04.1 David Gifford GA Hospitalization Is Key To Future Business

REDUCING HOSPITAL
READMISSIONS IS KEY TO
YOUR BUSINESS SUCCESS
David Gifford MD MPH
American Health Care Association
Atlanta GA
Jan 21st, 2015
Overview of Session
This session will provide an overview of recent federal
legislation and policy decisions that link quality (particularly
rehospitalizations) to payment and changes to public
reporting on SNF’s performance along with suggestions on
how to succeed in this changing landscape.
Learning Objectives:
1. describe the recent SNF Value Based Purchasing legislation that
implements up to a 2% withhold for SNF part A payments based
on your rehospitalization rates
2. understand how Georgia centers compare to peers on national
quality initiatives
3. apply five key steps to reduce SNF rehospitalizations
THE BUSINESS CASE FOR
LOWER HOSPITAL
READMISSION RATES
Use of Skilled Nursing Centers
Home
35%2
20%1
Hospital
SNF
23%1
ER
1.
2.
3.
4.
Mor et al., 2010
MedPAC 2010
Commonwealth 2011
Jencks NEJM 2009
19%4
Assisted
Living
Nursing
Home
Death
20%3
State Avg SNF Rehospitalizations 2014 Q2
Georgia
• 17% avg reduction
• 51% achieved AHCA Goal
• 35th to 31st best state 2011 to 2014
Nat
Avg
All AHCA members in 2104 Q2 OnPoint 30 rehospitalization
Change in State Avg. Rehospitalization
Rate (Q4 2011 – Q2 2014)
AHCA
Goal
Georgia
24 States >15% Goal
Getting Better
State Avg. Change 211 to 2014
AHCA members Average Reduction – 16.8%
7
Why Readmissions? Why Now?
•
Hospital readmissions represent a huge opportunity
for potential savings to the Medicare program
• Hospital Readmissions Reduction Program (HRRP)
•
•
•
•
Sec. 3025 of the ACA
Began October 1, 2012
Up to a 3% cut in Medicare Rates to Hospitals Part A
payments effective Oct. 1, 2014
CMS expanding this model to other provider types
Why Hospitals care about you
• HRRP is based on 30 d hospital readmission rates for
discharges with diagnosis of
• CHF
• Pneumonia
Orthopedic surgery
COPD
• Myocardial infarction
• Hospitals participating in ACO or Bundle payment demos
can only achieve savings by reducing rehospitalizations
• Hospitals/ACOs are Partnering with LTC providers
• Referring to low readmission providers
• Admitting patients directly from ER and clinics
But wait there’s more
• SGR fix in 2014 contained SNF VBP rehospitalization
2% withhold SNF Part A payments which may be
returned based on your rehospitalization score
• IMPACT act of 2014 requires CMS to publicly report
•
•
•
•
Rehospitalizations rates for short stay
Rehospitalization rates after SNF discharge
Hospitalization rates for long stay residents
Discharge back to community rates
• IMPACT act of 2014 requires hospitals provide quality
measures results to patients/families to help with
discharge planning
SNV VBP LEGISLATION
2014
SNF Rehospitalization linked to payment
Legislation in 2014 as part of SGR fix links SNF
rehospitalization to SNF Medicare Part A payments
• Uses a with-hold approach
• 2% “mathematical” withhold to create incentive pool
• Incentive pool is 50-70% of the withhold
• Incentive pool is “returned” to facilities based on their
rehospitalization performance score
• First adjustment to a SNF’s market basket will be in Oct
2018 based on performance likely starting in early 2016
How is withhold returned?
• Incentive pool is “returned” based on you rehospitalization
performance score
• Performance score is based on rehospitalization rate OR degree of
improvement from prior year(s)
• How this is calculated is TBD
• Top performers receive most or all of their withhold and possibly more
• Middle performers will receive some of their withhold
• Bottom 40% of performers receive little to none of their withhold
Legislation also requires Public Reporting
• Requires public reporting of SNF rehospitalization
• Confidential feedback reports by 2016
• Public reporting by 2017
• Development of a potentially avoidable rehospitalization
measure for use in 2019
• All measures need to be risk adjusted
SNF National Rehospitalization Rates
National Average
15.6%
At risk for
• 2% payment penalty;
• Dropped from
MCO/ACO Networks
Georgia Rehospitalization Rates
National Average
15.7%
AHCA Members 2014 Q2 OnPoint 30 Rehospitalizations
At risk for
• 2% payment penalty;
• Dropped from
MCO/ACO Networks
IMPACT ACT OF 2014
PAC Reform legislation
“IMPACT ACT OF 2014”
Legislation has four parts :
1. Incorporate standardized assessments
2. Public reporting of common quality measures
3. Provide quality measures to consumers when
transitioning to a PAC provider
4. HHS and MedPAC to conduct several studies
“IMPACT ACT OF 2014” Part 1
• Incorporate standardized assessment(s) (e.g. CARE tool)
into existing assessment tools across PAC providers
(LTCH, IRF, SNF, & HH) and acute care hospitals for
• Pressure ulcers
• Functional status
• Cognitive status
• Other as directed by Secretary
• Collect standard data at admission and discharge
• Fully Implement by Oct 2018
“IMPACT ACT OF 2014” Part 2
• Publicly report quality measures across settings
• Rehospitalizations
• Hospitalizations after discharge from PAC provider
• Discharge to community
• Pressure ulcers
• Medication reconciliation
• Incidence of major falls
• Patient preferences
• Efficiency measure(s): Avg Total Medicare Spend per Beneficiary
• Plus any other measures Secretary wants
• Measures to be approved by National Quality Forum (NQF)
• Public reporting starting by Oct 2018
“IMPACT ACT OF 2014” Part 3 & 4
• Hospitals and PAC providers must provide quality and
efficiency measures to beneficiaries to help them with
their PAC decision making
• Modify conditions of participation to incorporate QMs into the
discharge planning process
• Payment penalty of 2% for failure to collect and report
data
• Requires several studies and reports
• MedPAC and HHS develop plan to link quality to payment
• Review Risk adjustment methodologies
• Review use of socio-economic status in risk adjustment
CHANGES TO FIVE STAR
President’s Executive Action
Five Star Directs CMS
• Quality Measures
• Add additional quality measures to Five-Star (claims based suggested)
• Rehospitalizations
• Discharge back to community
• Antipsychotic use.
• Expand auditing of MDS data from 5 states to all states effective 01/01/15
• Implications Regarding Changes for Quality Measures
• Antipsychotics nursing home compare (AHCA Focus)
• Rehospitalization (AHCA OnPoint 30 vs CMS Claims vs MedPAC)
• Discharge to community (AHCA vs MedPac Claims)
• Revise scoring QM component, CMS establish new cut points (rebasing)
President’s Executive Action
Five Star Directs CMS
• Staffing Data
• Use payroll data, as mandated in ACA ,reported quarterly
• Add turnover and retention
• Validate staffing information
• Phase in use of electronic data to begin 01/15/15
President’s Executive Action
Five Star Directs CMS
• Continue and expand giving higher weight to quality and
staffing measures that independent sources have verified;
• Improve linkages to state-based websites for improved
access to information that is uniquely reported by states;
• Ensure the survey inspections in each state are
completed as required by statute (12-15 months, more
timely manner)
MEASURING HOSPITAL
READMISSIONS
Use Three Types of Measures
REAL TIME MEASURE (usually COUNTs)
 Track # of hospitalizations in past week
ACTUAL RATE (PROPORTION)
 Use Advancing Excellence INTERACT III tool
Use actual rate from LTC Trend Tracker OnPoint-30
BENCHMARK AGAINST OTHERS (RISK ADJUSTED)
 Use risk-adjusted OnPoint-30 rehospitalization rate
Using Counts: “Time Between Events”
• Simple counts
• # of hospitalizations last week, last month
• Time between events (e.g. OHSA employee injuries)
• # of days since last hospitalization
• As you increase the time between events you will improve on any
quality measure risk adjusted or not
• PROs
• Easy to display where all staff can see
• Provides rapid feedback
• CONs
• Does not allow compare to other providers
• Does not work if the number of patients is changing allot over time
Tracking Counts & Time Between Events
Rehospitalization Measures
• All measure have same format
% = Numerator
Denominator
# of persons sent to hospital
# of persons admitted to SNF
• Differ based on
• how they define numerator and denominator
• If and hoow they risk adjust
Tracking hospital transfers
• Measure(s)
• % admissions readmitted within 30d of admission for
• All readmissions, unplanned (only), and planned (only)
• All admissions from specific hospital
• Time between unplanned readmissions
AHCA SNF 30-Day Rehospitalization
• Readmissions = all patients admitted to a SNF from a
hospital for SNF Part A services who are sent back to any
hospital for any reasons within the next 30 days for either
inpatient admission or observation status
Expected Rate Calculation
• For each resident it examines which of the 33 risk
adjustment variables are present.
• Each risk adjustment variable has an associated probability of
being hospitalized
• For each resident we “sum” all the probabilities to assign the
person a probability of being hospitalized
• We sum all the resident’s probabilities in the SNF and divide by the
total number of residents to get expected rate
Risk Adjustment Variables Used
• Demographic
• Age >65
• Male
• Medicare as Primary Payor
• Functional Status
• Total Bowel Incontinence
• Eating dependent
• Needs 2 person assistance in ADLs
• Cognitive Impairment (Dementia)
• Prognosis
• End Stage prognosis poor
• Recently rehospitalized
• Hx of Respiratory Failure
• Receiving Hospice Care
• Clinical Conditions
• Daily pain
• Pressure Ulcer Stage >2 (split into 4
variables)
• Venous Arterial Ulcer
• Diabetic Foot Ulcer
• Diagnoses
• Anemia
• Asthma
• Diabetes Mellitus
• Hx of Viral Hepatitis
• Hx of Septicemia
• Hx of Heart Failure
• Hx of Internal bleeding
• Services & treatments
• Dialysis
• Insulin prescribed
• Ostomy care
• Cancer Chemotherapy
• Receiving Radiation Therapy
• Continue to receive IV Medication
• Continue to receive oxygen
• Continued tracheostomy care
Risk Adjustment Method
(
)
Actual Rehospitalization
National
Expected Rehospitalization X Average
=
Risk Adjusted
Rate
• National Average = 18.0
• Example 1: Actual > Expected
• (actual 20.0) ÷ (expected 15.0) = 1.33 * 18.0 = 24.0
• Example 2: Actual < Expected
• (actual 20.0) ÷ (expected 30.0) = 0.66 * 18.0 = 12.0
Actual to Expected Ratio >1 you rehospitalized more
people than expected
Use Actual to Expected Ratio
• Ratio is key to understanding how you are doing
compared to the patient population you are caring for
• Actual to Expected Ratio >1 you rehospitalized MORE
people than expected
• Risk adjusted rate will be higher than national average
• Actual to Expected Ratio <1 you rehospitalized FEWER
people than expected
• Risk adjusted rate will be lower than national average
How to interpret your results
• How do I compare to others? – look at risk adjusted results
• Are you getting better? – look at your actual results
• Are you admitting sicker patients? – look at your expected
• Are you admitting more or less than expected? – look at
your actual to expected ratio
How to interpret your results
• Risk adjusted is getting better but your actual & expected have not
- Means you are doing better compared to others but you are not improving much
- Your admissions have about the same acuity over time (e.g. they are
not sicker in Jun 2014 compared to Jun 2013 – based on expected rate)
- Your ratio is 1.0 or less meaning you send fewer patients back to the
hospital then expected (this is why your risk adjusted value is 3-4%
points less than your actual (21% vs 18%)
- - however you still have room to do better since your ratio is close to 1.0
most of the time.
WHERE DO I GET MY
DATA?
Where Can I Get Data on My Rates?
• Use Long Term Care Trend Tracker
• AHCA member benefit
• www.ltctrendtracker.com
• OnPoint-30 risk adjusted measure from PointRight
• Advancing Excellence
• Free excel tracking tools
• INTERACT excel spread sheet tracking tool
Survey History
Your
Member
Resource
Resident Characteristics
Staffing Information
AHCA Post-Acute Measures
CMS Five Star Rating
www.ltctrendtracker.com
Benefits of LTC Trend Tracker
• Member benefit for AHCA members
• Benchmarking against your peers
• Increases efficiency – saves you time
• Data in one central place – pulled using your Medicare
Provider number
Customer Service Assistance
help@ltctrendtracker.com
Unique to LTC Trend Tracker
• MDS-based Post-Acute Care Measures
• 30 Day SNF rehospitalizations (OnPoint 30)
• Discharge back to community
• Length of Stay (to be added by Jan 2015)
• RUG comparison data
• AHCA Quality Initiative
• Five Star Predictor
Customer Service Assistance
help@ltctrendtracker.com
LTC Trend Tracker Report
2014
STRATEGIES TO
SUCCESSFULLY REDUCE
HOSPITAL READMISSIONS
Its all about attitude
• What do you, your staff, your clinicians, your
consultants, your pharmacist, or your families think
when a resident gets sick?
A.
B.
C.
D.
E.
hospitalization is last resort
hospitalizations are the last place to go or is the first/default
choice?
if the doctor orders person to go, then hospitalization is
necessary.
if the person is acutely ill the hospitalization was not preventable
If the hospital admits them, then the hospitalization was
necessary
Factors Associated with low
rehospitalizations
• 47 Nursing homes in NY (N=26,746 patients)
• Measured Clinical and non-clinical factors associated with
rehospitalization rates
• Three strongest predictors
#1 Training provided to nursing staff on how to communicate effectively
with physicians about a residents condition
#2 Physicians who practice in this nursing home treat residents within
the nursing home whenever possible, saving hospitalization as a
last resort
#3 Provided better information and support to nurses and aides
surrounding end-of-life care
1Young
Y et al. Clinical and Nonclinical Factors Associated with potentially preventable
hospitalizations among nursing home residents in NYS. JAMDA 2011;12:364-371.
GA SNFs Change in Rehospitalization
(2011 – 2014)
Getting Better
GA AHCA Members
No change
Getting Worse
Target Individuals at high risk
• How can you determine who is at high risk for
readmission?
• Prior hospitalization in past 12 months is strong predictor
• ICU stay
• Long Hospital LOS (such as >10 days)
• How many risk factors that are used in OnPoint-30 Measure does
the resident have
• Quick and simple approach is to add up the number of 33 risk adjusted
variables a person has at admission to SNF
• Use systems to prevent adverse events that lead to hospitalizations
• Medication errors for medications that require monitoring
• Falls (often related to orthostatic hypotension)
• Infections
Tips on conducting Root Cause Review
for your rehospitalizations
• Approach as if every hospitalization was
preventable
• Defensive approach will justify all hospitalizations
• Look back up to 2 weeks prior to hospitalization
• Interview staff (including non-clinical staff re signs
resident “was different” from normal
• Count number of “stop & watch” completed
• Should have >2 on all rehospitalizations; of which 1 should be at least 3
days prior to hospitalization
• Look at SBARs completed and if there is trend in quality
of information or in the name of physician(s)
What Distinguishes High Performance?
• Seek to better understand factors that may contribute to
“high” performance or “at risk” performance SNFs
• High performance SNFs
• Top 25% or achieved reduction of 15% rehosp and antipsychotic
• At risk performance SNFs
• Bottom 25% or got 15% worse for rehosp and antipsychotic
• Compared SNFs on wide range of metrics and conducted
interviews
Quantitative Findings
No significant difference
• Bed size
• Ownership
• Independent vs. chain
• For-profit, vs non profit vs Gov
• Urban vs. rural
• Hours per patient day for
• RN, LPN, and CNA
• % patients with
Significant difference
• Five star
• overall rating
• health inspection
• staffing
• Citation history G or > /SQC
• Use of physical restraints
• Alzheimer/Non Alzheimer
• Payer mix (higher Medicaid)
Dementia
• Moderately or severely BIMS
score
• PASRR
• Life expectancy of < 6 months
• More RN vs. LPN staffing
• Quality measures
• LS falls, LS weight loss, LS/SS
pressure ulcers
Qualitative Findings
Characteristics of high
performance
• Visionary Leadership
• Innovative Leadership & Culture
• Focus on Quality Improvement
• Know as Proactive QI
• Utilize and Analyze Data to
Drive Improvement
• Staff Development/Elevated
Competencies of Staff – Clinical
& Non-Clinical
• Resources Available & In Touch
– within various networks
including corporation, local area,
association, etc.
Characteristics of at risk
performance
• Dated Culture
• Lack of Interest and Openness
•
•
•
•
•
•
to Data
Long Term Regulatory Issues
Long Term Reputation Issues
Weak Census/Referral Base
Limited Financial Supports
Limited Access and/or
Utilization of Resources
Staff Turnover
QUALITY AWARD
PROGRAM
Quality Award Program
• Based on Baldrige Performance Excellence for Health Care
• Three levels of distinction (Bronze, Silver, & Gold)
• Bronze: Organizational Profile
•
•
•
•
Principal Stakeholders and their Expectations
Key Performance Measures of Success/Failure
Strategic Opportunities and Challenges
Description of the Performance Improvement System
• Silver and Gold: Framework for Performance Excellence
•
•
•
•
•
•
•
Leadership
Strategic Planning
Customer Focus
Workforce Focus
Operations Focus
Measurement, Analysis and Knowledge Management
Results
• Similar framework to CMS QAPI program
3 Levels of Distinction
• Organizations must achieve the award at each level to
continue to the next level
1.
Bronze – Commitment to Quality (5 pages)
2.
Silver – Achievement in Quality (20 pages)
3.
Gold – Excellence in Quality (55 pages)
AHCA Member Participation
18%
Have not Applied
4%
Applied but no Award
76%
•
•
Applied and Received
Award
Approximately 3,022 facilities have submitted an application at any level since 1996
o 2,720 of those facilities are current members as of Oct 2011
Approximately 2,217 facilities have received an award at any level since 1996
o 2,070 of those facilities are current members as of Oct 2011
NCAL Assisted Living Participation
3%
6%
Have not Applied
Applied but no Award
Applied and Received
Award
91%
•
•
Approximately 289 AL facilities have submitted an application at any level
since 1996
o 265 of those facilities are current members as of Oct 2011
Approximately 191 facilities have received an award at any level since 1996
o 186 of those facilities are current members as of Oct 2011
# of Quality Award Recipients
Gold: 18
Silver: 395
Bronze: 3611
2015 Program Cycle – Dates and
Deadlines
• Intent to Apply Deadline
• Bronze Application Deadline
• Silver and Gold Application Deadline
• Bronze Applicant Notification
• Silver Applicant Notification
• Gold Applicant Notification
November 13, 2014
January 29, 2015
February 12, 2015
June 1, 2015
July 6, 2015
August 14, 2015
All deadlines listed are at 8 p.m. EST
Recertification Policy
• New policy implemented in 2014
• Recipients have 3-years to apply for next award level to
continue as an active recipient
• Recipients who become inactive will be considered “past
recipients” of the program
• For complete details; visit qa.ahcancal.org
Value of Quality Award
• Silver & Gold recipients have better
• Quality Measures
• Staff Retention & less turnover
• Resident Satisfaction
• Occupancy
• 5 Star Ratings
• Aligns with CMS QAPI program
• Financial performance
Value of Quality Award
% Facilities Deficiency Free
Percent of Facilities with Health Citation-Free Inspections
18%
15%
12%
9%
6%
3%
0%
2010Q1
2010Q2
2010Q3
2010Q4
2011Q1
2011Q2
AHCA Golden & Silver
2011Q3
2011Q4
% Receiving 4 or 5 Stars
% Facilities 4 or 5 Stars
100
90
80
73
70
60
50
43
40
30
20
10
0
Quality Award
Recipients
All Others
Contact Information
David Gifford MD MPH
SR VP for Quality & Regulatory Affairs
American Health Care Association
120 L St. NW
Washington DC 20005
Dgifford@ahca.org
202-898-3161
www.ahcancal.org