MSG would like to thank Critical Signal Technologies for their generous support of this webinar!

1. MSG would like to thank Critical Signal Technologies for their generous support of this webinar!

3. Nancy D. Vecchioni, RN, MSN, CPHQ Vice President Medicare Operations, MPRO Co-Lead MI STA*AR IHI Improvement Advisor

4. Reducing Re-Hospitalizations: Background Re-hospitalizations are: • Frequent • 18% of all Medicare hospitalizations are 30 day re-hospitalizations • Average >20% for certain patient populations • Costly • 30-day re-hospitalizations account for $15B in Medicare annual spending • In total, hospitalizations account for one-third >$2T US healthcare spending • Potentially avoidable • 76% of Medicare re-hospitalizations were “potentially preventable” based on 3M definition • 14-46% in general hospital populations in retrospective clinician reviews • Actionable for improvement • Individual delivery systems and health services researchers have demonstrated dramatic (30-90%) reduction of 30-day readmission rates for certain patient populations ( such as patients with HF)

5. 40% of Medicare beneficiaries are discharged from an acute care hospital stay to a post-acute care setting; of those, roughly half enter a nursing home for skilled nursing care or rehabilitation services.HCUPnet. 2009 [cited 2009 July 21]; Available from: http://hcupnet.ahrq.gov. Mor et al. (2010) report that on average 23.5% of SNF residents are rehospitalized within 30 days of an acute care hospital discharge amounting to a total annual cost of $4.35 billion for Medicare alone based on analysis of CMS data from 2000-2006; their study further noted a 29% increase in rehospitalizations during this time period. Michigan has the sixth greatest SNF resident readmission rate (25.8%) in the US, At an estimated $175 million Medicare expenditure annually. Michigan also has the fifth greatest rate of prior nursing home use among rehospitalized residents. Figure 1: Rehospitalization Rates in Total and by Prior Nursing Home Use among Medicare Beneficiaries, 2000-2006 (Mor, V., et al., The Revolving Door Of Rehospitalization From Skilled Nursing Facilities. Health Affairs, 2010. 29(1): p. 57-64)

6. If Re-hospitalizations are Prevalent, Costly, and Able to be Reduced, Why Haven’t They Been? • Hospital-level barriers • Financial disincentives (volume-revenue), no financial incentives, not part of P4P contracts, not high on priority list, limited disease-specific efforts • Community-level barriers • Not common to engage organizations across continuum to collaborate on improving care, frustration between inpatient and post-acute providers, unfamiliar with availability of community resources and community based organizations lack of IT connectivity, no reimbursement for coordination • State-level barriers • Lack of population-based data, lack of understanding costs of poor quality on systems, effect of fragmented payer market and lack of CMS participation

7. Patients Tell us How to Improve Care • Inadequately prepared for the next setting • Conflicting advice for illness management • Inability to reach the right practitioner • Difficulty navigating the health care system

9. Hospital Readmissions Reduction Program (section 3025) • Reduction in payments to hospitals with excessive readmissions • Definition of “readmissions” includes the readmission to the same or another hospital • Excessive readmissions will be defined by the HHS secretary

10. ReadmissionsHealthcare reform provisions Up to 3% cut to all DRGs for readmissions over expected Up to 1% in FY 2013, 2% in FY 2014, not to exceed 3% in 2015 and beyond Initially AMI, CHF, PN Expands to COPD, CABG, PTCA, and other vascular in 2015 10 year savings: $7.1 B Hospital Readmissions Penalties capped at 2%. (FY 2014) Hospital Readmissions Penalties capped at 3% (FY 2015 and beyond) Hospital Readmissions – HHS Shares data with hospitals on 3 Selected conditions: Penalties Capped at 1% (FY 2013) 2017 2010 2011 2012 2013 2014 2015 2016 10 10

11. Adult Medical Discharges Pediatric Medical Discharges Reporting Template: Overall Rate

12. Michigan Medicare Patient 30-Day All Cause Readmission Rates (%) by County, 2009 Statewide Medicare Patient Readmission Rate= 18.8% Readmission Rates are Greatest in Southeast Michigan Medicare FFS Inpatient Data, ISAT Database

13. Mi Medicare FFS 30-Day All Cause Readmission Rate by Age, Race & Sex, Michigan Medicare (FFS) Beneficiaries Discharged from a Michigan hospital from January 1, 2008 through June 30, 2010

14. Mi Medicare FFS 30-Day All Cause Readmission Rate by Selected Diagnoses, Michigan Medicare (FFS) Beneficiaries Discharged from a Michigan hospital from January 1, 2008 through June 30, 2010

15. Mi Medicare FFS Urban vs. Rural Hospital 30-Day All Cause Readmission Rate, Michigan Medicare (FFS) Beneficiaries Discharged from a Michigan hospital from January 1, 2008 through June 30, 2010

16. Mi Medicare FFS 30-Day All Cause Readmission Rate by Physician Follow-up Prior to Readmission or 30 days, Michigan Medicare (FFS) Beneficiaries Discharged from a Michigan hospital from January 1, 2008 through June 30, 2010

17. Factors Contributing to Re-hospitalizations • Health Literacy • Lack of coordinated care • From inpatient to outpatient settings (follow-up appointments, medication management, etc.) • Amongst clinicians in outpatient settings (primary and specialty care, home care and primary care, etc.) • Unreliable medication management • Natural history of disease • Patient/family caregivers’ lack of understanding of care needs • Barriers to access (including the uninsured, geographical distance, difficulty arranging post-discharge follow-up appointments, etc.) • Missed opportunities with discharge planning • Unreliable identification of need for and referral to services

19. Capacity to: Obtain, process, understand basic health information and services Make appropriate healthcare decisions (act on information) Access/navigate healthcare system Health Literacy

20. 90 million adults have trouble understanding and acting on health information Population of US in 2009 = 307,065,550 29% of the United States Population Approximately one in three people on this call Health Literacy

21. Frequently missed appointments Incomplete registration forms Non-compliance with medication Unable to name medications, explain purpose or dosing Identifies pills by looking at them, not reading label Unable to give coherent, sequential history Ask fewer questions Lack of follow-through on tests or referrals Red Flags for Health Literacy

22. “How would you take this medicine?”395 primary care patients in 3 states Patient Safety: Medication Errors • 46% did not understand instructions ≥ one label • 38% with adequate literacy missed at least one label • Davis TC , et al. Annals Int Med 2006 105 Health Literacy • Universal Precautions Toolkit

23. Rates of Correct Understanding verses Demonstration“Take Two Tablets by Mouth Twice Daily”

24. Handing Off and Receiving the Baton

25. Deficits in Information Handover between Acute Care and Extended Care Facilities • 22% of transfers had no formal summary of information; • Legible summaries were available only 56% of the time; • Secondary diagnoses were missing from 30% of transfers; • Only 51% had allergies documented; • Mental status was missing in 33% of cases; • Lab, chest x-ray, and EKG results were missing 31%, 67%, and 61% of the time, respectively; • Do-not-resuscitate (DNR) orders and advanced directives were absent from 87% of transfers; • Dietary information was missing 19% of the time; and • Clarification of information was difficult because identification of hospital physician was only legible 41% of the time and phone numbers only 33% of the time. • National Hospital Discharge Annual Survey 2001; Health US 2003. Available at: http://www.cdc.gov/nchs/about/major/hdasd/listpubs.htm.

26. Your specialist did not receive basic medical information from your primary care doctor Your primary care doctor did not receive a report back from a specialist Test results/medical records were not available at the time of appointment Doctors failed to provide important medical information to other doctors or nurses you think should have it No one contacted you about test results, or you had to call repeatedly to get results Any of the above Nearly Half of U.S. Adults Report Failures to Coordinate Care Percent U.S. adults reported in past two years: Source: S. K. H. How, A. Shih, J. Lau, and C. Schoen, Public Views on U.S. Health System Organization: A Call for New Directions (New York: The Commonwealth Fund, Aug. 2008).

27. hmmmm……. heart failure?... ……(what?)…. 30%......aspirin…. Mr. Smith. It looks like you have severe congestive heart failure. Your cardiac enzymes were negative, but your ejection fraction was only 30%. You’ll need to take some diuretics, an ACE-I, a beta blocker, and aspirin. Yes doctor.

28. Unreliable Medication Management

29. Medication Use in the Elderly • 20% community dwelling elderly (>65) take 10 or more medications • Adherence drops with increasing the number of doses per day • Average adherence falling from 80% (once daily) to 50% (4 times a day) • Studies documented an average of 1 unnecessary drug per patient • Adverse events occur with number of medications • 5 to 35% per year • Responsible for 10% of readmissions • Communication gaps resulted in 37% of remediable adverse drug events • Hospitalized elderly-44% were discharged with at least 1 unnecessary medication

30. Barriers to Medication Adherence and Targeted Solutions • Forgetting to take • Patient believes drug is not needed, ineffective or too many • Difficulty taking (opening bottles, swallowing) • Cost

31. 81% of patients requiring assistance with basic functional needs failed to have a home-care referral 64% said no one at the hospital talked to them about managing their care at home Flawed Process Discontinuity between inpatient and outpatient providers Inadequate Communication Lack of medication reconciliation Inadequate patient education Clark PA. Patient Satisfaction and the Discharge Process: Evidence-Based Best Practices. Marblehead, MA: HCPro, Inc.; 2006. Current Discharge Process

32. Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital

33. MI STA*AR Overview • An Institute for Healthcare Improvement (IHI) initiative to reduce avoidable 30-day rehospitalizations • Commonwealth Fund grant • May 2009 – May 2013 • MPRO and MHA co-leading statewide initiative • Improvement Advisors to assist teams • Three states selected as partners in this initiative (Massachusetts, Michigan, Washington)

34. Goals • Increase patient and family satisfaction with transitions in care and with coordination of care • Reduce each state’s all-cause 30-day rehospitalization rates by 30 percent

35. Steering Committee Members • Tina Abbate Marzolf CEO, Area Agency on Aging 1-B • Caroline Blaum, MD, MS Gerontologist, University of Michigan • Amy Boutwell, MD, MPP Institute for Healthcare Improvement • Peggy Brey Deputy Director, Office of Services for the Aging, MDCH • Laura Champagne Executive Director, Citizens for Better Care  • Ed Gamache President, Michigan MICAH  • David Herbel President & CEO, Aging Services of MI  • Jeanette Klemczak, RN, MSN Chief Nurse Executive, MDCH  • David LaLumia President & CEO, HCAM  • Cecelia Montoye, RN, MSN, CPHQ Michigan Chapter , American College of Cardiology • Susan Moran Bureau Director, Medicaid Program Operations and QA  • Richard Murdock Executive Director, MAHP  • Julie Novak Executive Director, MSMS  • Larry Abramson, DO Michigan Osteopathic Association • Appointment Pending Michigan Hospice & Palliative Care  • Tom Simmer, MD Senior VP & CMO, BCBSM  • Nancy Vecchioni, RN, MSN, CPHQ VP Medicare Operations, MPRO  • Sam R. Watson, MSA, MT (ASCP)Senior VP Patient Safety and Quality, MHA • Appointment Pending Policy Advisor, Office of Governor • Robert Yellan, JD, MPH President and Chief Executive Officer, MPRO • Harvey Zuckerberg Executive Director, MHHA

38. Interventions Acute Care • Providing from three to 30-day supply of medications at transition home • Health plans overriding their formulary • Switch from brand to generic medications e.g., 8 medications 40 dollars a month • Follow-up appointments made prior to the patient transition • Nurse calls patients 48 hours post transition • Home visits to patient within 1 to 2 days of transition • Extended care, home health and health plan case managers make visits to hospitalized patients and discuss case with the hospital team • Patients/care givers assist in design of educational materials • Standardization of communication handover • Transitions to nursing homes between 11am and 2pm • Non nursing staff conducting Teach Back • Standardized transition form • Case managers in emergency department • Integration of interventions in EMR

39. Interventions Home Health Care Front load visits Sliding scale medications SBAR communication After hours care-24-7 Telehealth EMR bracelet Standing orders Program redesign to incorporate patient coaching model Emergency department liaison Standardize transition form Extended Care/LTAC • Total implementation of INTERACT • Standardized communication • Standardized process for determining transfers to hospital • Care paths • Consistent assignment/consolidated med pass • Verbal communication prior to transition • Work with patient/care giver to make follow-up appointment to PCP • Call patient 48-72 hours after transition home • Shift huddles to discuss high risk residents • Standardized transition form

40. Teach Back • Explain needed information to the patient or family caregiver • Ask in a non-shaming way for the individual to explain in his or her own words what was understood • If a gap in understanding is identified, offer additional teaching or explanation followed by a second request for Teach Back Schillinger D et al. Closing the loop: physician communication... Arch Intern Med. 2003;163:83-90.

41. Teach Back questions for patients with HF: What is the name of your “water pill”? What weight gain should you report to your doctor? What foods should you avoid? Do you know what symptoms to report to your doctor? Teach Back: Measuring Patient Understanding

43. INTERventions to reduce Acute Care Transfers • Goals • Increase the use of strategies and tools that may help reduce ACT of nursing home residents by utilizing the INTERACT TOOL KIT, and • Decrease the number of potentially avoidable ACT of nursing home residents that result in emergency room visits and/or hospitalizations. http://www.qualitynet.org/dcs/ContentServer?c=MQTools&pagename=Medqic%2FMQTools%2FToolTemplate&cid=1211554364427

44. INTERventions to reduce Acute Care Transfers • Communication about residents with acute changes in condition among staff at the nursing home as well as between the nursing home and hospital; • Care paths for common acute conditions in nursing home residents that guide treatment in the nursing home when feasible; and • Advance care planning that will assist in reducing potentially avoidable acute care transfers of residents who are terminally ill and/or on a palliative care plan

45. To improve the quality of care people receive at the end of life through effective communication of patient wishes, documentation of medical orders and a promise by health care professionals to honor these wishes. http://www.ohsu.edu/polst/

47. Standardization of communication and information between sending and receiving organizations • Acute and Post Acute Care providers identified critical information • Implementing into EMRs and electronic communication between providers Does not replace verbal handover communication

49. Additional Community Initiatives • FUSE • Patient coaching provided by area agencies on aging • Call to Care • Aligning processes with between healthcare and community based organizations and resources • SOAR (Stepping Stones to Recovery) • Medication Reconciliation across the continuum of care • Many more

50. Mi Medicare FFS MI STA*AR 30-Day All Cause Readmission Rate by Quarter among Medicare (FFS) Beneficiaries Discharged from a Michigan hospital between January 1, 2008 and June 30, 2010