reducing avoidable readmissions effectively...
TRANSCRIPT
Reducing Avoidable Readmissions Effectively (RARE)
Mark SonnebornVP, Health Information & Analytics
13-October-2017
About Minnesota
Size: 225,163 km2
Population: 5.5m• Most in Minneapolis/St. Paul
Climate: Brutally cold in winter
These are averages – it can get way worse“Land of 10,000 Lakes”
equivalent to Victoria
Things you may know from Minnesota
Usually, the Super Bowl is held in places like Miami . . .
Miami in January: 15/25 Celsius
Healthcare financing in US/MN
Commercial insurance• In MN, mainly through 3 health plans (this is different in every state) Government
• Medicaido For low-income – mix of state and federal funding
• Medicareo For people over 65 years old – all federally fundedo High users of inpatient care
Mostly paid “fee for service”• However, “value-based purchasing” is emerging
Healthcare delivery system in Minnesota
142 Hospitals• 78 have fewer than 25 beds• 70% are part of a system• 100% have electronic medical records
~18,000 licensed physicians• 75% of physicians are employed by hospital/health system
o This is very unusual compared to the rest of the USo Most practice in large group clinics – also unusual
• Primary care vs. specialty physicianso Rural: 80/20; Metro: 45/55
Minnesota has low-cost, high-quality healthcare
AK
AL
ARAZ
CA
COCT
DC
DE
FL
GA
HI
IAID
ILIN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NCND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SDTN
TX
UT
VA
VTWA WI
WV
$6,000
$7,000
$8,000
$9,000
$10,000
$11,000
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Overall Quality Meter (2016 - B)
Value Comparison by State, All Medicare Spending vs. Overall Quality Score (updated April 2017)
Nat'l Avg.
Sources: A - 2015 CMS data, Apr 2017B - NHQR State Snapshots, May 2016
Overview of the RARE Campaign
Video
https://www.youtube.com/watch?v=kqLIfSjsGA8&feature=youtu.be
Why focus on 30-day hospital readmissions?Business View
Federal• 3% penalty on Medicare for “greater readmissions than expected”
o Looks at specific conditions and now, hospital-wideo Only big hospitals
Minnesota • Medicaid payments reduced by 10% in 2011, but . . .• Can earn back 5% with 5% fewer readmissions by 2013
Readmissions in a changing payment environment
Old (i.e., up ‘til now) model• Readmissions = suboptimal quality of care, but…
o Reimbursed for both admissions!
Future (or at least probable) model• Readmissions are a cost, not a revenue
Transitional phase• Penalties for readmissions• Hospitals spend resources to reduce readmits, and get less revenue
when they doo a.k.a. “the double whammy”
Campaign Design
Focused on hospitals with support of providers, health plans, other key stakeholders Designed to improve coordination of care and reduce
fragmentation of the health care system Engage other key stakeholders—readmissions not just hospital
issue• Over 100 “community partners” in addition to hospital participants
Goal-setting
By end of 2012: • 20% reduction in two years (4,000 avoidable readmissions)• 16,000 more nights of sleep in their own beds• Estimated $10,000 inpatient costs per avoided readmission
By end of 2013:• 6,000 avoidable readmissions (24,000 nights)• 20% reduction from baseline
Strategies to reduce readmissions
Medication Management Transition Care Support Patient & Family Engagement Comprehensive Discharge Planning Transition Communication
Fire Department approached Park Nicollet
• 70% of calls for St. Louis Park Fire Department are EMS calls (about 10/day)– Many of these calls are from our patients who have been
discharged• Opportunity to impact the pre-911 timeframe
– Proactive intervention vs. reactive based on 911 call (resulting in fire, police, ambulance response)
– Reinforce discharge messages in the patient’s home setting• Park Nicollet said YES! Let’s partner!
Main components of the firefighter visit
• Review of the following:– Meds - does the patient know what medications he/she should
be taking? – Red flags - does the patient know the signs and symptoms to
be aware of? • Does the patient know who to call and when?
– Is there a follow up appointment scheduled? • PEAT - Physical environment assessment• Connect patient with any necessary resources
The integral role of data in RARE. . .
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2009 2010 2011 2012-1 2012-2 2012-3 2012-4 2013-1 2013-2 2013-3 2013-4
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Potentially Preventable Readmissions in Minnesota 2009 - 2013 4th Qtr
Goal MN RARE
RARE Campaign Launched
Data source – MHA Database• All-payer inpatient claims for all MN hospitals
o But, can only look at readmit to same facility 22% readmits to different facility “An inaccurate scale can still tell you if you’ve lost weight”
Software – 3M Potentially Preventable Readmissions o 3M’s clinical experts developed methodologyo Each record designated as admission or readmissiono Calculates severity-adjusted PPR rates by condition & by hospital
“Potentially Preventable Readmissions”
Review:How to interpret PPR results
PPRsAt Risk Cases
Actual Rate
Expected Rate
Expected PPRs
Target PPRs
Difference from Target A/E Ratio
172 3,820 4.5 5.0 ** 192.3 153.9 18.1 0.90
PPRs is the actual number of PPRs detected during the time period
How to interpret PPR results
“At Risk Cases” is the denominator – it’s all cases, minus the exclusions (not that many)
PPRsAt Risk Cases
Actual Rate
Expected Rate
Expected PPRs
Target PPRs
Difference from Target A/E Ratio
172 3,820 4.5 5.0 ** 192.3 153.9 18.1 0.90
How to interpret PPR results
Actual Rate is PPRs divided by At Risk Cases
PPRsAt Risk Cases
Actual Rate
Expected Rate
Expected PPRs
Target PPRs
Difference from Target A/E Ratio
172 3,820 4.5 5.0 ** 192.3 153.9 18.1 0.90
How to interpret PPR results
Expected Rate – this is a unique number for every hospital based on their patient population. Generally, hospitals with more severely ill patients will have higher expected rates.
PPRsAt Risk Cases
Actual Rate
Expected Rate
Expected PPRs
Target PPRs
Difference from Target A/E Ratio
172 3,820 4.5 5.0 ** 192.3 153.9 18.1 0.90
How to interpret PPR results
One star is statistically “worse than expected” (or higher); Two stars is “no different than expected”; Three stars is “better than expected” (or lower)
PPRsAt Risk Cases
Actual Rate
Expected Rate
Expected PPRs
Target PPRs
Difference from Target A/E Ratio
172 3,820 4.5 5.0 ** 192.3 153.9 18.1 0.90
How to interpret PPR results
Expected PPRs is the Expected Rate times the At Risk Cases
PPRsAt Risk Cases
Actual Rate
Expected Rate
Expected PPRs
Target PPRs
Difference from Target A/E Ratio
172 3,820 4.5 5.0 ** 192.3 153.9 18.1 0.90
How to interpret PPR results
Target PPRs is 20% less than Expected PPRs
PPRsAt Risk Cases
Actual Rate
Expected Rate
Expected PPRs
Target PPRs
Difference from Target A/E Ratio
172 3,820 4.5 5.0 ** 192.3 153.9 18.1 0.90
How to interpret PPR results
Difference from Target is your actual PPRs (first column) minus the Target PPRs.
The goal for this hospital is to reduce by 18 PPRs per year.
PPRsAt Risk Cases
Actual Rate
Expected Rate
Expected PPRs
Target PPRs
Difference from Target A/E Ratio
172 3,820 4.5 5.0 ** 192.3 153.9 18.1 0.90
Actual to Expected Ratio
Actual Rate
Expected Rate A/E Ratio
4.5 5.0 0.90
An A/E Ratio above 1.0 is more than expected; below is less than expected.
The goal for the RARE campaign is to get the A/E ratio down to 0.80
Hospital Analyses
Hospital-identified summary-level • This was key – even though not shared publicly, provided some
transparency
Hospitals also may access their record-level data• Through a secure portal at MHA
Updated quarterly• And still is today
So how did we do?
2013 John M. Eisenberg Patient Safety and Quality Award Winner!
83 hospitals and 100 community partners have prevented 7,975 avoidable hospital readmissions, helping patients spend 31,900 more nights in their own beds
Reduced inpatient costs by an estimated $70 million
The RARE Campaign is one of the largest coordinated improvement initiatives undertaken by the Minnesota health care community.
Work on five key areas that, if not managed well, are known to be main contributors to avoidable hospital readmissions: 1. Comprehensive discharge planning 2. Medication management 3. Patient and family engagement 4. Transition care support 5. Transition communications
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2009 2010 2011 2012-1 2012-2 2012-3 2012-4 2013-1 2013-2 2013-3 2013-4
Actu
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Exp
ecte
d Ra
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Potentially Preventable Readmissions in Minnesota 2009 - 2013 4th Qtr
Goal MN RARE
RARE Campaign Launched
This is what we won our award for – what’s happened since?
Reducing Readmissions, Post-RARE
Coordination of Care Initiative Mental Health Community Partners Network Partnerships across the continuum
• Certified Community Behavioral Health Clinics
Coordination of Care Initiative
Collaborative effort with QIO to bring providers from designated communities together to coordinate care that meet the needs of the patients served in their communities. Quarterly in person meetings Monthly workgroup meetings
o10 communitieso405 organizations
o Hospital, SNF, ALF, Clinic, Home Health, Hospice, Pharmacy, Community Organizations
o1,097 participantso35 workgroups
Mental Health Community Partners Network
This recently completed initiative offered an opportunity for representatives of hospitals to connect and collaborate with their community partners toward improving care transitions for people with mental illness. An outgrowth of the RARE Mental Health Collaborative, the Mental Health Community Partners Network utilized meetings and webinars to share information on bright spots in care transitions and helped to develop collaboration skills.
Partnerships across the continuum
CCBHC: Certified Community Behavioral Health Clinics MHA mental and behavioral health committee convened a subgroup to develop a statewide care transition and communication
approach for CCBHC patients. This subgroup will collaborate with the CCBHCs and hospitals and health systems to determine, develop and disseminate methods and tools to enhance continuity of care.
Northwestern MH Center:6 hospitals in service area
Northern Pines MH Center:7 hospitals in service area
Wilder Children and Family Services, People Incorporated, Ramsey County MH:17 hospitals in service area
Zumbro Valley MH:3 hospitals in service area
Post-RARE
Summary
PPRs – and especially the A/E ratio – were an important tool to monitor progress on reducing readmissions• And remain so today
MN hospitals have been able to sustain the gains made during the RARE campaign through focus, effort, and persistence
Challenges/Lessons Learned
Measurable goals to drive actions Campaign goal setting – numbers vs percent Convincing some hospitals that they have an issue with
readmissions Creating role for Community Partners Need for patient/family engagement and activation
Challenges/Lessons Learned
Do the right thing—bigger than any one organization Different way to work Leveraging expertise/dividing the work Sharing credit Broke down barriers, resulted in mutual respect, desire to do
more together
