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22670 Haggerty Road, Suite 100, Farmington Hills, MI 48335 www.mpro.org Save Your Census: Strategies to Prevent Re-hospitalization March 30, 2010 Joint Provider/Surveyor Training 9SOW-MI-7.2-09-

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Save Your Census:. Strategies to Prevent Re-hospitalization. March 30, 2010 Joint Provider/Surveyor Training - PowerPoint PPT Presentation

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Page 1: Save Your Census:

22670 Haggerty Road, Suite 100, Farmington Hills, MI 48335 www.mpro.org

Save Your Census:Strategies to Prevent

Re-hospitalization

March 30, 2010Joint Provider/Surveyor Training

9SOW-MI-7.2-09-60

Page 2: Save Your Census:

Background:Hospitalization of Nursing Home Residents are:

• Common

• Often disruptive for the resident and family

• Fraught with many complications

• Costly

• Sometimes an inappropriate and avoidable use of the Emergency Room

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Page 3: Save Your Census:

SNF Admissions/Readmissions:

• 40% of Medicare beneficiaries are discharged to a post acute setting. (SNF, Home Care, Hospice)

• 50% of these enter a nursing home for rehabilitation or long term care

• The rate of SNF 30 day rehospitalizations grew 29% between 2000 and 2006 from 18.2% to 23.5%

• The total cost for these re-admissions: $4.34 Billion

Source: The Revolving Door of Rehospitalization From Skilled Nursing Facilities, 1.2010 /29:1 Health affairs

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Page 4: Save Your Census:

Michigan Data for 2006:

• 65,477 skilled nursing home episodes

• 25.8% were re-hospitalized within 30 days of the initial hospitalization

• Total re-hospitalization payments:$175.35 Million

Source: The Revolving Door of Rehospitalization From Skilled Nursing Facilities, 1.2010/ 29:1 Health affairs

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Page 5: Save Your Census:

Top 5 Re-admissions from SNF:

• Heart Failure

• Respiratory Infection

• Urinary Tract Infection

• Sepsis

• Electrolyte Imbalance

Source: Medicare Payment Advisory Commission, Washington D.C., 2006

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Page 6: Save Your Census:

These Re-admissions:

• Are potentially avoidable

• Account for 78% of all thirty-day SNF Re-hospitalizations

• Cost Medicare $3.39 Billion in 2006

Source: Medicare Payment Advisory Commission, Washington D.C., 2006

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Page 7: Save Your Census:

Other Costs of Re-hospitalizations:

• Negative outcomes associated with medical errors

• Stress for patients and caregivers

• Duplication of tests or procedures

• Functional decline of patients

• Loss of SNF revenue due to empty beds

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Page 8: Save Your Census:

Why do Re-hospitalizations Occur?

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• Transfer of information to the next care setting is often incomplete

• Receiving practitioners often do not know the patient and his or her preferences for care

• Practitioners have no accountability once a patient leaves their care

• Patients and caregivers have few tools to navigate all the settings

Page 9: Save Your Census:

The Care Transitions Project:

• Three year Initiative ending July 31, 2011

• Focused in the Greater Lansing Area

• Goals of project: ■ Reduce hospital readmissions of Medicare

Beneficiaries■ Improve collaboration across care settings

►Acute care, LTAC, SNF, HHC/Hospice/ Physicians

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Page 10: Save Your Census:

Skilled Nursing Facilities’ Role:

• Used INTERACT Toolkit to identify drivers of readmissions

• Implemented evidence-based interventions from INTERACT Toolkit to decrease the likelihood of readmissions

• Implemented Care Transition Coaching

• Joined Cross Setting Work group to reduce heart failure re-admissions

• Send PCP a discharge summary prior to rehab patient discharges

• Increased utilization of home care upon discharge

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Page 11: Save Your Census:

Burcham Hills Improvement Journey:

• Improving communication through patient-centered care■ Welcoming program■ 3 day care conferences■ Inclusion of patient and family in discharge planning

• Improving communication across the continuum■ Adding a new staff position:

► Improved communication between residential community, hospital, and healthcare center

►Risk assessments

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Page 12: Save Your Census:

Ingham County Medical Care Facility's Improvement Journey:

• Admission Assessments

• RN Gate keeper

• Staff Education

• Monitoring Results

• Cross Setting Collaboration through the heart failure workgroup

• Care transitions coaching

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Page 13: Save Your Census:

How Does a SNF get started?

• Obtain data:■ Monthly hospital readmission numbers■ Monthly emergency department visits

• Determine potential drivers of readmissions■ Use INTERACT “Review of Acute Care Transfers” audit

tool

• Initiate or Join a cross-setting Collaborative to improve communication across settings.

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Page 14: Save Your Census:

Use Interact Tools for:

• Reducing avoidable acute care transfers

• Early identification of a change in resident status

• To guide nursing home staff through a comprehensive resident assessment when a change is noted

• Improve documentation

• Enhance Communication

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Page 15: Save Your Census:

Find the INTERACT II toolkit at:

•http://interact.geriu.org

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Page 16: Save Your Census:

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Page 17: Save Your Census:

MPRO’s Care Transitions Team:

Donna Beebe, Project Manager

[email protected] or 248-465-7354

Sandra Soronen, Project Coordinator

[email protected] or 248-465-7347

Barbara J. Smith, Project Manager

[email protected] or 248-465-1310

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Page 18: Save Your Census:

22670 Haggerty Road, Suite 100, Farmington Hills, MI 48335 www.mpro.org

MPRO’s Mission:Improving quality, safety and efficiency

across the healthcare continuum.

This material was prepared by MPRO, the Medicare Quality Improvement Organization for Michigan, 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.

9SOW-9MI-7.2-10-83