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Preventable Hospital Readmissions: Prediction and Prevention } Jan Berger, MD, MJ, Chief Medical Officer, Silverlink Communications

Understanding and Preventing Surgical Readmissions: A Surgeon’s Perspective } John F. Sweeney, MD, FACS, W. Dean Warren Distinguished Professor of Surgery Chief, General and Gastrointestinal Surgery, Emory University Hospital Health Plan Tactics For Reducing Medical and Surgical Unplanned Readmissions } Linda Weiland, VP, Provider Network Innovation and Partnerships, Highmark Inc. } Andrew Bloschichak, MD, Senior Medical Director, Quality & Medical Performance Management, Highmark, Inc.

Final Comments – Strategies for Going Forward } Allen Grimes, Jr. MD, FACS, Regional Medical Director, Health Guidance Organization, Humana

Wrap up and Discussion } Liza Greenberg, RN, MPH, AAPPO Moderator

JAN BERGER, MD, MJ

Preventable Hospital Readmissions: Prediction & Prevention

Chief Medical Officer Silverlink Communications, Inc.

November 26, 2012

This is Not a Single Stakeholder Issue

4

Hospital Readmissions Remain a Challenge

5

$15B

49.5%

$11,300 Opportunity to reduce costs – for Medicare alone

Readmitted within 7 days

Average cost per Medicare hospital stay

20% Medicare members readmitted within 30 days

0 2 4 6

8 10

12 14

16 18

20

0 5 10 15 20 25 30 35

Percent of Readmissions Percent of Potentially Avoidable Readmissions

Days Following Discharge

Perc

ent o

f Pat

ient

s R

eadm

itted

Source: Medicare Payment Advisory Commission. 2007. Report to the Congress: Promoting Greater Efficiency in Medicare. Washington, DC: Medicare Payment Advisory Commission, p. 107; the percent of potentially avoidable readmissions was estimated using 3M software and 2005 Medicare claims data

Readmission Rates for Medicare Beneficiaries

A Percentage of Readmissions are Avoidable

6

16.7% or less

16.8%-19%

19% or more

Readmission Rates by State

Source: 2007 Medicare SAF data

There are Geographic Variations in Hospital Readmissions

7

Unplanned Readmissions Related to Initial Stay Likely Offer Best Opportunity for Savings & Care Improvement

Related to Initial Admission

Unrelated to Initial Admission

Planned Readmission

A planned readmission for which the reason for readmission is related to the reason for the initial

admission.

A planned readmission for which the reason for readmission is not related

to the reason for the initial readmission.

Unplanned Readmission

An unplanned readmission for which the reason for readmission is related to the reason for the initial admission.

An unplanned readmission for which the reason for readmission is not related to the reason for the initial admission.

8 Source: American Hospital Association

Hospital Readmissions Becomes an Increasingly Important Star Measure

9

STARS CUT POINTS

1 >32% 2 >17% to<=32% 3 >12% to <=17% 4 >5% to <=12% 5 <=5%

"   Measure: Readmission to a hospital within 30 days of being discharged

"   Description: % of seniors (65+) members discharged from a hospital stay or readmitted within 30 days for the same condition as their recent hospital stay or a different one.

"   Risk Adjustment: Rate of readmission takes into account how sick patients (age, gender, discharge condition, comorbidity) were when they went into the hospital the first time to make comparisons among plans meaningful.

"   Age Bands: 65-74, 75-84, 85+

"  Weight: 3

All Medicare Advantage plans also need to submit a QIP focused on All Cause Readmission to CMS for 2012. Cost savings potential is very significant at $11.3K per Medicare discharge.

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It Has Caught the Hospital’s Attention: It Goes Beyond Star…. §  Voluntary reporting began in 2009

§  Section 3025 of ACA; Hospital Readmissions Reduction Program

§  Hospitals’ financial risk program kicked off Oct 1, 2012 with a 1% inpatient payment risk

§  Risk escalates up to 3% by Oct 1, 2014

§  Focus begins with heart attacks, pneumonia and heart failure

10

What is Going Wrong?

§  Lack of patient understanding of medical issue

§  Confusion around medications

§  Lack of appropriate inpatient staff “hand off” to ambulatory providers

§  Follow-up visits not scheduled

§  Lack of appropriate caretaker support for follow up

§  Psycho-social issues not identified and addressed

11

Hospital-Based Interventions

12

While Care Transitions Programs Aim to Reduce Readmissions – There are Gaps

13

Address only a portion of the

population Focus on

medical issues Assume physician

knowledge

Reliance on predictive models

Focus on the discharge

process at the time of discharge

Predicting the Risk of Hospital Readmissions: Easier Said Than Done

Objective: Synthesize the available literature on validated readmission risk prediction models, describe their performance, and assess their suitability for clinical or administrative use.

JAMA, 2011; 306(15): 1688-1698

Risk Prediction Models for Hospital Readmissions: A Systematic Review

14 Kansagara, JAMA, 2011

§  Models developed for hospital comparison and clinical intervention purposes

§  Most models in both categories perform poorly

§  Most models have relied on comorbidity and utilization data

§  Few models have examined social determinant variables

Addressing the Entire Population Through Innovation and Integration with Care Management

15

Technology-Assisted Nurse Interventions

Technology Interventions

Consistency, Auditability, Scale

Highest-Risk Patients

High-Risk Patients identified via technology and triaged to humans

Technology improves outcomes in scale for the

“engage-able” population

Low-risk & low engagement Lower Effort Technology Interventions

Nurse-Patient Interventions

Engage All Patients on All Major Areas of Risk

§  Clinical

§  Family / caregiver

§  Financial

§  Psycho-social

16

Scale and Triage Post-Hospital Discharge Processes

17

Post

-Hos

pita

l Dis

char

ge

§  29% of patients responding to post-discharge survey had at least one issue that requires care management follow-up

§  50% of those who were identified with a readmission risk factor would have been missed through the client’s predictive model.

Haven't filled Rx 31%

Need help around the house

19% Financial barriers

to care 15%

Needs same day follow up with care manager

13%

No follow up with provider

11%

Need transportaCon

11%

62%

71%

0%

20%

40%

60%

80%

Medicare Commercial

Post-‐Discharge Survey CompleCon

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Risk Factors for 30-day Hospital Readmission in General Surgery Patients

John F. Sweeney, MD W. Dean Warren Distinguished Professor Chief of General and Gastrointestinal Surgery Vice Chair for Clinical Affairs Chief Quality Officer Department of Surgery

Framing the Problem ��

•  CMS began reporting readmission rates in 2009

•  Affordable Care Act – Section 3025

•  CMS proposed methodology for adjusting hospital reimbursements based on readmission rates

•  Affordable Care Act upheld as constitutional by US Supreme Court June 28, 2012

•  Door is now wide open for CMS to begin enforcing Section 3025.

Developing a Strategy��

•  EUH readmission rate above UHC median

•  General Surgery contributor

•  Reviewed 6 month time frame of General Surgery readmissions from UHC databases Heterogeneous population Difficult to draw conclusions/identify areas for

improvement

•  Needed new strategy ��

Developing a Strategy��

PROCEDURE CPT CODE COLECTOMY+/-‐ COLOSTOMY 44140-‐44160,44188,44204-‐44208, 44210-‐44213,

44227, 44238

SMALL INTESTINE RESECTION 44187, 44202-‐44203, 44227, 44238, 44120-‐44121, 44125-‐44128, 44130

CHOLECYSTECTOMY/INPATIENT 47562-‐47564, 47579, 47600, 47605, 47610, 47612, 47620

CHOLECYSTECTOMY/OUTPATIENT 47562-‐47564, 47579, 47600, 47605, 47610, 47612, 47620

PANCREATECTOMY 48140, 48145-‐48146, 48148, 48150, 48152-‐48155, 48160

APPENDECTOMY 44955,44970, 44979, 44950-‐44960 BARIATRIC SURGERY 43644-‐43645, 43770-‐43774, 43842-‐43848,

43886-‐43888, 43800, 43651-‐43652, 43659

PROCTECTOMY +/-‐ COLECTOMY +/-‐ ANASTOMOSIS 44155, 44157-‐44158, 44212, 45110-‐45114, 45116, 45119-‐45121, 45123, 45395, 45397

LYSIS OF ADHESIONS 44005, 44180 LIVER RESECTION 47120, 47122, 47125, 47130

Procedure Over

72 hours within

72 hours Total

Encounters

72hour to 30 day re-‐admission

rate

72 hour re-‐admission

rate

Total re-‐admission

rate

CHOLECYSTECTOMY/IN&OUT 12 5 500 2.40% 1.00% 3.40%

COLECTOMY COLOSTOMY 21 11 263 7.98% 4.18% 12.17%

BARIATRIC SURGERY 6 2 255 2.35% 0.78% 3.14%

APPENDECTOMY 2 5 214 0.93% 2.34% 3.27%

DRAIN PERITONEAL ABSCESS/NOT APPENDICEAL 34 3 212 16.04% 1.42% 17.45%

SMALL INTESTINE RESECTION 18 7 171 10.53% 4.09% 14.62%

VENTRAL HERNIA REPAIR 14 1 167 8.38% 0.60% 8.98%

PARATHYROIDECTOMY 2 1 151 1.32% 0.66% 1.99%

PANCREATECTOMY 16 3 134 11.94% 2.24% 14.18%

LIVER RESECTION 4 2 98 4.08% 2.04% 6.12%

J Am Coll Surg 2012;215:322-330

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��

•  Link EUH NSQIP data to Emory CDW to identify all readmissions –  2242 patients from 2009-2011 –  182 patients readmitted

•  Recognize that some readmissions elsewhere might not be captured

•  Patient profile

•  Procedure Profile

•  Role of Complications in readmissions ��


��


��

•  Preoperative characteristics associated with readmission –  Diabetes –  Tobacco abuse –  Dyspnea –  Disseminated Cancer –  Open Wound –  Chronic Steroids –  Unintended weight loss –  Acute Renal Failure –  Vent Dependent

��

P < 0.05


��

Leveraging Investments in Quality to Enhance HSR:Readmission Project ��


��


��

•  Profile of high risk patient identified –  Patient Characteristics –  Operative Procedure

•  Complications are significant drivers

•  In general operations are planned interventions

•  Implement protocols and pathways

•  Enhance transitions of care coordination ��

Thank You Questions?

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Engaging Providers in Improvement: Outcomes of a Pay-for-Performance

Readmission Reduction Program

Linda R. Weiland Vice President, Provider Network Innovation & Partnerships Andrew Bloschichak, MD Senior Medical Director, Quality & Medical Performance Management

@COPYRIGHT Highmark Inc. 2011. All rights reserved. This information is confidential to Highmark Inc. and cannot be copied or distributed without permission of Highmark Inc.

Highmark Overview

Membership: 4.8 million members Operating Markets: W. Pennsylvania, C. Pennsylvania, West Virginia and Delaware Claims processed: > 201+ million per year Employees: 22,000 employees Corporate social mission: $150 million for programs in support of the mission Number of Accounts: 22,595

Why Pay-for-Performance?

39

•  Quality Improvement with savings

•  Escalating consumer demand for high quality safe care that is cost effective

•  Align payment for the delivery of evidenced-based care

•  Means to align provider reimbursement with performance

Sustained Quality

Performance Efficiency

Member Value

Quality Blue Hospital Pay-for-Performance Program

FY 2002 •  6 participating hospitals



40 41

Program Structure

• Level I: 1 Indicator • Level II: 2 Indicators • Level III: 4 Indicators

Program Levels

• Level 1: 1% • Level 2: 2% • Level 3: 3%

Reimbursement at Risk

• Provider reported • Nine month program year

Program Data

• Hospital Efficiency • Infection Prevention • Process of Care

Categories

• Planning • Action • Measurement • Results • Critical Analysis

Evaluation

Quality Blue FY 2013 Program Indicators

42

Hospital Efficiencies •  ED Throughput •  Readmissions •  Imaging Efficiency

(New)

Infection Prevention •  Surgical Safety •  MRSA •  CDI •  IP-GNR •  Device-Associated

(New/Level III only)

•  CLABSI (Level I & II only)

•  CAUTI (Level I & II only)

Process of Care •  Perinatal •  GWTG®-Stroke •  VTE Prevention •  Diabetes •  GWTG®-Heart Failure •  Palliative Care •  Sepsis

Engaging Providers in Improvement: Outcomes of a Pay-for-Performance

Readmission Reduction Program

@COPYRIGHT Highmark Inc. 2011. All rights reserved. This information is confidential to Highmark Inc. and cannot be copied or distributed without permission of Highmark Inc.

Why Readmissions?

44

2007 MedPAC Report to Congress

NEJM Jencks 2009 Article

AHRQ 2010 Report

(Medicare Payment Advisory Commission, 2007)

(Jencks, Williams, & Coleman, 2009)

(Jiang & Wier, 2010)

17.6% of Medicare admissions resulted in readmissions within 30 days $15B in spending $12B for potentially preventable readmissions

1 in 5 Medicare patients readmitted within 30 days 50.2% of patients readmitted had no physician visit between discharge and readmission

1 in 10 non-obstetric Medicaid patients (age 21-64) hospitalized in 2007 for a medical condition had at least one readmission within 30 days

CMS Penalties for High Readmissions

•  As of October 1, 2012, CMS has initiated penalties to hospitals exceeding expected readmission limits •  FFY 2013 Penalty: Up to 1% of CMS Reimbursements •  Over 2,200 (67%) of nation’s hospitals been penalized

278

1933

1156

# Hospitals Receiving CMS Penalties for Readmits

Max Penalty: 1% Other Penalty: <1% No Penalty

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Poor Coordination

of Care & Quality Issue

Defects in Care

Gaps in Transition Planning

Communication Failure

Medication Errors

Delays in Post Discharge

Appointments

Quality Issues Driving Readmissions

46 (Bisognano & Boutwell, 2009)

34 hospitals participating in Readmissions indicator for FY 2012

47

FY 2010 •  22 hospitals •  Reduce 7-day and

30-day all-cause readmissions

•  Provide and improve coordination of care efforts

•  Included maternity and pediatrics

FY 2011 •  31 hospitals •  New hospital 2 yr

commitment •  PCPI Care

Transitions measures

•  Patient assessment •  Excluded maternity

and pediatrics

FY 2012 •  33 hospitals; 16

second year •  2 year commitment •  PCPI Care

Transition measures scored

•  Excluded maternity and pediatrics

Quality Blue Readmissions Indicator Over Time

Readmissions Indicator: 2013 Mandate

•  Mandatory Participation for Level II & III •  Based upon Highmark Network claims-based IP

readmissions w/in 30 days, all cause, rate •  Readmission rates ≥7% mandated •  Readmission rates <7% excluded •  Maternity and Pediatrics excluded

•  Scored Metrics •  Decrease 7-day & 30-day readmissions to IP & Obsv

•  Defect-free Transition of Care Bundle

•  Reconciled medication list upon discharge

•  Transition record upon discharge

•  Transition record transmitted to facility/provider within 24 hours

•  Assess patient’s perceptions of care transition planning

48

FY 2013 •  Mandatory for all

Level II & III hospitals

•  63 hospitals participating

•  Continued focus on data, care transitions, patient perception and readmit reduction

Understanding the Readmission Population

•  Encourage hospitals to examine readmissions to better define their target population •  Recommend analysis & identification of:

–  Top readmission DRGs

–  Top reasons for readmission

–  Trends by physician, service, facility

–  Trends by day of week, shifts

–  Seasonal influences

–  Correlations between adverse outcomes & non-compliance with best practices

49 50

20%

16%

15% 9%

8%

7%

7%

3% 3%

3% 3% 2% 2% 2%

30-Day Readmission Top DRGs HF

Sepsis

COPD

Renal Failure

Esophagitis/ Gastroenteritis/Misc Digestive Disorders Others

Pneumonia

Kidney & Urinary Tract Infections

Respiratory Failure/Infections

Cellulitis

Percutaneous CV Proc

Arrthymic Conduct Disorder

Post-Op Infection

Pulmonary Edema * 2011 Program Data

Quality Blue Top Readmission DRGs (2011)

Defect-free Care Transition Bundle

Transmittal within 24 h

Transition of Care Form

Reconciled Med List

Transitions of Care

•  Required to sample 7-day readmissions to inpatient & observation status

•  Defect-free Care Transition Bundle (AMA/PCPI Care Transitions Measures)

–  Patients/Caregivers receive a reconciled med list at discharge

–  Patients/Caregivers receive a Transition Record at time of discharge

–  Transition Record transmitted to facility or next level provider within 24 hours of discharge

51

52

35.0

20.0

57.6

18.8

82.5

60.4

90.1

58.7

0 10 20 30 40 50 60 70 80 90

100

Reconciled Med List

Trans of Care Record

Transmittal ToC Defect Free Care

Com

plia

nce

(%)

2011 Year End 2012 Year End

136%

188%

56%

212%

Compliance with Transition of Care Bundles 2nd Year Participant Results (17 hospitals)

53

44.5

15.6

49.4

12.4

84.6

59.3

84.1

51.4

0 10 20 30 40 50 60 70 80 90

Reconciled Med List

Trans of Care Record

Transmittal ToC Defect Free Care

Com

plia

nce

(%)


90%

279%

70%

315%

Compliance with Transition of Care Bundles 3rd Year Participant Results (10 hospitals)

54

Readmissions Measures: Patient Perception of Transition Planning •  Hospitals required to engage their 30-day readmit population to better understand why the

patient felt they were returning to the hospital

•  Opportunity for the hospital to hear the patient perspective

•  Dialogue that occurs in these interviews help hospitals to learn more about the patient’s comprehension of their disease, their social, economic and personal resources and/or limitations

•  Hospitals have expanded these interviews beyond topics of care transitions to include discussion around:

•  Diet •  Weight management •  Medication management

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Readmissions Analysis

•  Hospitals must provide an analysis and/or commentary of the following items:

•  Coordination of care throughout the admission

•  Interventions implemented to aid in reducing readmissions

•  Describe collaborative efforts in reducing readmissions with care providers in community

•  Coordination of care for discharge •  Transition in Care programs •  Medication reconciliation •  Other follow-up processes

•  Deficiencies of compliance with defect-free care transition bundle

•  Describe processes used to identify patients at high risk for readmission

•  Results of the patient assessment and how the patient education process was improved

•  Describe processes in place for completion of the POLST (PA), POST (WV), MOLST (NY)

55 55

Most Common Interventions Across Quality Blue Hospitals

56

28

2220 20

1715

12 11

0

5

10

15

20

25

30

ECF Collab MultidiscHuddles

Follow-‐up Appt Trans of CareRN

MD DischargeOrders

MDEngagement in

Data

Nurse ReadmitDashboards

Post DC Calls

# H

ospi

tals

Par

ticip

atin

g

Bridging the Gap: Reaching Out to ECFs

•  28 of 33 hospitals actively engaging ECFs / external programs (e.g. SNF, ECF, Home Care, Hospice)

•  Meeting Topics Include:

– Quality data –  Advanced directives –  Palliative care –  Care transition forms – Medication reconciliation –  Patient diet –  Heart failure

57

•  Readmit rates •  Patient listings •  Dashboards •  Report cards

Sharing Data

•  Members of Hospital Readmit Committee

•  RCA of every readmission •  Developing care transitions

competencies •  Consistent forms •  POLST forms •  Enhanced communication

Internal Involvement

•  Monthly meetings •  Quarterly forums •  On-site education at ECF

Education

Care Transitions Huddles

•  Many hospitals instituting a daily huddle to discuss discharge planning and care transitions

58

Multidisciplinary

•  Nursing •  Case Management •  Social Services •  Medical Staff •  Pharmacy •  Dieticians •  Respiratory •  Quality/Patient

Safety •  Therapies (PT/OT/

Speech)

Huddle Topics

•  Care Transitions •  Caregiver Support •  Medication Mgmt •  Discharge Planning •  Diet •  Readmission Risk

Follow-up Appointments Scheduled Prior to Discharge

59

•  Appointments made by: –  Nursing, Case Management, Hospitalist, Care Transitions Nurse

•  Working with physician practices to block schedule time for chronic patient discharges (CHF, COPD)

•  Attempting to arrange CHF visits within 3 days of discharge

Post-Discharge Follow-up Phone Calls

•  Phone calls completed by: –  Pharmacists, Nursing,

Hospitalists, Transition of Care Nurse, Case Management

•  Timeframe for calls: –  24, 48, 72 hours, 5 days, within

30 days •  Targeted populations

–  CHF, COPD

60

Follow-up Call Foci

General health

Prescriptions filled

Follow-up appt

Pending tests

Medication review

Diet

Weight

Questions

Example Best Practices

Geisinger •  Plan for acute care follow up occurs at

time of admission by communicating the patient’s readmission risk score to the PCP in a formal format

•  Create post discharge follow up appointment for every patient

•  Geisinger community health services has a comprehensive interdisciplinary LIFE Geisinger team to coordinate and/or provide all needed healthcare including primary care and specialist physician services

61 @COPYRIGHT Highmark Inc. 2011. All rights reserved. This information is confidential to Highmark Inc. and cannot be copied or distributed without permission of Highmark Inc.

Conemaugh •  Ensure follow-up appointment scheduled

and encourage compliance

•  Phone call to patient if not admitted to home health within 24 hours

•  Use teach back method with scripting: “I want to be sure I was clear in my explanation. What will you tell your caregiver when they ask what we discussed”

Readmission Rate Reduction

•  Hospitals voiced difficulty in ability to reduce readmissions within the 9 month program year

•  Despite significant improvement in care transitions, not seeing definitive reduction in readmission rates; Beginning to see stabilization vs. further increase in rates

•  Hospitals are provided additional comparative views at program year end to aid in their readmission reduction efforts

– Readmission profiles

– Highmark Quality Blue Readmission Initiative data

62

FY 2012 Readmission Rates

63 Presentation Title or Footnote area

0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0

05 06 07 12 15 17 18 19 20 22 24 25 26 29 30 31 33 34 37 39 40 41 42 43 45 50 51 52 56 59 64 67 70 82

Rea

dmis

sion

Rat

e

Hospital ID

FY 2012 Readmission Rates for 7-Day Inpatient and Observation by Hospital ID vs. All QB Participating Hospitals - Aggregate

Hospital All QB Participating Hospitals

QB Rate: 4.5

0.0

4.0

8.0

12.0

16.0

20.0

05 06 07 12 15 17 18 19 20 22 24 25 26 29 30 31 33 34 37 39 40 41 42 43 45 50 51 52 56 59 64 67 70 82

Rea

dmis

sion

Rat

e

Hospital ID

FY 2012 Readmission Rates for 30-Day Inpatient and Observation by Hospital ID vs. All QB Participating Hospitals - Aggregate

Hospital All QB Participating Hospitals

QB Rate: 13.5

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FY 2012 Readmission Rates 2nd Year Participants

64

0.0

2.0

4.0

6.0

8.0

05 06 07 12 15 17 18 19 20 22 24 29 30 31 33 39 40 41 42 43 45 50 51 52 56 59 64

Rea

dmis

sion

Rat

e

Hospital ID

FY 2012 Readmission Rates for 7-Day Inpatient and Observation by 2-Year Participant Hospital ID vs. Baseline

Baseline 7-Day Inpatient & Observation Readmission Rate FY 2012 7-Day Inpatient & Observation Readmission Rate

0.0

5.0

10.0

15.0

20.0

25.0

05 06 07 12 15 17 18 19 20 22 24 29 30 31 33 39 40 41 42 43 45 50 51 52 56 59 64

Rea

dmis

sion

Rat

e

Hospital ID

FY 2012 Readmission Rates for 30-Day Inpatient and Observation by 2-Year Participant Hospital ID vs. Baseline

Baseline 30-Day Inpatient & Observation Readmission Rate FY 2012 30-Day Inpatient & Observation Readmission Rate

Hospital Readmission Rates for 2nd Year Participants: Year End Performance: 2011 vs. 2012

3.51

11.00

0.691.85

4.26

12.85

3.51

10.87

0.82.17

4.37

13.04

0

2

4

6

8

10

12

14

IP 7-‐day IP 30-‐day Obsv 7-‐day Obsv 30-‐day Combined 7-‐day Combined 30-‐day

Read

mit Ra

te (%

)


65

Hospital Readmission Rates for 3rd Year Participants: Year End Performance: 2011 vs. 2012

4.05

12.47

0.681.85

4.74

14.32

3.95

12.05

0.721.88

4.68

13.93

0

2

4

6

8

10

12

14

16

IP 7-‐day IP 30-‐day Obsv 7-‐day Obsv 30-‐day Combined 7-‐day Combined 30-‐day

Read

mit Ra

te (%

)


66

-2.5%

-3.4%

-1.3%

-2.7%

5.9% 1.6%

Hospital Challenges

•  Competing priorities within the hospital •  EHR implementation •  Multiple upgrades, processes being implemented simultaneously •  Physician buy-in with Transition of Care forms •  New Transition of Care processes many times increase staff workload •  Lengthening time to discharge negatively impacting patient satisfaction •  Cumbersome medication reconciliation process

67

Hospital Lessons Learned

68

•  Fragmented processes •  Continuous staff education required to ensure successful change •  Underutilization of Home Health services •  Lack of understanding re: SNF capabilities •  You must listen to the patient – really hear them – to ensure the discharge

plan will meet their needs

Next Steps for Highmark

QB ACO

QB Hospital

QB PCMH

QB Physician

69 Presentation Title or Footnote area

•  Opportunities to “connect” programs and providers

•  Working on similar projects from different perspectives

•  Example Readmission Opportunities:

–  Hospital and physician practice communication (care transitions)

–  Structures across providers to discuss high risk patients and strategies

–  Access to care (blocked schedules, etc.) for high risk patients

–  Care coordination via PCMH / ACO models

–  Expanded use of Highmark health resources

Questions?

70

www.aappo.org

[email protected]

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