How Hospital Readmissions Impact Skilled Nursing Facilities (HRRP)

1. How Hospital Readmissions Impact Skilled Nursing Facilities (HRRP)

2. Contact Information Joyce Freville, Ph.D., CHC, CHPC Compliance Matters, LLC jfreville@twc.com (502) 494-0115 Compliance-matters.org

3. OBJECTIVES: • By the end of the session, participants will be able to: • Understand key requirements of the HRRP • Identify potential factors influencing readmissions • Identify steps to prevent avoidable hospital readmissions • Understand the role of physical therapists in communication, coordinated discharge planning, follow up care, and advocacy in reducing acute hospital readmissions

4. Hospital Readmission Rates • 20% discharged to a SNF • 19.6% readmitted in 30 days • 34% readmitted in 90 days • 67.1% had been discharged with medical conditions • 51.5% discharged after surgical procedures were rehospitalized or died within a year Source: Jencks et al N Engl J Med 2009;360:1418-28

5. Rates of Rehospitalization within 30 days after Hospital Discharge Source: Jencks SF, et al. N Engl J Med 2009;360:1418-1428

6. Hospital Readmission Rates • 70.5% rehospitalized for a medical condition within 30 days after a surgical discharge • 50% within 30 days saw their doctor before their readmission • 90% within 30 days appear to be unplanned • $17.4 billion/year estimated cost to Medicare

7. HRRP Requirements • Hospital readmission within 30 days of a discharge from the same or another hospital • Medicare patients ages 65 and older • Planned readmissions do not count as readmission in 30-day measure • Readmission counted once regardless of number of “unplanned” readmission during 30-day post

8. Key Requirements of the HRRP • Fiscal years 2013 and 2014 include conditions: • Acute myocardial infarction (AMI) • Heart failure (HF) • Pneumonia (PN)

9. Key Requirements of the HRRP • Fiscal year 2015 (October 2014) includes additional conditions: • Congestive obstructive pulmonary disease (COPD) • Elective total hip arthroplasty (THA) • Elective total knee arthroplasty (TKA)

10. Health Reform to Address Avoidable Readmissions • Public reporting of readmission rates • Penalties against hospitals with "excess" readmissions (above expected rates) for targeted conditions imposed October 1, 2013 • Sole community hospitals, Medicare-dependent small rural hospitals, and low volume conditions are exempt from penalties • 2014 Budget proposes 3% reduction for nursing homes beginning 2017

11. Exercise • Mrs. Smith had a heart attack and was admitted to General Hospital on January 1st. She was discharged to Acme Nursing on January 5th with a diagnosis of acute myocardial infarction (AMF). • On February 3rd, Mrs. Smith was readmitted to County Hospital for a fall.

12. Exercise • Is this considered a 30-day readmission? • Why or why not?

13. Percent of Patients Readmitted within 30 Days of Discharge Source: Dartmouth Atlas of Health Care http://www.dartmouthatlas.org/data/map.aspx?ind=192&ch=201&tf=23&loct=3&extent=-14071323.410590487%202305693.8872850095%20-7398676.589409513%206806306.112714991

14. Readmission Factors • 69% were non compliant with meds • 51% lacked knowledge of how to use therapy devices • 45% inadequate knowledge of medications • 42% unable to self manage care • 37% had no follow up visit with physician • 31% develop infection post discharge Source: AARC webcast August 28-12 “Hospital to Home-efforts at Reducing Hospital Readmissions”. Greg Spratt BS, RRT; Kimberly Wiles BS, RRT; Becky Anderson RRT.

15. Implications Nursing home, home health agency, hospice, pharmacy, and physician practices influence hospital admission rates Coordinating these providers can help hospital escape penalties for patient care breakdowns Hospitals should improve discharge process, but also coordinate with SNF

16. Exercise • Mr. Jones was admitted to Excellent Hospital on March 1st for pneumonia. He was discharged to All Care Nursing Home on March 5th.

17. Exercise • Pair up with one other person. Take five minutes, and come up a plan to transition him into the skilled nursing facility. • Come back together, and discuss to find common answers.

18. Key Components of Effective Transitional Care • Engage patients early in hospitalization • Give patients comprehensive post-discharge instructions on medications, self-care, and symptom recognition and management • Assist patients in setting up and keeping follow-up physician appointments • Follow patients post-discharge • Source: Mathematica Study: Key Components of Effective Transitional Care • http://www.ahrq.gov/professionals/systems/hospital/red/readmissions/readslide22.html

19. Factors Influencing Readmissions • Inadequate communication with primary care physicians • Inadequate education of patient • Drug therapy • Poor coordination with other community providers

20. Factors Influencing Readmissions • Early physician follow-up after discharge for medical and surgical hospitalizations • Primary care clinicians have proven strengths in providing patient care coordination and longitudinal follow-up

21. Poor Transfer of Information to Primary Care Physician • 25% of the residents require additional outpatient work-ups: (Source: Archives of Internal Medicine. 2007; 167: 1305-11) • 41% inpatients discharged w/ pending test result • 2/3 of physicians unaware of results • 37% of tests actionable and 13% urgent (Source: Annals of Internal Medicine. 2005; 143(2): 121-8) • Discharge summary not readily available: • Only 12-34% at first post-discharge appt; 51-77% at 4 weeks • Discharge summary lacking key components: • Hospital course (7-22%) • Discharge medications (2-40%) • Test results (33-63%) • Pending tests (65%) • Follow-up plans (2-43%) (Source: JAMA 2007; 297(8): 831-41)

22. Studies of Hospital Readmissions • Only half of the patients rehospitalized within 30 days had a physician visit before readmission; • Unknown if lack of physician visit causes readmissions—but poor continuity of care, for many chronically ill patients. • 19% of Medicare discharges are followed by an adverse event within 30 days—2/3 are drug events, the kind most often judged "preventable."

23. Factors Influencing Readmissions (cont’d) • Lack of timely post-discharge physician visit: • Primary care physician unaware of hospitalization. • Patient has no primary care physician.

24. Factors Influencing Readmissions • Poor transfer of information to patient: • 37% able to state purpose of all medications • 14% knew the common side effects • 42% able to state their diagnosis • Result: • Poor patient understanding of how to use medications after hospital discharge • Patient doesn’t understand warning signs that warrant an emergency call to their physician • Lack of clarity on patient’s end of life care preferences lead to unwanted rehospitalization Source: Courtesy of Michael Paasche-Orlow, MD, Mayo Clinic Proceedings. August 2005; 80(8):991-994

25. Factors Influencing Readmissions (cont’d) • Quality of nursing home, home health agency, and primary care drive both admission and readmission rates • Patient characteristics that lead to admissions also lead to readmissions • Practice patterns in non-hospital settings that lead to admissions for these groups also lead to readmissions

26. Factors Influencing Readmissions (cont’d) • Poor transfer of information to ambulatory caregivers: • Hospital to nursing home staff • Hospital to primary care physician • Lack of clarity on end of life care preferences

27. Factors Influencing Readmissions (cont’d) • Poor patient knowledge and non-disclosure of current drug therapy, and/or inadequate medication reconciliation, can yield drug therapy duplication or interaction • Many patients are unlikely to ascribe adverse effects to causes, might not ask for change in drug therapy

28. Reported Diagnosis-specific Reasons for Avoidable Readmissions • COPD [chronic obstructive pulmonary disease], Pneumonia Patients— • Many patients need, but do not receive, home health care • Pneumonia readmissions may reflect need for end of life care

29. Reported Diagnosis-specific Reasons for Avoidable Readmissions • Cardiac Patients— • Cardiologists may rely on primary care to arrange follow up care for heart failure patients • Readmissions appear to be much higher for heart failure patients with behavioral diagnoses

30. Reported Diagnosis-specific Reasons for Avoidable Readmissions • Post-surgical Patients— • Surgeons not arranging for post-surgical primary care • Inadequate teaching of the patient in caring for their body after surgery: • Incision care • Post-CABG [coronary artery bypass graft] patients, expecting to be pain free, seek readmission for angina

31. How Many Readmissions are Avoidable? • What proportion of readmissions are truly "avoidable"? No one knows; • Many rehospitalized before seeing a physician; • Hospitals, physicians, HHAs, nursing homes and pharmacists can prevent more readmissions working together than hospitals can by improving discharge process alone.

32. Exercise • After meeting with the CEO of the local hospital, you learned that the hospital reimbursement was reduced by 1% due to excessive readmissions. The CEO made it clear that unless your facility reduced the readmissions from your facility, she would stop referring patients to your facility.

33. Steps to Prevent Avoidable Hospital Readmissions • Review clinical data • Identify and address trends • Address high-risk rehospitalization conditions • Be willing to refuse a referral

34. Review Clinical Data • Look at the reasons why a patient was rehospitalized; • Was it a premature discharge? • Was the patient’s health status clinically correct? • Were there errors in the discharge instructions? • Were medication instructions unclear? • Immediately address such issues and any related data discrepancies with case managers to reduce problems

35. Identify and address trends • Address troubling trends with case managers; • Review the thoroughness and timing of discharge plans; • Work with hospitalists and attending MDs who have discharged patients who require rehospitalization • Determine how better to identify the patient’s needs before accepting the referral

36. Standardized Assessments and Procedures • Physicians and skilled nursing facilities should use a standardized assessment • Medicine reconciliation • Care Goals • Data on recent inpatient admissions • Physician should arrange a palliative consult for anyone with more than three hospitalizations in the last 6 months

37. Cardiac Recovery Program • Pre-admission process to ensure that any needs for specialized equipment are met prior to the resident being admitted to the nursing facility and that cardiac monitoring protocols are defined and established. • Plan of care should be communicated to the IDT and documented on the individual resident care plan • Educate residents, families and caregivers in the disease process, prevention and wellness components of cardiac recovery Reference: Capitosti, S., Rowell, C. Therapy Services' Role in Reducing Hospital Re-admissions. http://healthcare-executive-insight.advanceweb.com/Long-Term-Care/Web-Extras/Long-Term-Care-Feature/Therapy-Services-Role-in-Reducing-Hospital-Re-admissions.aspx

38. Palliative Care Program • Pre-admission process • Meet specialized equipment needs prior to the resident being admitted to the nursing facility • Define and establish therapeutic interventions • Assessment of swallow (how does breathing affect safety of swallow mechanism) • Chest percussion • Education in diaphragmatic breathing exercises • Pursed lip breathing technique • Compensatory strategies such as energy conservation, prioritizing daily activities and lifestyle modifications Reference: Capitosti, S., Rowell, C. Therapy Services' Role in Reducing Hospital Re-admissions. http://healthcare-executive-insight.advanceweb.com/Long-Term-Care/Web-Extras/Long-Term-Care-Feature/Therapy-Services-Role-in-Reducing-Hospital-Re-admissions.aspx

39. Palliative Care Program (Cont’d) • Communicate plan of care to the IDT and document it on the individual resident care plan • Establish a baseline for resident's respiratory status i.e., quality of breathing, lung sounds, breath movements, blood pressure and pulse oximetry readings during daily activities Reference: Capitosti, S., Rowell, C. Therapy Services' Role in Reducing Hospital Re-admissions. http://healthcare-executive-insight.advanceweb.com/Long-Term-Care/Web-Extras/Long-Term-Care-Feature/Therapy-Services-Role-in-Reducing-Hospital-Re-admissions.aspx

40. Multidisciplinary Root-cause Analysis • Hold bimonthly, 30-minute conferences with medical director and other facility leaders • Focus on the root-cause problems that led to the readmission • Include nurses, nurse aides, therapists, social workers, and administrator • Discuss selected cases, focusing on the root-cause problems that led to the readmission

41. Multidisciplinary Root-cause Analysis (cont’d) • May include family members, on-call physicians, and/or representatives from pharmacy, activities, therapy, dietary, and admissions • Send all attendees an e-mail documenting the lessons learned from the case

42. Address High-risk Rehospitalization Conditions • Ensure care plans and staffing patterns can effectively treat patients • Recognize when rehospitalization is the most appropriate and medically necessary option • Highest risk of rehospitalization -CHF and elevated carbon dioxide levels in those with chronic obstructive pulmonary disease, poor renal function.

43. Role of Therapy • Assess resident upon admission to determine if they are at risk for developing an acute change of condition • Evaluate those residents identified as high risk for developing an acute change of condition • Develop a clinically appropriate therapy plan of care • Be effective interdisciplinary team players • Enhance skills with best practice programs directed in key clinical areas • Communicate with the interdisciplinary team (IDT) Reference: Capitosti, S., Rowell, C. Therapy Services' Role in Reducing Hospital Re-admissions. http://healthcare-executive-insight.advanceweb.com/Long-Term-Care/Web-Extras/Long-Term-Care-Feature/Therapy-Services-Role-in-Reducing-Hospital-Re-admissions.aspx

44. Fall Prevention • Therapy screening for residents identified as high risk for falls; • Implement a formalized process to evaluate falls by the IDT • Include defined parameters in care plan that indicate a need for a therapy evaluation, i.e., standardized balance and gait assessments along with a written physician's order for manual muscle testing, endurance, cognition and safety assessments

45. Fall Prevention cont’d • Review documentation from nursing and therapy related to balance with transfers / standing / walking; both standing and sitting balance • Evaluate seating and wheelchair positioning, particularly as it relates to safety, mobility and potential falls, as needed • Address continence management needs

46. Strength/Endurance/Self-Care • Utilize standardized assessments for measuring functional task components to establish and support the resident's individual plan of care • Identify specific and measured progress using graded activities and exercises • Identify resident goals and level of knowledge (this will help establish needed education)

47. Strength/Endurance/Self-Care • Educate on the use of adaptive equipment to maximize independence • Align exercises and therapeutic activities with disease and event specific guidelines for recovery such as: • Progressive resistive exercise • Low impact aerobics • Weight training, etc.

48. Strength/Endurance/Self-Care • Integrate therapy outcomes into the facility's ongoing quality improvement processes for unplanned hospital transfers • What can patients / residents do at home for exercise and strengthening?

49. Role of Therapy • Occupational Therapy • Collaborate with nursing to assess the resident’s cognitive ability to retain new or on-gong education • Determine best mode of learning i.e. Written, verbal, video-recorded http://c.ymcdn.com/sites/www.homehealthsection.org/resource/resmgr/csm2014_handouts/hh_3b_6710.pdf Source: Bemis-Doughterty, A., Delaune, M.F. (September 27, 2011). The value of physical therapy in reducing hospital readmissions.

50. Role of Therapy • Physical Therapy • Establish daily mobility program from day one post discharge (walking, rolling, sit to stand, standing for __ minutes) • Incorporate resident education regarding disease process or medical condition into the resident’s mobility program