A Presentation of the Revolving Door/Dartmouth Atlas Project

1. A Presentation of the Revolving Door/Dartmouth Atlas Project Presented by: Trisha Dicke, RN, BSN, FNP-S Susanne Lester-Bennett, RN, FNP-S Tami Pohorenec, RN, BSN, FNP-S

2. The Revolving Door/Dartmouth Atlas Project • by the Robert Wood Johnson Foundation • What is the Revolving Door? • Revolving door syndrome is the terminology utilized to describe the patients who return to the hospital within days of being released. • According to the federal government, 1 in 5 patients will be readmitted to the hospital within 30 days of being discharged. • (Darthmouth Institute, 2011)

3. What is the purpose of the Dartmouth Atlas project? • It documents variations in medical resources that are distributed and used in the United States. It utilizes Medicare data to provide detailed information regarding the analysis of national, regional, local markets, individual hospitals and their affiliated physicians. • The purpose of the reports is to help policymakers, the media, and health care analysts improve understanding of the efficiency and effectiveness of our health care system. • The data this group provides is valuable in guiding the formation and the foundations of the continuous efforts that are geared toward improving the health and health care systems across the nation. • (Darthmouth Institute, 2011)

4. Project Findings • From 2008-2010 there was little progress made in the reduction of hospital readmission rates. • In 2010, 1 in 8 surgical Medicare patients were readmitted within 30 days. • In 2010, 1 in 6 Medicare patients were readmitted within 30 days after receiving other medical care. • Data show that quality outcomes and cost of medical care vary greatly across regions and hospitals within the Medicare population with chronic illness, near end of life. • The highest regional rate for 30-day medical readmission was 18.1 percent in Bronx, N.Y., in comparison, a low of 11.4 percent was found in Ogden, Utah. • (Darthmouth Institute, 2011)

5. The highest regional rate for 30-day surgical readmissions was 18.3 percent in Bronx, N.Y., compared to a low of 7.6 percent in Bend, Oregon. • Thirty day readmission rates were interrelated among all cohorts studied, indicating that if the readmission rate is high for one cohort it will be high for the others. • This correlation demonstrates the fact that there is most likely widespread system-level factors that are common within various regions that influence readmission rates; regardless of illness. • (Darthmouth Institute, 2011)

6. Quality and efficiency of care is often determined by accident; determined by where patients live and seek care. • Overall patients spent fewer days in the hospital during their last 6 months of life. • Hospice enrollment increased by 15%. • Days spent in ICU and usage of physician visits remained relatively stable. • Data showed and increase in numbers of physician usage. • (Darthmouth Institute, 2011)

7. System Location and Evaluation The data collected in The Dartmouth Atlas Project was evaluated on the micro-meso-macro-level. Micro-organization specific; looking at the specific data from a specific organization. Meso-Regional within the state; comparing different hospitals from region to region. Macro-Nationwide; comparing state by state and organization systems across the nation. (Darthmouth Atlas Project)

8. Why are these findings significant? • Medicare and Medicaid services began reductions in Medicare reimbursement for hospitals with high rates of readmission. The Medicare Payment Advisory Commission (MedPAC) reported that Medicare expenditures for potentially preventable re-hospitalizations may be as high as $12 billion a year (Jencks, Williams, & Coleman, 2009). • Many times, readmissions are avoidable. Readmissions occur due to: • Differences in health status. • The quality of inpatient care, discharge planning, and care coordination. • Poor communication with families. • The availability of long term post hospital care and local primary care. • The use of hospitals as a place to receive general care.

9. What do these findings mean for an organization? Reducing the readmission rate is an important element of the proposals for financing health care reform. These proposals will drastically change the accountability of hospitals for patients' outcomes after discharge. The National Quality Forum has adopted various methods of measuring hospital performance based on the rate of readmission, and the Centers for Medicare and Medicaid services indicated an interest in making the readmission rate a measure for value-based hospital payment. • Documenting these patterns help keep the focus on health care systems that need changing and those that are changing.Studies also show that more spending, more days spent in hospital and more physician visits are not necessarily equated with better care, outcomes or patient satisfaction • (Darthmouth Institute, 2011)

10. What do these findings mean for a system? System behavior reveals itself as a series of events over time. It is an interconnected set of elements that is coherently organized in a way that seeks to achieve a common goal. A systems structure is the source of system behavior(Meadows, 2008). If we consider the hospital as our “system”, significant findings are depicted in the following chart:

11. Controlled studies have shown that certain interventions at the time of discharge sharply reduce the rates of re-hospitalization among patients with heart failure and other Medicare beneficiaries, and preliminary reports suggest that these and other interventions are more effective when used more widely(Jencks, Williams, & Coleman, 2009). Although claims data are less informative about follow-up care after surgical procedures (because of the global surgical fee), many patients who are discharged after a surgical procedure may benefit from earlier medical follow-up, since a substantial majority of postsurgical re-hospitalizations are for medical conditions (Jencks, Williams, & Coleman, 2009).

12. Bedside Significance System failure in coordinating care for patients upon discharge. Hospital systems must develop adequate discharge planning within their community settings to avoid unnecessary re-admissions. Lack of proper discharge planning leads to increased readmission rates and increased overtime staff costs (Venne, 2011). Those hospitals that do not employ discharge planners may need to re-think the discharge process and/or decrease patient assignment levels for those nurses handling patient assignments including discharge planning. Hospitals face a penalty of 1% of their total Medicare billings if their re-admission rates are excessive. This penalty will rise to 2% in 2014, and 3% in 2015 (Darthmouth press release, 2011). APRN in the administrative roles will need to re-examine the roles of hospital nurses. Cost constraints may lead to hiring greater numbers of less costly help for bedside care (Barclay, 2006).

13. Primary Care Follow Up After Discharge Less than ½ of patients discharged from the hospital had an appointment to see their primary care provider within two weeks. Among academic medical centers the percentage was slightly higher. These data underscore the importance of care coordination in reducing avoidable re-hospitalizations (Darthmouth press release, 2011). Primary care providers are dropping in numbers. The availability of patient appointments within a reasonable timeframe has become increasingly more difficult to access. The APRN can be instrumental in buffering this reality (PBS podcast, 2011).

14. References Barclay, L. (2006). Licensed Ppractical nurses may be able to fill gap in the nursing shortage. Retrieved from: http:// www.medscape.com/viewarticle/541297 Goodman, D., Fisher, E., Wennberg, J., Skinner, J., Taber, S., Bronner, K. (2013). Tracking improvement in the care of chronically ill patients: a DarthmouthAtlas brief. Retrieved from: www.dartmouthatlas.org/downloads/reports/ EOL_brief_061213.pdf‎ Jencks, S.F., Williams, M.V., & Coleman, E.A. (2009). Re- hospitalizations among patients in the Medicare Fee-for- Service Program. New England Journal of Medicine,360,1418-1428. Lavizzo-Mourey, R. (2013). The Revolving Door: A Report on U.S. Hospital Readmisisons. Retrieved from http://www.rwjf.org/ content/dam/farm/reports/reports/2013/rwjf404178

15. Meadows, D. H. (2008). Thinking in Systems: A primer. White River Junction, VT: Chelsea Green Publishing. PBS. (Producer). (2011, May 26). Are nurse practitioners the solution to shortage of primary-care doctors? Retrieved from: http:// www.pbs.org/newshour/bb/health/jan-june11/ nurses_05-26.html The Dartmouth Atlas of Health Care. (2013). Retrieved from http:// www.dartmouthatlas.org/tools/ The Darthmouth Institute. (2011). U.S. hospitals, facing new Medicare penalties, show wide room for improvement at reducing readmission rates. Retrieved from http:// www.dartmouthatlas.org/.../press/ Post_Acute_Care_Release_092811.pdf‎ Venne, K. (2011). Marquette professors find nurse staffing, overtime hours, effect readmission rates, emergency room visits. Retrieved from: http://www.fiercehealthcare.com/press- releases/marquette-professors-find-nurse-staffing-overtime- hours-affect-readmission-?cid=xtw_humancap