Reducing Readmission Risk through High Quality

Transitions

Jane Brock, MD, MSPHCFMC

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Medicare spending

The hottest topic in healthcare reform

• 19.6% readmitted in 30d• $17.4 Billion (2004)

Medicare To Penalize 2,211 Hospitals For Excess Readmissions

http://www.kaiserhealthnews.org/Stories/2012/August/13/medicare-hospitals-readmissions-penalties.aspx

..much of what drives hospital readmission rates are patient- and community-level factors that are well outside the hospital’s control.”

Care in the US is too hospital-centric 1949Medical services alone won’t be adequate 1954We should integrate medical and social support 1956Care patterns are local, and reflect capacity to deliver care 1973Hospital costs are unsustainable 1980Hospital readmissions are prevalent 1984The Health Care Financing Administration could direct appropriate subcontractors to do things that would prevent readmissions 1984

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The ACA and Integrating Care

= Reduce readmissions!

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What we learned about readmissions

What causes readmissions?

No Community infrastructure for achieving common goals

Unreliable system supportLack of standard and known processesUnreliable information transferUnsupported patient activation during transfers

Provider-Patient interfaceUnmanaged condition worseningUse of suboptimal medication regimensReturn to an emergency department

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The Basics of Interventions:

I think it’s an elephant!

-5.7% (p<.001)-2.1% (p=.08)P=.03 (difference)

And it worked

Rehospitalizations/1000

Summary of results

5.7% ↓(1 hospitalization for every 1000 Medicare beneficiaries)

2.7x that experienced by comparison communities

Rehospitalizations

$4,000,000 $1,000,000vs.

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Integrating Care for Populations & Communities, August 2011

• Improve the quality of transitional care by recruiting communities to work together

• Reduce 30-day readmissions by 20%• Through community convening– Tools• Root cause analysis• Social Network Analysis Diagrams• Hot-spotting maps

– Data, data, data (e.g., readmission/admission metrics; reach/intervention effectiveness measures)

# of Engaged Communities 375

# of Beneficiaries Living there 13,062,093

# Communities with Signed Coalition Charter 221

# Communities Receiving Formal Funding 81

# Recruited Hospitals 859

# Recruited Nursing Homes 1,533

# Recruited Home Health Agencies 901

# Recruited Hospice Facilities 342

# Recruited Dialysis Facilities 91

# Recruited Outpatient Physicians > 1,927

QIO Progress by March 31, 2013

National Coalition of QIO-recruited Communities Early Progress

9.1%

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CohortNumber of Fee-for-Service Medicare

Beneficiaries

CMS FY 2011* Readmissions/

1000

CMS FY 2012** Readmissions/

1000

Relative Improvement

RateEarly CCTP communities (3.1.12)

791,977 63.8 58.7 8.0%

Early QIO Communities (7.31.12)

4,085,170 55.9 51.5 7.8%

National 35,836,293 57.6 53.4 7.1%

Select Relative Improvement: Readmissions

Person-level Interventions

CoachingCare Transitions Interventionwww.caretransitions.orgBecome a tightrope walker forever

Navigator/Care CoordinatorSomeone to hold your hand while you walk the tightrope

Transitional Care Nursehttp://www.transitionalcare.info/Someone to carry you over the bridge

• Standardize your transfer processes• Standardize information transfer• Know the capabilities of your partners• Track and know your data

Institution-level Interventions

Red http://www.bu.edu/fammed/projectred/

BOOST http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm

Interact http://interact2.net/

BPIP http://www.homehealthquality.org/Education/Best-Practices.aspx

Collective Impact

• Common agenda• Standard measurement system• Mutually reinforcing activities• Continuous communication• Backbone support organizations

Collective Impact. Stanford Social Innovation Review, Winter 2011.http://www.ssireview.org/pdf/2011_WI_Feature_Kania.pdf

Channeling change: Making collective impact workhttp://www.fsg.org/Portals/0/Uploads/Documents/PDF/Channeling_Change_SSIR.pdf?cpgn=WP%20DL%20-%20Channeling%20Change

Coalition-level ‘interventions’

Kania and Kramer: Embracing Emergence. http://www.ssireview.org/blog/entry/embracing_emergence_how_collective_impact_addresses_complexity

Structure of Collaboration

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• Regularly scheduled forum for interaction/social interaction– Somebody has to keep email lists, schedule

meetings, bring food(!)– Leverage ‘interventions’

• Common metrics• Structure to permit case discussion• Progress tracking – community metrics

In the real world..

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• Paid agency for interventions serving as a backbone– WITH OTHER WORK AND HISTORY IN THE

COMMUNITY– Ideally with local funding

• New community-based services• Presence of community provider in the hospital• Internal data tracking process – to adapt..• Accountability to broader constituency

And the CCTP

Jan07-Mar07

N = 66590

Apr07-Jun07

N = 64621

Jul07-Sep07

N = 62060

Oct07-Dec07

N = 62822

Jan08-Mar08

N = 65689A

Apr08-Jun08

N = 61781

Jul08-Sep08

N = 59098B

Oct08-Dec08

N = 59962

Jan09-Mar09

N = 61517C

Apr09-Jun09

N = 58825

Jul09-Sep09

N = 56395

Oct09-Dec09

N = 57766

Jan10-Mar10

N = 60616D

Apr10-Jun10

N = 59422

Jul10-Sep10

N = 57984

Oct10-Dec10

N = 59630

18.80%

19.00%

19.20%

19.40%

19.60%

19.80%

20.00%

19.68%

19.48%

p=0.0024

Baseline Quarter Readmissions = 12,926First quarter after intervention readmissions = 12,151

About Measures and Penalties..

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• 3 yrs’ discharges• ‘Excess readmission ratio’• Added across 3 conditions• Ratio= 1-(O/E)

Hospital payment reduction

1% → 2% → 3%

• Added exclusions for planned readmissions• Added conditions – CABG, COPD, hip fx?• 2 MN = inpatient stay

• And the continuing problem of Observation Stays..

Important Updates

Risk stratification modelsKansagara et al. JAMA 306(15), 2011

High Risk I’ll be back

• Demographics – age, gender, SES• Comorbidities - # or score• Utilization – hospitalization, ED use over

recent period• # of medications at discharge

• LACE = 0.68

Risk Stratification

• Mental health dx• Substance use/abuse• Functional status• Preparation/confidence

Better identification

Disparities SES and readmissions

Heart Failure• Black Medicare patients’ readmissions higher

(RR=1.09, 106-1.13) than white patients*• Income significantly associated with readmission in

heart failure (adjusted odds ratio for quartile 1:4 comparison, 1.18; 95% confidence interval, 1.10 to 1.26, p <0.0001).**

*Race, quality of care, and outcomes of elderly patients hospitalized with heart failure. JAMA. May 21;289(19):2517-24, 2003.**Socioeconomic status as an independent risk factor for hospital readmission for heart failure. Am J Cardiol. Jun 15;87(12):1367-71, 2001.

SES and Readmissions

• Not accounted for in measures

• 3-4% risk difference• ?Neighborhood

effects• ? Stratification by %

low SES

A much broader notion of ‘bundling’

BMJ Qual Saf 2011;20:826e831.

Better Health forthe Population

Better Carefor Individuals

Lower CostThrough

Improvement

Better Health forthe Population

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Who lives here and what do they want/need?