MHA Keystone Center - Michigan Association for Local Public Health

The Michigan Health & Hospital Association
(MHA) Keystone Center Approach to Reducing
Avoidable Readmissions
Overview
• MHA Keystone Center background
• Readmissions background
– The context for the readmission policy
– The Hospital Readmission Reduction Program (HRRP)
– Current state of readmissions
• Care transitions in Michigan
– STate Action on Avoidable Rehospitalizations (STAAR)
initiative
• Summary
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MHA Organization
Michigan Health
& Hospital
Association
Non-profit Michigan
corporation (501-c-6)
Hospital
Purchasing
Service
Michigan non-profit
association
MHA Service
Corporation
For-profit Michigan stock
corporation
HealthPAC
Political action
committee formed
under state statute
MHA Health
Foundation
Non-profit Michigan
corporation (501-c-3)
MHA
Unemployment
Comp Program
MHA
Keystone
Center
Informational IRS return
filed by individual
participants
Non-profit Michigan
corporation (501-c-3)
Represents legal control (ownership and/or
complete authority to operate)
Hospital Councils
Non-profit Michigan
corporations
(501-c-6 or 3)
Represents affiliation agreement and/or board
position (operating cooperation and coordination)
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MHA Keystone Center
The MHA Keystone Center uses evidence-based best practice in
combination with cultural improvement to effect change in
patient/resident safety and quality.
Vision
Healthcare that is safe, effective, efficient, patient centric, timely and
equitable.
Mission
To lead the nation in quality and patient safety through the diffusion
of change using patient-centered, evidence-based interventions
supported by cultural improvement.
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MHA Keystone Center
MHA Keystone
Center
Non-profit Michigan
corporation (501-c-3)
MHA Patient
Safety
Organization
Collaboratives
Federally-certified PSO
National
Projects
Michigan
Projects &
Hospital
Engagement
Network
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Safety & Quality Issues
•
•
•
•
•
•
•
•
•
•
•
•
Preventable readmissions – transitions of care
Injuries from falls and immobility
Adverse drug events
Pressure ulcers
Elopements
Behavioral health
Catheter-associated urinary tract infections
Central-line-associated bloodstream infections
Obstetrical adverse events
Surgical-site infections
Venous thromboembolism
Ventilator-associated pneumonia
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MHA Keystone Center Background
• The MHA Keystone Center uses evidence-based best practice
in combination with cultural improvement to effect change in
safety and quality.
• Nonprofit organization created in 2003 by the MHA
─ United voice to practitioners
─ Support for evidence-based care
─ Rigorous measurement
Healthcare safety and quality are not competitive – the tide
raises all ships
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Context for the Readmission Policy
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Background: Payment Reform
“Estimates suggest that as much as $700 billion a year in health
care costs do not improve health outcomes.”
- Peter Orszag, Former Director of the Congressional Budget Office
9
Background: Payment Reform
• Focus on quality of care when determining provider
reimbursement
• Implemented through Medicare, Medicaid and private
commercial contracts
• Affected providers:
– Hospitals
– Individual clinicians
– Managed care organizations
– Accountable care organizations
10
Why all the Talk about Readmissions?
Safety
• Institute of Medicine report made clear the consequences of
poor transition management
Quality
• Poor care coordination and use of evidence-based approaches
• Large number of readmissions may be preventable
Cost
• Centers for Medicare & Medicaid Services (CMS) indicates $13
billion in savings or $25 billion across all US payers
*MedPac 2007 Report to Congress; Promoting Greater Efficiency in Medicare. Chapter 5: Payment Policy for Inpatient Readmissions
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Readmission Definition
CMS’ readmission definition:
An admission to a subsection(d) hospital within 30 days of a
discharge from the same or another subsection(d) hospital;
Adopted readmission measures for the applicable conditions of
Acute Myocardial Infarction, Heart Failure and Pneumonia
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html
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The Hospital Readmission Reduction Program (HRRP)
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HHRP
Background
• Recommended by Medpac in 2007, 2008 Reports to Congress
• Public reporting of readmissions began in 2009 on Hospital Compare
Authority
– Adopted as part of Patient Protection and Affordable Care Act
(PPACA) (section 3025) in 2010
– Codified in SSA, §1886(q)
– Initial program policies in fiscal year (FY) 2012 inpatient prospective
payment system final rule
– Regulations at 42 C.F.R. §412.152
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Legislative Context Shapes HRRP
• PPACA (2010) was to provide all Americans with affordable
healthcare
– Faced stiff opposition
– To get it passed, programs had to be inserted that would
reduce the total cost burden of the bill
• HRRP is one of those cost reduction programs
– Estimated to reduce Medicare payments by $7.1 billion
(between 2013-2019)
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HHRP Overview
• The HRRP is a reimbursement penalty approach for general acute care
hospitals that have readmissions deemed “excess” by CMS
– Began FY 2013 (Oct. 1, 2012)
– Reduction is capped at 1% in 2013, 2% in 2014 and 3% in 2015 and
beyond
– Reductions apply to total diagnosis-related group reimbursement
• Readmissions deemed excess are determined using three specific
conditions endorsed by the National Quality Foundation
–Acute Myocardial Infarction
–Heart failure
–Pneumonia
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Readmissions
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Admissions Rate by County
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Readmissions Rate by County
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Current State Of Readmissions
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Community-based Care Transitions Program (CCTP)
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STate Action on Avoidable Rehospitalizations (STAAR)
• The Institute for Healthcare Improvement (IHI) launched the
STAAR initiative
• In Michigan, this initiative was known as MI STA*AR
– Effort led by the MHA Keystone Center and MPRO,
Michigan’s health care quality improvement organization
– May 2009 through June 2013
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Goals
• Reduce statewide 30-day rehospitalization rates by 30 percent
• Increase patient and family satisfaction with transitions in care
and with coordination of care
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STAAR Approach
Improve transitions between settings
• Cross-continuum teams
• Collaborative learning
• State-based mentoring and quality improvement infrastructure
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Regional Strategy*
• Hospital-level
– Improve the transition out of the hospital for all patients
– Measure and track 30-day readmission rates
– Understand the financial implications of reducing rehospitalizations
• Community-level
– Engage organizations across continuum to collaborate on improving care, partner with
non-clinical community based services
– Ensure post-acute providers are able to detect and manage clinical changes, develop
common communication and education tools
• State-level
– Develop state-level population based rehospitalization data
– Convene all payer discussions to explore coordinated action
– Link with efforts to expand coverage, engage patients, improve health information
technology infrastructure, establish medical homes, contain costs, etc.
– Establish state strategy, use regulatory levers
* IHI
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Participating Hospitals
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STAAR Key Changes for an Ideal Transition
1. Perform an Enhanced Assessment of Post-Hospital Needs
A. Involve family caregivers and community providers as full
partners in completing a needs assessment of patients’ homegoing needs
B. Reconcile medications upon admission
C. Create a customized discharge plan based on the
assessment
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STAAR Key Changes
2. Provide Effective Teaching and Facilitate Enhanced Learning
A. Customize the patient education materials and processes
for patients and caregivers
B. Identify all learners on admission
C. Teach-back
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STAAR Key Changes
3. Provide Real-time Handover Communications
A. Reconcile medications at discharge
B. Provide customized, real-time critical information to next
clinical care provider(s)
C. Give patients and family members a patient-friendly discharge
plan
D. For high-risk patients, a clinician calls the individual listed as
the patient’s emergency contact to discuss the patient’s status
and plan of care
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STAAR Key Changes
4. Ensure Timely Post Acute Care Follow-up
A. For high-risk patients: prior to discharge, schedule a faceto-face follow up visit to occur within 48 hours after discharge
B. For moderate-risk patients: prior to discharge, schedule a
follow-up phone call within 48 hours and schedule a physician
office visit within five days
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A Model for Learning and Change
Three Questions
+
Plan-Do-Study-Act
(PDSA)
=
The Model
for
Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make
that will result in
improvement?
Act
Plan
Study Do
The PDSA Cycle for Learning and Improvement
Act Plan
-What changes
are to be made?
-Next cycle?
-Objective, questions
and predictions (why)
-Plan to carry out the
cycle (who, what,
where, when)
Study Do
-Complete the analysis
of the data
-Compare data to
predictions
-Summarize what
was learned
-Carry out the plan
-Document problems
and unexpected
observations
-Begin analysis of
the data
LEAN Tools
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Cross-continuum Teams
• Convening of community partners across the continuum of
care
– Identify barriers and develop strategies for coordinating care
– Provides opportunity to build relationships, learn from one
another
• Reinforces that readmissions are not solely a hospital problem
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Key Community Players
•
•
•
•
•
•
Health department
Home healthcare agencies
Physician clinics
Skilled nursing facilities
Free clinics
Area agencies on aging
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Impact
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Many Interventions
• STAAR
• Project BOOST (Better Outcomes for Older adult Safe
Transitions)
• Project RED (Re-Engineered Discharge)
• Coleman model
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Barriers
• Resources
– Time
– Staff
• Multiple initiatives can lead to project fatigue
• Limitations within electronic medical records
• No single intervention to impact readmissions
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Opportunities
• Improving awareness of community resources
• Utilization of post-acute care settings and community-based
organizations
• Coordinating efforts
• Readmissions are a community issue
• Coordinated care across the healthcare continuum is needed
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Care Transitions Coordinating Team
• Effort to align and coordinate statewide activities
• Provides strategic direction for care transitions work in the
state
• Members include Michigan Transitions of Care Collaborative,
the Greater Detroit Area Health Council, MPRO, the Michigan
Health Information Network, the Hospice & Palliative Care
Association of Michigan and others
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Acknowledgements
•
•
•
•
MPRO
Institute for Healthcare Improvement
Robert Wood Johnson Foundation
Michigan hospitals
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Summary
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References
• MedPac 2007 Report to Congress; Promoting Greater
Efficiency in Medicare. Chapter 5: Payment Policy for Inpatient
Readmissions
• Centers for Medicare & Medicaid Services:
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/AcuteInpatientPPS/Readmissions-ReductionProgram.html
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Questions
Contact us:
• Danielle Barnes, MS
– DBarnes@mha.org
• Bryan O. Buckley, MPH
– BBuckley@mha.org
• Laura Fournier, MA
– LFournier@mha.org
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MHA Patient Safety & Quality Guidebook
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