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HRET HIIN Readmissions
Connecting the Patient Voice to Readmissions Reduction Approaches
April 6, 2017
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Welcome and Introductions
Lauren KaderabekProgram Manager | HRET
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• HAPU/I | Nip It In the Bud: Targeting Early Detection April 13, 2017 2:00pm - 2:45pm (CST)
View all upcoming events
Upcoming Events
Agenda for Today
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1:00-1:05 p.m. Welcome and IntroductionsIntroduction to today’s event and agenda overview. Lauren Kaderabek
Program Manager, HRET1:05-1:10 p.m. Readmissions Data Update
Review the overall HRET HIIN progress on readmissions. Julia Heitzer, M.S.Data Analyst, HRET
1:10-1:30 p.m. Project ACHIEVE Overview and FindingsA presentation and discussion opportunity with Dr. Mark Williams focusing on the Project ACHIEVE qualitative study results, which surveyed over 250 patients across the nation on their reasons for readmissions.
Mark Williams, M.D.Chief Transformation and Learning Officer, UK HealthCare system
Director of the Center for Health Services Research and Professor and Vice-Chair of the Department of Internal Medicine, University of Kentucky
1:30-1:40 p.m. Understand Data to Reduce Readmissions A presentation and discussion opportunity with Dr. Rebekah Gardner focusing on how to utilize readmissions data to drive readmissions reduction.
Rebekah Gardner, M.D.Senior Medical Scientist, Healthcentric Advisors
Assistant Professor of Medicine, Brown University
1:40-1:50 p.m. Patient Voice in Project DesignAn interview and discussion opportunity with a HIIN hospital who has incorporated the patient voice into their readmissions reduction programming.
Belinda Sanderson, RN, BSNQuality Director, Baptist Memorial Hospital-Golden Triangle
1:50-2:00 p.m. Action Items and Next Steps Review of readmissions resources and support provided through the HRET HIIN including the updated 2017 readmissions change package.
Discuss action items and next steps.
Pat Teske, RN, MHAImprovement Advisor, Cynosure Health
Lauren Kaderabek Program Manager, HRET
Readmissions Data Update
Julia Heitzer, MSData Analyst| HRET
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Readmissions Data Update
• Based on preliminary data submitted as of March 17, 2017, the HRET HIIN is observing a 4% reduction in all-cause 30 day readmissions.
• Based on this preliminary data, we estimate the HRET HIIN has prevented nearly 6,000 readmissions to date, representing just over $92 million in cost savings.
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Connecting the Patient Voice to Readmissions Reduction Approaches
Mark V. Williams, MD, FACP, MHMDirector, Center for Health Services Research
Professor & Vice Chair, Dept. Internal MedicineChief, Division of Hospital Medicine
A Problem For A Long Time
• Rosenthal, J. M. and D. B. Miller"Providers have failed to work for continuity."
Hospitals 53(10): 79-83.
“Continuity of patient care between different health care settings has been advocated for nearly 20 years, but little has been done to affect it. The study described here emphasizes the current lack of effort by health care providers in hospitals andnursing homes to find a workable solution.”
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So, What Should We Do?
Discharge Instructions
Do you have any ?’s
What did that mean? “No”
Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence
Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence
Acknowledgement & Disclaimer
Funding Acknowledgement: This work was supported through a Patient-Centered Outcomes Research Institute (PCORI) award (Contract #TC-1403-14049).
Disclaimer: All statements in this presentation, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors or Methodology Committee.
Background• Patients in the U.S. suffer harm too often as they move
between sites of health care, and their caregivers experience significant burden.
• The usual approach to health care does not support continuity and coordination during such “care transitions” between hospitals, clinics, home or nursing homes.
• Poorly managed patient care transitions can lead to worsening symptoms, adverse effects from medications, unaddressed test results, failed follow-up testing, and excess re-hospitalizations and ER visits.
We do not know what outcomes matter mostto patients and their caregivers and
what approaches work best.
Background
Funded by the Patient Centered Outcome Research Institute (PCORI), Project ACHIEVE brings together nationally recognized leaders in health care, transitional care and research methods in partnership with patients and caregivers to evaluate the effectiveness of current efforts at improving care transitions.
This multi-site study aims to develop recommendations on best practices for
patient-centered care transitionsand guidance for spreading them across the U.S.
Phase 1: Qualitative Research
• Focus Groups and Key Informant Interviews• Recorded interviews transcribed verbatim• Grounded Theory and Constant Comparative
Analysis• 243 Patients & Caregivers Interviewed− Transcripts of 2,000 pages single spaced
• 63 Provider Participants
Boston Medical Center Team
• Brian Jack, MDProfessor & ChairDepartment of Family MedicinePrincipal Investigator for Project REDCo-Principal Investigator, Project ACHIEVE
• Suzanne Mitchell, MD, MPHAssociate Professor of Family MedicineCo-Investigator, Project ACHIEVE
Qualitative Research – Major Themes Patient/Caregiver Goals
– Feeling prepared and capable– Unambiguous accountability – Feeling cared for and about
Transition services linked to achieving these goals– Purposeful and actionable information – Collaborative discharge planning – Empathic language and gestures – Anticipating needs– Providing uninterrupted care
• Communication – what makes it good?−−−
Purposeful – what is going on, education Supportive – emotional, empathy, trust Collaborative – questions, shared decision-making
• Anticipating needs− Transportation, Medication, Equipment, Caregiving
responsibilities, Supportive care
• Continuity of care• Coordination – conflict, agreement • Access to care• Abandonment • Feeling known – understanding, trust
Major Themes
“…everyone thinks I have people waiting around in cars, or I drive, that seems to be—I—I haven’t driven since ‘76 and all my friends are workaholics and getting them to tear themselves away for more than five seconds is almost impossible. And uh I—I had a hell of a time with the doctors. Like I’m supposed to have someone take me home after surgeries but I don’t have anybody, so they were doing all this trick stuff to keep from putting me under. And um –”
Anticipating Needs
“they had set up the doctor’s appointments -- the follow ups that I needed for him. And they had filled the prescriptions in the pharmacy downstairs for me. So it literally was a great experience in the fact that they explained it line by line to me, they gave me the prescriptions…somehow we were waiting for pharmacy and the pharmacy brought it up… that all helped, because that’s… fifty million things in my head … that took some things off the list…it kind of set up a plan for me…as I’m going home”
Anticipating Needs
“I had to change my medication from Prograf to Rapimmune…And they didn’t have it…Between all the medical centers around here, no one had the medication… so I panicked…I couldn’t get it anywhere. They said, ‘Well we have the 1 mg but we don’t have 2 mg.’ ‘Well can’t you give me two 1mg?’ ‘No, you have to go back to your doctor’... I had been making phone calls to everybody… trying to get in touch with doctors… trying to get in touch with pharmacists… all the different sections and the next day, luckily I was able to get it, but … late...it was really stressful…if you’re given the medicine in the hospital, give you enough to make sure you have it. Make sure they have it downstairs... I mean that’s life and death. You know?”
Continuity of Care
“Well, I feel like they really made sure that I um, like they made sure that I had an appointment to follow up with my doctor. They made sure I felt well enough to leave.
They made sure that my medications were ready and in fact they wouldn’t even let me leave until the pharmacy confirmed that my medications were ready.
They gave me a lot of information about following up and taking care of myself outside of the hospital. I just felt like they were really compassionate, caring, you know…”
Continuity of Care
“I want to know what’s going on and what do I have to expect, because I’m the one in the long run that’s dealing with this. I mean, my husband is dealing with it but I’m the one that ultimately (is) taking care of him, and going to have to see this through you know…tell me what you’re saying in laymen’s terms. I’m not a doctor and I want to know exactly what’s going on.”
Communication
“I think if they had looked at me as the main objective and the main source of communication…And I should’ve had input into discharge, what the aftercare was gonna be. Somebody should’ve advised me on what the aftercare was gonna be. If you’re gonna hold me accountable to be the nurse, then you need to train me to be the nurse. You need to get me the supplies to be the nurse. Instead of sending me home with nothing”
Communication
Goals and Services
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Rebekah Gardner, MDSenior Medical Scientist
Healthcentric Advisors, New England QIN-QIO
QIN-QIOs:Working with providers
to get to the root of the problem
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Rebekah Gardner, MD Senior Medical Scientist, New England QIN-QIOAttending Physician, Rhode Island HospitalAssociate Professor of Medicine, Brown University
Supporting individual providers for a community solution...
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Perform root cause
analysis
Identify readmission
drivers
Select and implement
intervention
Track process and
outcome data
Determine effectiveness
The Purpose Of Root Cause Analysis
• Understand underlying issues at your hospital
• Identify readmission patterns specific to your community
• Guide intervention selection and focus
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Build The Full Picture
1. Analyze available data
2. Capture the patient and family/caregiver perspective
3. Gather community information and input
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Multidisciplinary Readmissions Committee
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• QIO Reports– Quarterly– Medicare FFS– Not risk adjusted
• Internal data• Chart review
Include PFAC members in this committee
New England QIN-QIO Reports
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New England QIN-QIO Reports
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• Trends over time
• Admissions, readmissions, ED and obs
• Top index and readmission diagnoses
• Days to readmission
• Disposition, LOS
• Patient demographics
Capture Patient Perspective
• Why did they need to come back to hospital?• Do they believe it could have been avoided?• Collect data on:
– Follow-up care– Red flags – Medications– Diet– Supports
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Conduct patient interviews upon readmission
Gather Community Input
• Convene post-acute and community partners– Explore readmissions and other measures – Share internal root causes
• Understand available resources• Map pathway for patients
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Ask patients to inform the community story
Next Steps…
Once you know what to target . . .
. . . the QIN-QIO and HRET HIIN can help identify interventions and feasible measurement strategies
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Perform root cause analysis
Identify readmission drivers
Select and implement
intervention
Track process and outcome data
Determine effectiveness
Interested in learning more? Contact your local QIN-QIO or HRET HIIN
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Thanks to our participating hospitals and our HRET HIIN Partners: CT Hospital Association, Maine Hospital Association, Massachusetts Health & Hospital Association,
New Hampshire Foundation for Healthy Communities, and the Hospital Association of RI
This material was prepared by the New England QIN-QIO, the Medicare Quality Innovation Network-Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMSQINC312017030952
Baptist Memorial Hospital- Golden TriangleColumbus, MS
• 315 Bed Community Hospital• Primary PCI facility• Level III Trauma center• Behavioral Health Services• Cancer Center• ER Visits: 64,117• Births: 896• Average Daily Census: 110• More than 100 medical and surgical
physicians representing almost every medical specialty.
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Challenge: ReadmissionsFocus: Pneumonia (PN) Readmission
• Why - received penalty last 2 years due to high PN readmission rate• How - using KATA to lower PN readmission rate
• Identify True North – where do we want to be in 9 months?• Team – Get Better Jump Start (case manager, educator, nursing, respiratory care, PT,
quality, Sr. Leader, MD champion)• Deep dive into our current condition and identify obstacles• 3-day rapid-cycle PDSA to:
1. Develop hypothesis targeting obstacles- discharge education and communication between caregivers
2. Developed a Job Instruction Breakdown (JIB) for all staff (nursing and ancillary) standardized education approach
3. Utilize Training Within Industry (TWI) on patients – similar to teach-back 4. Developed Pneumonia aftercare instructions
• Piloted on 47-bed Medical-Oncology unit using KATA- completed pilot on March 31, 20171. Change to multi-disciplinary meeting (MDM) with the RN, case manager and
facilitator report flow using detailed checklists and PN talking points2. Incorporated EPIC – LACE+ score to trigger automatic referrals for PT, respiratory
and home care3. Established pneumonia standard work (flowchart)
• Plan for spread underway41
What We Learned…• The JIB is working
– Patients are able to repeat back the important steps– Key points and reason for key points about the diagnosis– Taking medications– Activity/mobility– Nutrition– Reason for referrals.
• Since the pilot, most readmissions are now coming from Skilled Nursing Facilities (SNFs). How do we include SNFs in our work?
• LACE+ tool in EPIC is a good predictor for readmission and there is a need to educate providers.
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GBJS KATA Boards
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Action Items and Next Steps
Lauren KaderabekProgram Manager | HRET
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Pat Teske, BSN, MHAImprovement Advisor| Cynosure Health
Action Items And Next Steps
• Here’s a sneak peak at what’s ahead…– Updated 2017 change
package and top ten checklist
– Whiteboard video series– Fishbowl series
• Readmissions resources available on the HRET HIIN website
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Updated: 2017 Readmissions Change Package- coming soon
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2017 Driver Diagram
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2017 Driver Diagram
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2017 Driver Diagram
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Preventable Readmissions Top Ten Checklist
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Whiteboard Video Series
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11 short videos that compliment the CP and Top 10 list
Fishbowl Series- Starts 5/25/17
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Ransom Memorial
Hospital - KS
NCH, FL
Cullman Regional Medical Center - AL
Memorial Medical Center
- NM
Hancock Regional
Hospital - IN
Ransom Memorial
Hospital - KS NCH Healthcare System-FL
Cullman Regional Medical Center -
AL Memorial Medical Center -
NM
Hancock Regional
Hospital - IN
Thank You!
Find more information on the HRET HIIN website: www.hret-hiin.org
Questions or Comments: [email protected]
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