Overview

1. The Michigan Health & Hospital Association (MHA) Keystone Center Approach to Reducing Avoidable Readmissions

2. 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

3. MHA Organization Michigan Health & Hospital Association Non-profit Michigan corporation (501-c-6) MHA Health Foundation Non-profit Michigan corporation (501-c-3) Hospital Councils Non-profit Michigan corporations (501-c-6 or 3) Hospital Purchasing Service Michigan non-profit association HealthPAC Political action committee formed under state statute MHA Service Corporation For-profit Michigan stock corporation MHA Unemployment Comp Program Informational IRS return filed by individual participants MHA Keystone Center Non-profit Michigan corporation (501-c-3) Represents legal control (ownership and/or complete authority to operate) Represents affiliation agreement and/or board position (operating cooperation and coordination)

4. 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.

5. MHA Keystone Center MHA Keystone Center Non-profit Michigan corporation (501-c-3) Collaboratives MHA Patient Safety Organization Federally-certified PSO National Projects Michigan Projects & Hospital Engagement Network

6. 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

7. 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

8. Context for the Readmission Policy

9. 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

10. 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

11. Why all the Talk about Readmissions? *MedPac 2007 Report to Congress; Promoting Greater Efficiency in Medicare. Chapter 5: Payment Policy for Inpatient Readmissions

12. Readmission Definition http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html 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

13. The Hospital Readmission Reduction Program (HRRP)

14. 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

15. 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)

16. 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

17. Readmissions

18. Admissions Rate by County

19. Readmissions Rate by County

20. Current State Of Readmissions

21. Community-based Care Transitions Program (CCTP)

22. 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

23. Goals Reduce statewide 30-day rehospitalization rates by 30 percent Increase patient and family satisfaction with transitions in care and with coordination of care

24. STAAR Approach Improve transitions between settings Cross-continuum teams Collaborative learning State-based mentoring and quality improvement infrastructure

25. Regional Strategy* * IHI • 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

26. Participating Hospitals

27. STAAR Key Changes for an Ideal Transition • 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’ home-going needs B. Reconcile medications upon admission C. Create a customized discharge plan based on the assessment

28. 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

29. 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

30. STAAR Key Changes 4. Ensure Timely Post Acute Care Follow-up A. For high-risk patients: prior to discharge, schedule a face-to-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

31. Act Plan Study Do A Model for Learning and Change What are we trying to accomplish? Three Questions How will we know that a change is an improvement? + What change can we make that will result in improvement? Plan-Do-Study-Act (PDSA) = The Model for Improvement

32. The PDSA Cycle for Learning and Improvement Act Plan -Objective, questions and predictions (why) -Plan to carry out the cycle (who, what, where, when) -What changes are to be made? -Next cycle? 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

33. LEAN Tools

34. 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

35. Key Community Players Health department Home healthcare agencies Physician clinics Skilled nursing facilities Free clinics Area agencies on aging

36. Impact

37. Many Interventions STAAR Project BOOST (Better Outcomes for Olderadult SafeTransitions) Project RED (Re-Engineered Discharge) Coleman model

38. Barriers • Resources • Time • Staff • Multiple initiatives can lead to project fatigue • Limitations within electronic medical records • No single intervention to impact readmissions

39. 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 

40. 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

41. Acknowledgements MPRO Institute for Healthcare Improvement Robert Wood Johnson Foundation Michigan hospitals

42. Summary

43. 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-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

44. Questions Contact us: • Danielle Barnes, MS • DBarnes@mha.org • Bryan O. Buckley, MPH • BBuckley@mha.org • Laura Fournier, MA • LFournier@mha.org

45. MHA Patient Safety & Quality Guidebook