Region 2’s Approach to on the Reducing Readmissions

Region 2’s Approach to on theReducing Readmissions

Craig S. Kovacevich, MA Associate Vice President

Waiver Operations & Community Health Plans Office of the President

The University of Texas Medical Branch at Galveston

Wednesday, August 20, 2014

Working Together to Work Wonders

Regional Health Partnership: Region 2

2

UTMB


Regional Health Partnership: Region 2

Galveston

Brazoria

Nacogdoches

Angelina

Shelby

Sabine

San

A

ug

ustin

e

Jefferson

Orange

Jasper

New

ton

Liberty

Hardin

TylerPolk

San Jacinto

UTMB

• 16 counties

• Population of nearly 1.5 million people

• Covers nearly 14,500 square miles

• Urban and rural with varying infrastructure challenges

• 25% of population is uninsured

• 27% of population is on Medicaid or Medicaid/Medicare (dual eligible)

• More than 50% of the region is designated as Health Professional Shortage Area in Primary Care and/or Mental Health

Working Together to Work Wonders 4

RHP 2 Community Needs Assessment

• Access barrierso Personal resource challenges (i.e. transportation)o Lack of insurance coverage

• Health care workforce shortageso Physicians (primary and specialty care)o Mental/behavioral health providerso Allied health professionals (mid-level providers, nurses, etc.)o Dentistso Community Health Workers/Patient Navigators

• High ED utilization and 30-day readmission rate• Chronic disease Incidence

o Diabeteso Heart & vascular related diseases

• Mental health related morbidity and mortality


• Expand access to and coordination of:o Patient-centered primary care o Behavioral health care serviceso Health promotion and disease preventiono Specialty care services o Chronic disease management

• Improve quality of care through:o Continued process improvementso Collaborative learning opportunitieso Development of innovative solutions

• Grow health system resources by:o Expanded and enhanced healthcare workforce training o Educate future healthcare professionals through interdisciplinary

training that contemplates tomorrow’s delivery system

RHP 2 Regional Goals and Objectives

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• Goals:o Expand quality improvement reporting capacity by improving

utilization of people, processes and technology…with an end goal of reducing as many avoidable readmissions as possible

o Share best practices, provide education and training to clinical and administrative staff and design more timely and efficient data collection systems…with an end goal of reducing as many avoidable readmissions as possible

o Learn about content and about rapid cycle improvement from subject matter experts, project staff/learning collaborative coaches and each other…with an end goal of reducing as many avoidable readmissions as possible

o Incorporate the BOOST model (Better Outcomes for Older adults through Safe Transitions) from the Society for Hospital Medicine as a framework for addressing Preventable Readmissions…with an end goal of reducing as many avoidable readmissions as possible

RHP 2 Readmissions Learning Collaborative

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o Three “In-Person” Meetings: January, May and August 2014o 14 different organizations have actively participated, including Public and Private

Hospitals, Critical Access Hospitals, Physician Group Practices and Behavioral Health Centers

o Sharing of challenges and successes by all participating organizations – even if they do not have DSRIP projects directly tied to readmissions

o Calls are held twice a month (first call of the month: project status updates; second call of the month: “push” of information on performance improvement topics)

o BOOST Model “Areas of Focus”o 8P Risk Scale - Prior Hospitalization, Problems with Medications, Psychological,

Principal Diagnosis, Physical Limitations, Poor Health Literacy, Patient Support and Palliative Care

o General Assessment of Preparedness (GAP) Tool for Clinical Assessment -Done at minimum on three (3) occasions: admission, nearing discharge and discharge

o Patient Preparation to Address Situations Successfully (Patient PASS) - Patient’s perception of their condition(s) and requirements for self-management

o Teach-back - To discover what the patient really understands about their condition, hospitalization, home treatment and follow-up care

RHP 2 Readmissions Learning Collaborative

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• Development of competencies for new reimbursement models and population health management

• Establishment of new affiliations and community relationships to improve coordination of and access to healthcare services

• Engagement of regional stakeholders, including additional providers, community organizations and patients

• Advancement of the “Triple Aim” in through enhanced collaboration: o Improve the patient experience via quality and overall satisfactiono Advance the health outcomes of populationso Reduce the per capita cost of care

RHP 2: Our “Shared” Opportunities

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• 57 year old male with a history of COPD• Medicare patient• Five (5) admissions in a six (6) week span (totaling 11 inpatient days)

• All admissions for shortness of breath/COPD exacerbation• Teach-back and clear discharge plan documented for each

discharge• Follow-up phone calls made

• Were any of the readmissions preventable?

Readmissions Case Study #1

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• 57 year old male with a history of COPD• Six (6) previous admissions in 2014 • History of Medication non-compliance• Limited funds spent on cigarettes and marijuana• History of non-compliance with fluid restrictions and dietary

recommendations• Home Health (HH) and Community Health Program (CHP) referrals were

made

• The readmissions were not avoidable• Patient deemed hospital dependent due to:

• Non-compliance of medical orders and recommendations• Rapid disease progression

• Determination of hospital dependency allows for:• More appropriate use of inpatient resources and planning• Recognition that HH and CHP are sometimes not able to solve

readmissions due to patient non-compliance

Readmissions Case Study #1 (continued)

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• 30 year old female with a history of Crohn’s Disease• Managed Medicaid patient• Five (5) day index (initial) admission

• Teach-back and clear discharge plan documented for discharge• Follow-Up phone call(s) made• Patient discharged with Narco for pain (40 tab)

• Patient readmitted after 10 days for Abdominal pain (before outpatient follow-up visit could occur)

• Was the readmission preventable?

Readmissions Case Study #2

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• 30 year old female with a history of Crohn’s Disease• Documentation shows that she had severe disease• Pain was uncontrolled• Patient was not hospital-dependent• Patient referred to Community Health Program (CHP) during

readmission

• This readmission was avoidable• Determination of non-hospital dependency made:

• Patient initially discharged with inadequate pain medication• Documentation of pain indicated a stronger Rx required

• Referral to CHP should have been made at initial discharge vs. at readmission discharge

• During follow-up call, patient indicated concerns with pain that should have triggered an ambulatory appointment or outreach visit by CHP personnel.

Readmissions Case Study #2 (continued)

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Working Together to Work Wonders 13

Thank You

Please visit our regional website at:

http://www.utmb.edu/1115/

Region 2’s Approach to on the Reducing Readmissions

Documents

Transcript of Region 2’s Approach to on the Reducing Readmissions