Virginia Nurses Association Chapter 5

January 17, 2013

Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN Senior Director, Galloway Consulting Research Associate Professor, University of Virginia, School of Nursing Editor in Chief, American Nurse Today

National Quality Strategy (2011) National Strategy for Quality Improvement in Health Care (HHS) Better Care: Improve the overall quality--more

patient-centered, reliable, accessible, and safe.

Healthy People/Healthy Communities: address behavioral, social and, environmental determinants of health; deliver higher-quality care

Affordable Care: reduce the cost of quality health care

for individuals, families, employers, and government

National Quality Strategy

Partnership for Patients (2011) Better Care, Lower Costs Public-private partnership that will help improve the quality, safety and affordability of health care for all Americans

• Keep patients from getting injured or sicker.

By the end of 2013, preventable hospital-acquired

conditions would decrease by 40% compared to 2010.

• Help patients heal without complication.

By the end of 2013, a 20% decrease in hospital

readmissions from 2010 (related to a complication

during a transition across care settings)

Condition of Affordable Care Act

Effective October 1, 2012 AMI, Heart Failure, Pneumonia

2,211 hospitals penalized $280 Million—maximum of

1% of Medicare base payments

October 1, 2013 can rise to 2% base payments

Additional diagnoses

Source Kaiser Health News

Estimated impact:

1 out of 5 Medicare patients readmitted in 30 days = 2.6 Million people

Cost = $26 billion annually (additional impact on Medicaid and private insurance)

Hospitals with higher proportion of poor and/or African American patients had higher rates

Reflects complications or poor transitions threatening safety and survival

Patient characteristics Demographics Socioeconomic status Behaviors Disease status

Activities and events associated with hospital care Environmental factors Terminal illness and multiple chronic medical and

mental health conditions Poor support systems and services in community such as

housing, transportation, other assistance

Meet three of the Institute of Medicine’s 6 aims of care Safe

Effective

Efficient

Patient-centered

Timely

Equitable Achieved from provider to provider and setting

to setting

Reduce risk of readmission Providers of all disciplines cooperate

Patient Centered

Plan of Care

Health care providers

Patient Preferences

Community resources

Social

Services

Across time And settings

Involve patients and families as the most consistent element

Training for activation and self care skills

Patient-centered care plan:

▪ Negotiated

▪ Responsive to medical and social situation

▪ Assures services available

▪ Shared across settings

Standardized, accurate, and timely communication and information exchange between transferring and receiving provider

Medication reconciliation Safe transportation Timely DME Hand off means sending provider relinquishes

responsibility for care only after patient received by clinician at new location

Affordable Care Act (section 3026) implemented April 2011 by Centers for Medicare and Medicaid (CMS)

Aim: to improve patient transitions from hospitals to other settings 5 year program; $500 million Opportunity for hospitals with high readmission

rates to partner with community-based organizations (CBO) and CBOs that provide transition services

Test models for improving care transitions for high risk Medicare patients; focus on preventable complications

Services Offered: Care transition services: 24+ hours before

discharge Post discharge education so patients

understand potential problems and signs of changing/deteriorating condition Timely

Culturally appropriate

Linguistically competent

Services offered (continued) Timely interactions between patients and

post acute and other outpatient providers Patient centered self management

support Complete medication review and

management

Rationale: align incentives for providers by bundling payments for services across an episode of care

4 models Reduce fragmentation Improve coordination across providers and

settings

Retrospective Payment Bundling—set a target payment with discount to Medicare rate (may be able to share savings) #1 Hospital stay only—discounts Inpatient

Prospective Payment rate; MD fees stable #2 Inpatient stay and post acute care to include +30

to +90 days #3 starts at discharge from hospital then +30 days

post discharge #2 and #3 both include discounts for hospital and

MD/other provider fees; includes lab, DME, prosthetics/orthotics, supplies, Part B drugs

Prospective Payment Bundling—set a target payment with discount to Medicare rate (may be able to share savings) continued

#4 Single payment to hospital for all services of inpatient stay including MD/other providers

All models incentivize avoidance of readmissions

Care Transitions Intervention

Eric Coleman, MD, MPH

University of Colorado

Transitional Care Model

Mary Naylor, PhD, RN, FAAN

New Courtland center for Transitions and Health

University of Pennsylvania

BOOST—Better Outcomes for Older adults

through Safe Transitions

Society of Hospital Medicine

Project RED—Re-engineered Discharge

Boston University

Intervention focuses on 4 pillars Medication self management

Understand medications and have system to ensure correct intake at home

Dynamic patient centered record Understand and manage personal health record (PHR)

Follow-up Patient schedules and completes follow up with primary and specialist care

Red Flags Knows how to recognize signs of condition decline and how to respond

Tools Patient centered record (PHR) Structured discharge preparation checklist Patient self-activation and management

session with Transitions Coach® Transitions Coach® follow up visit at SNF or

home plus phone calls

34 of 47 Community-based Care Transitions Model sites are using this intervention

7 strategies—collectively create effective care transitions (↓ 30 day readmissions 20-50%) Greater engagement of patient and family care givers Acknowledge essential status of family care givers as

essential care team members Implement performance measures Define accountability during transitions Build professional competency in care coordination Explore and implement technological solutions to

improve exchange of information/communication across settings

Align financial incentives to promote cross setting collaboration

Targets older adults with 2+ risk factors History of recent hospitalization

Multiple chronic conditions or medications

Poor self-health ratings Managing transitions across settings and

changes in condition ↓readmissions 28% first 24 weeks and 13%

within a year (Kaiser Permanente patients) Reduced costs 39% per patient ($5,000)

within year after hospitalization

Transitional Care Nurse (TCN) Advanced practice nurse with a masters

degree in nursing with advanced knowledge and skills in the care of older adults

Caseload of 15-20 patients In-hospital visit Home visit Nurse visit with physician

Key components Patient and caregiver understanding

Patient education

“Translating” information Medication reconciliation and management Transitional care (not ongoing case management)

Help patient and family develop knowledge, skills, and resources to prevent decline and/or re-hospitalization

Facilitate connections to needed care

Goal: improve hospital discharge process

30 day readmission rate (older adults; general medicine)

Improve patient satisfaction and H-CAHPS scores related to discharge

Improve flow of information between inpatient and outpatient providers and settings

Identify high risk patients and specific tailored interventions to lower risk for adverse events

Improve patient and family preparation for discharge

Key elements Mentoring to customize interventions Comprehensive implementation guide—

many tools available to public Longitudinal technical assistance BOOST collaboration BOOST data enter

Combination of tools for interventions shown to decrease readmissions BOOST mentors hospital teams

Map current processes and create and implement action plans for organizational change.

Provides a suite of evidence-based clinical interventions that can be easily adapted and integrated into each unique hospital environment

105+ sites enrolled in year long mentoring ↓30 day readmission rate 21%

Goal: reduce readmissions and yield high patient satisfaction Key Factors

Educate patient about diagnosis throughout stay

Patient involved in setting follow up appointments

Patient knows what tests were not completed in the hospital

Post discharge services are organized

Medication plan confirmed

Key factors (continued)

Discharge plan reconciled with national guidelines and critical pathways

Care provider reviews with patient actions to take if a problem develops

Discharge summary has expedited transmission to post acute providers

Care providers assess patient understanding of plan

Patient received written discharge plan

Patient receives phone follow up 2-3 days post discharge to discuss plan or any problems

Unique feature

Louise—virtual discharge advocate

74% of patients preferred the virtual nurse

Results in development phase

34% lower costs

30% lower rate of hospital utilization

15-20% reduction in 30 day readmission rate

16-24% reduction in ED use

Keep focus on all safety and quality improvement initiatives

Recognize transitions as times of vulnerability

Assess vulnerable populations for risk factors including health care disparities

Take action to improve overall care that prevents adverse events and mitigates risk factors

New evidence: Improving education, environment, and

workload can lead to lower readmission rates (in addition to evidence on lower RN overtime hours)

Hospital Nursing and 30-Day Readmissions Among Medicare Patients With Heart Failure, Acute Myocardial Infarction, and Pneumonia

McHugh, Matthew D. PhD, JD, MPH, RN; Ma, Chenjuan PhD, RN

Medical Care 2013;51: 52-9

Participate in the Partnership for Patients Follow trends in reimbursement for quality

and penalties for “off-quality” Champion the use of tools to improve

transitions in care Celebrate successful reduction of

readmissions and improved patient experiences

Community-based Care Transitions Program http://www.innovations.cms.gov/initiatives/Partnership-for-Patients/CCTP/index.html?itemID=CMS1239313 Roadmap to Better Care Transitions and Fewer

Readmissions (Partnership for Patients) http://www.healthcare.gov/compare/partnership-for-patients/safety/transitions.html#BackgroundonCareTransitions Care Transitions Intervention (Coleman) http://www.caretransitions.org/overview.asp Project BOOST http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&TEMPLATE=/CM/HTMLDisplay.cfm&CONTENTID=27659 Project RED http://www.bu.edu/fammed/projectred/