READMISSION MANAGEMENT

Jacquelyn Paynter, RN, MPH, CCMExecutive Director of Care Management

Burden of Readmissions

How big is the problem?

Fiscal Year FFY2013 FFY2014 FFY2015Targeted Conditions Heart Failure, AMI,

PneumoniaHeart Failure, AMI, Pneumonia

Heart Failure, AMI, Pneumonia COPD, CABG, PCI, Vascular Procedures

Aggregate payment withhold penalties Up to 1% Up to 2% up to 3%

The Top 15 DRG drivers of readmissions at Dekalb Medical are Heart Failure, Renal Failure, Psychosis, Sepsis, COPD, Pneumonia, Respiratory Failure, Red

Blood Cell Disorders, GIB, UTI,and Diabetes. These patient populations represent 33% (ND) and 48%(HD) of the overall readmission volume with an average

readmission rate of 15.5%.

According to an IHI sponsored demonstration project, the key drivers of unplanned readmissions were driven by health care delivery system failures in 4 key

areas:

• ENHANCED ADMISSION ASSESSMENT

• PATIENT AND FAMILY CAREGIVER EDUCATION

• HANDOVER COMMUNICATION

• DISCHARGE PLANNING

• COMMUNITY CONNECTION

Beginning October 1, 2012 (Federal Fiscal Year 2013), the Patient Protection and Affordable Care Act (PPACA) statute will penalize hospitals and integrated

delivery systems with higher than expected readmission rates.

Readmission Management Imperatives

Natl Avg Crude Rate

Eligible Discharges

Number of Readissions

Predicted Risk Adjusted Hospital Rate

Expected Risk Adjusted National Rate

Excess Readmission

Ratio

North DecaturAMI 19.2 109 25 22.1 21.6 1.0230HF 24.6 560 125 22.7 23.6 0.9636

CAP 18.5 494 79 16.6 17.6 0.9446Hillandale

AMI 19.2 23 3 20.3 21.1 0.9612HF 24.6 145 31 22.9 23.7 0.9645

CAP 18.5 95 25 19.0 16.6 1.1412

CMS Hospital Compare

FFY13 Pay for Performance Period: 7/1/08-6/30/11

Implemented heart failure focused care coordination

Structured systematic readmission risk assessment

Processes to identify ED and inpatient recidivist populations

Expanded ED social work coverage and scope

Bedside Rx delivery

Post-discharge phone calls

Diagnosis based ZONES discharge education

Readmission Achievement

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16%

18%

30-day Readmissions to Same Hospital

Hospital Jurisdiction : 80th Percentile State : 80th Percentile National: 80th Percentile

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Medicare All Cause All Hospital Readmission TrendFFY12 Q1 PEPPER Report – North Decatur

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30-day Readmissions to Same Hospital or Elsewhere

Hospital Jurisdiction : 80th Percentile State : 80th Percentile National: 80th Percentile

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Medicare All Cause All Hospital Readmission TrendFFY12 Q1 PEPPER Report – North Decatur

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30-day Readmissions to Same Hospital

Hospital Jurisdiction : 80th Percentile State : 80th Percentile National: 80th Percentile

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Medicare All Cause All Hospital Readmission TrendFFY12 Q1 PEPPER Report - Hillandale

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30-day Readmissions to Same Hospital or Elsewhere

Hospital Jurisdiction : 80th Percentile State : 80th Percentile National: 80th Percentile

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Medicare All Cause All Hospital Readmission TrendFFY12 Q1 PEPPER Report - Hillandale

Multidisciplinary Collaborative Care Coordination Program

What did we do?

ADMISSION ASSESSMENT

Readmission Risk AssessmentED Case Management*Medication Reconciliation*

PATIENT/FAMILY EDUCATION

Zone EducationWalgreens Bedside Rx Delivery and 72hr f/up callsVNHS Preferred Home Health Provider

HANDOVER COMMUNICATION

Hospitalists fax discharge summary and medication reconciliation to PCPCase Management provides an electronic discharge summary to post-acute providers (HHA,SNF,Dialysis)

DISCHARGE PLAN Walgreens Bedside Rx DeliveryMedication Reconciliation*Post Acute Services (HHA, DME, SNF, Dialysis, Hospice)

COMMUNITY CONNECTION

VNHS Preferred Home Health Provider48 hr Post-Discharge CallsPCP Follow-up Appointments*Post-Discharge Transition Clinic*

Implementation of the 5 Care Transition Pillarsat Dekalb Medical

CARE TRANSITION FOCUSDISCHARGE PROCESS

•

Implemented Walgreens Bedside Rx Delivery• ND Campus (May 2011)• Hillandale Campus(January 2012)

Key Functions• Ensures patient receives the medication upon discharge• Supports patient satisfaction with discharge experience• Pharmacy consultation provided, if needed• Caregiver included in consult• Reaffirms understanding of medication while patient still in healthcare

system• Immediate start of therapy on discharge• 15-30 minute turn-around time• Provides 30-day supply of medications• Ability to refill at any pharmacy of patients choice• Follow-up phone call from clinical pharmacist within 72 hours of discharge

Methods & Results

How well did we do it?

CARE TRANSITION FOCUSDISCHARGE PROCESS

•

Walgreens Bedside RX Delivery Results at Dekalb Medical

Volume Statistics North Decatur Hillandale

Discharges 455 1810

Non-Bedside Rx Discharges 370 1503

Bedside Rx Discharges 85 307

Penetration Rate 18.7% 17.0%

Dekalb Medical is among the highest volume

Bedside Delivery programs in the U.S.

Results

• Submitted study to Dekalb’s institutional review board (IRB)• Approved on April 25, 2012 (DM Protocol #040512) • Retrospective cohort • Census of all discharges (all payors)• Controls from

a. Hospital’s historic data (a type of retrospective cohort study)

b. Contemporaneous matches from non-participating facility

(i.e., Hillandale campus compared to North Decatur campus)• Multiple logistic regression, controlling for demographic and

clinical variables

Descriptive StatisticsVariableHistoric

Hillandale

Contemporaneous

Hillandale Historic

North DecaturContemporaneous

North Decatur

Bedside Delivery

North Decatur

n (count of qualifying admits)   4232   7024   13283   19089   1516

30-day readmit (%, n) 9.5% 400 10.8% 757 10.6% 1408 11.5% 2191 5.6% 85

LOS (mean ± SD) 4.3 5.1 4.3 9.6 5.5 6.4 5.1 240.7 4.0 4.2

age > 65 (%, n) 30.8% 1305 31.3% 2197 41.1% 5459 41.8% 7988 29.3% 444

age (mean ± SD) 54.9 18.0 55.0 18.4 59.5 17.7 59.5 18.0 55.7 15.3

HF_case (%, n) 3.5% 148 2.1% 146 1.7% 227 1.1% 207 0.3% 5

AMI_case (%, n) 1.3% 56 1.1% 74 1.0% 130 1.4% 271 1.6% 24

PN_case (%, n) 4.87 206 4.2 295 3.52 468 3.65 696 1.72 26

Medicaid (%, n) 12.0% 509 12.8% 902 9.9% 1312 10.6% 2028 9.3% 141

Race: Other (%, n) 2.1% 90 1.3% 93 5.0% 669 5.5% 1040 4.2% 64

Race: Black (%, n) 92.3% 3908 92.8% 6521 62.1% 8242 63.1% 12038 59.8% 907

Race: White (%, n) 5.5% 234 5.8% 410 32.9% 4372 31.5% 6011 36.0% 545

30 Readmission Rates are comparatively lower for Bedside Rx patients

Adjusted risk of readmission

Independent variables and covariates OR 95% CI Pr > ChiSqMale 0.954 0.896 1.014 0.1316Age 65 + 1.302 1.221 1.389 <.0001Medicaid 1.437 1.31 1.577 <.0001Race (Reference Group: White) 0 Black 1.243 1.153 1.339 <.0001 Other 0.896 0.757 1.061 0.2019Month 1.019 1.01 1.029 <.0001LOS 1.026 1.022 1.031 <.0001CMS Conditions (Reference: without condition) HF 1.554 1.267 1.905 <.0001 AMI 0.428 0.292 0.627 <.0001Interventional group comparison (Reference Group: Bedside Delivery) 0 Historic Hillandale 1.572 1.232 2.005 0.0003 Contemporaneous Hillandale 1.879 1.488 2.373 <.0001 Historic North Decatur 1.828 1.458 2.293 <.0001 Contemporaneous North Decatur 2.071 1.655 2.591 <.0001

The lower readmission rate for Bedside Rx patients is statistically significant

Facilitate PCP identification/referrals/appointments

Accurate medical history and medication reconciliation

Provide structured patient/family education

Establish nurse navigator/coach programs

Implement ED Case Management 7 day/wk 11a-11p

Provide transitional care clinic for P4P readmission discharges

Strengthen systematic handover communication between care providers

Further enhance use of Care Transition Home Health Visits and 30 day Post Discharge Medication

Management

Care Coordination Enhancement Opportunities

DISCUSSION