharge Planning FTEs A University Hospital
Calculations are based on data obtained from the American Hospital Directory as well as 2015 ACMA Survey benchmarks. Hospital data is hypothetical, but represent characteristics of a typical regional hospital.
Length of Stay Improvements
SNF LOS
Index Reduction
~0.25 days
5%Net savings
(~8x ROI)
$1.2MHome Health LOS
Index Reduction
~0.6 days
12%
6-month Results after implementing automated
discharge technology
Acute Rehab LOS
Index Reduction
~0.4 days
8%
Case Study: Collaboration with Post-Acute
Facilities Drives Improvements and Outcomes
With better community integration as its goal,
OSF launched a preferred skilled nursing
network with 17 member facilities in late 2012.
These members are required to meet the
following standards:
• Overall rating of four or five stars from CMS
• Quality rating of three, four, or five stars from CMS
• Registered nurses on-site 24/7
• Ability to start IV lines 24/7
• Ability to admit patients within two hours
OSF HealthCare, an eight- hospital system in Peoria, Ill., views collaborations with post-acute providers as a critical piece of its Pioneer ACO strategy:
“Our focus has been on how to play better together. We are trying to achieve better integration in our system and at the same time, work on better integration within our community.”
See more at: http://www.hfma.org/acutepostacute/#.VtRz_dpwVzs.email
-- Tara Canty, COO for accountable care and senior vice president for government relations
Total Value Opportunity for AMK Hospital
Low High
Reduction of Length of Stay
SNF Days $446,157 $1,338,472
Home Health Days $559,363 $1,006,853
Acute Rehab Days $145,868 $273,503
Reducing Clerical Tasks
Cost Per Year Performing Clerical
Tasks $274,624 $366,165
Total Baseline Value $1,426,012 $2,984,993
Incremental Gross Revenue
Increased Capacity $1,045,616 $3,124,966
• Reduction in LOS for patients discharged to post-acute care driven by less than 30 minute response times and no-cost national network
• Improved efficiency by reducing the amount of time spent (faxing, copying, phone calls) on clerical tasks
• Incremental revenue gain from admissionsand improved throughput
*Data used in these calculations provided by AMK staff during the on-site Workflow Assessment on June 23, 2015.*All cost savings and efficiency gain estimates are conservative and based on Ensocare’s experience with over 150 clients.
Care Coordination Solution
The best solution is a combination of:
Evidence-based medicine – Efficient process – Enabling technology
Source: The Advisory Board
High Care Team Deployment Low
Low Technology Deployment HighHigh-Risk
PatientGroups
Low-RiskPatientGroups
