Post on 26-Jun-2018
8/20/2013
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The Problem of Hospital ReadmissionsReadmissions
#811 Saturday, November 2, 2013
4:15‐5:45
Mary Newberry MSN RNDirector
Home Health/Diabetes Center/Outpatient InfusionRiverside Heath Care, Kankakee, Illinois
Objectives
Demonstrate an increased understanding ofDemonstrate an increased understanding ofDemonstrate an increased understanding of Demonstrate an increased understanding of the physical and financial impact of a the physical and financial impact of a hospital stayhospital stayIdentify the driving forces for attention to Identify the driving forces for attention to the cause of hospital readmissionsthe cause of hospital readmissionsDescribe the strategies to improve Describe the strategies to improve transitions of care and reduce readmissionstransitions of care and reduce readmissions
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Health Care Today
Medicare benefitMedicare benefit
d d d lld d d llConcern regarding Medicare dollarConcern regarding Medicare dollarWhy the concern?Why the concern?
Is it that we have been careless? Is it that we have been careless?
What is the problem?What is the problem?
The issue is multiThe issue is multi‐‐faceted, but basically….faceted, but basically….H lth C i th U it d St t i tt dH lth C i th U it d St t i tt dHealth Care in the United States is pretty goodHealth Care in the United States is pretty good
Advances in medicineAdvances in medicine‐‐‐‐ People are living longer!People are living longer!
Increased age, increased risk for chronic diseaseIncreased age, increased risk for chronic disease
Aging of AmericaThe number of Americans age 55 and older will almostolder will almost double between now and 2030 from 60 million today (21% of the total US population) to 107.6 million (31 percent of the population) – as the Baby B h iBoomers reach retirement age
(Experience Corps, n.d.)
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Aging of AmericaThe likelihood that an American who reaches th f 65 illthe age of 65 will survive to the age of 90 has nearly doubled over the past 40 years – from just 14% of 65‐year‐olds in 1960 to 25 %% at present By 2050, 40% of 65‐year‐olds are likely to reach age 90!
(Experience Corps, n.d.)
Health Stratification of the Population
Level 5: Institutionalized difficult to place
Level 3: Identified Disease State
Level 4: 3 + Chronic Diseases
Level 2: Risk Factors Exist
Level 1: Healthy
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What Are Chronic Diseases?
Chronic diseases are noncommunicable illnesses that are prolonged in duration, do not resolve spontaneously, and are rarely
cured completely
(Centers for Disease Control and Prevention [CDC], 2011)
Reasons for Increase in Chronic Diseases
Aging of AmericaAdvances in treatment of acute diseaseEarlier screening and diagnosis of chronic diseaseLifestyle factors: sedentary, diet (obesity), smoking, stress
(Suter, et.al., 2008)
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Prevalence of Chronic Illness INCREASING
More common among older adults
Ab t 133 illi A i l 1 i 2 d ltAbout 133 million Americans—nearly 1 in 2 adults—live with at least one chronic illness
More than 75% of health care costs are due to chronic conditions
Approximately one‐fourth of persons living with a h i ill i i ifi li i i i d ilchronic illness experience significant limitations in daily activities
(Centers for Disease Control and Prevention [CDC], 2011)
Prevalence of Chronic Illness INCREASING
160
180
dition
s
60
80
100
120
140
ople W
ith chronic cond
0
20
40
1995 2000 2005 2010 2015 2020 2025 2030
(Anderson, 2010)
Num
ber P
eo(M
illions)
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Cost Concerns
Three in four dollars spent on health care in the U.S. are for patients with one or more chronic conditions
25% Total U.S. health spending in 2006 = $2.1 trillion
75%
(Devol & Bedroussian, 2007)
Hospital ChallengeChanging from Acute Care Focus to CCM
Higher percentage of patient population with chronic diseases complicating things
Rushed hospital practitioners focused on addressing shortRushed hospital practitioners focused on addressing short term issues/admitting diagnosis
Staff inadequately trained to engage patients and work collaboratively
Clinicians are struggling with the patient labeled as “non‐compliant”
Lack of time processes or reimbursement for careLack of time, processes or reimbursement for care coordination
Lack of time, processes or reimbursement for follow‐up to ensure good daily disease management
Little or no discussion regarding end‐of‐life decision making
(Suter, et.al., 2008)
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Health System Today: Acute Care System
NOT Focused on Chronic Problems
Budgets are based upon admissionsBudgets are based upon admissions
Focus has been to decrease length of stay (LOS)
Increased utilization of hospitalists
Shrinking reimbursement
Uninsured/ charity burden on hospitalization / ED visits
(Suter, et.al., 2008)
Challenges of the Chronically IllMultiple co‐morbid conditions leading to increased care complexity (75%)
Multiple medications (unfilled RXs and poor adherence) greater care complexity– greater care complexity
Multiple physicians and barriers to care coordination among providers
Gaps in transitions of care
Patients inadequately trained to manage their illnesses
Inconsistent evidence‐based care
Patient goals identified too late in the end‐of‐life trajectory
(Suter, et.al., 2008)
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The Impact of Hospitalization
Hospitalization StatisticsHospitalization Statistics
38% of admissions are over 65
49% f t t l d h it li d49% of total days hospitalized are over 65
Kleinpeil, Fletcher, & Jennings, 2008)
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Hospitalization StatisticsHospitalization Statistics
Primary Causes of Hospitalization for those >65
Heart FailureHeart Failure
Coronary Artery Disease
Pneumonia
COPD
StrokeStroke
Most arrive via the Emergency DepartmentKleinpeil, Fletcher, & Jennings, 2008)
Anatomy and Physiology of BedrestAnatomy and Physiology of Bedrest
Musculoskeletal
SkinSkin
Bones
Pulmonary
GU
GI/NutritionGI/Nutrition
Brain
Kleinpeil, Fletcher, & Jennings, 2008)
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Impact of HospitalizationBed rest is a Problem
Musculoskeletal
1.5% loss per day
5% loss per day if >65
Impact of loss on strength, balance, flexibility
Weakness leads to falls
Rapid deconditioning
R diti i t k h l thReconditioning takes much longer than deconditioning
(Hermes, 2010)
Impact of HospitalizationBed rest is a Problem
Skin
Direct Pressure (from lying in bed)Capillary pressure
~ 2 hours can lead to some degree of necrosis
Moisture, Shearing (friction) further complicate
Result: 20% of time pressure sores develop
(Hermes, 2010)
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Impact of HospitalizationBed rest is a Problem
BonesLoss 50 times faster than normal when on bedrest
1 week in hospital…takes 5 months of normal activity to recover bone loss
Can lead to ↑bone fracturesNow AND later
Impact greater with aging
(Hermes, 2010)
Impact of HospitalizationBed rest is a Problem
LungsNormal aging process ↓ residual volume P02
Formula to assess impactP02=90‐(age‐60)
Bed rest further subtracts ~8%
Example:p
80 y/o patient
90‐(80‐60)=70% P02‐8%
=62%
(Hermes, 2010)
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Impact of HospitalizationBed rest is a Problem
GenitourinaryNormal aging: 5‐15% incontinent
Men: often issues related to BPH
Women: atrophy/pelvic floor relaxation
When hospitalized, ↓ability to compensatep ,↓ y p
Incontinence then ↑ to 40‐50%
(Hermes, 2010)
Impact of HospitalizationBed rest is a Problem
GI/Nutrition/HydrationNormal aging process 25‐30% undernourished
Albumin levels, Hemoglobin, lymphocyte screening
When in hospital, further impactMeal times altered
Decreased taste and thirst
Estimate 600 cc lost in 1st 24 hours
Can result in instability, blood pressure changes
(Hermes, 2010)
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Impact of HospitalizationBed rest is a Problem
BrainVaries in severity
Delirium, fluctuations in mood, thinking, attention, confusion
Alterations in level of consciousness
Causes↓or altered sensory inputs
↓ oxygen perfusion to brain (PO2)
MedicationsMedications
Inpatient staff may not be aware that this is not normal for the patient!
(Hermes, 2010)
Impact of HospitalizationBed rest is a Problem
Nosocomial InfectionsHospital acquired infections
CausesDevices (ET tubes, IV, NG, catheters)
Decreased or inadequate attention to handwashing
Increased vulnerability
ImpactpGU
Pulmonary
GI
(Hermes, 2010)
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Hospital Discharges
Can be problematic for the patientAre we surprised?
Do you know WHY?
Multiple physicians
Multiple medications
No caregiver
In a hurry to leave
Ride is waiting for them
Lack of clarity in instructions/complex instructions
TOO MUCH information at one time
The Health Care Experience…
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The Reality is…Health system in US must change
Unsustainable in its current formHospitals are currently designed to address acuteHospitals are currently designed to address acute care issuesNot just one thing wrong with a patient
The healthcare crisis in America is a chronic care crisis
Trying to manage chronic care in an acute care systemAnd…its not working
Affordable Care Act—Changing Incentives/Penalties
We are witnessing a changing health system (and its painful)
Efforts underway to control rising costs due to:
ReadmissionsFocus of discussion today
End of life expenseFraud and abuse in the system
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Affordable Care Act—Changing Incentives/PenaltiesWe are witnessing a changing health system
Medicare Cuts?Not really—F&A initiatives yChanging incentives/penalties reimbursementRAC audits have changed hospital practice
Recovery Audit ContractorsIncentivized for $$ penalties
Medicare Criteria for admissionMedicare Criteria for admissionObservation UnitsClinical Decision Units (CDU’s)
PPACA‐‐Motivation for ChangeHospital Readmissions Reduction Program
Begins FY 2013gInpatient PPS hospitals penalized for higher than expected readmission rates
30‐day readmission, ANY cause
HF, AMI, PneumoniaPotential for 1% in 2013; 2% in 2014, 3% 2015 and beyond
Applies to all Medicare discharges
2015: list to expandCOPD, elective THA or TKA
(Stone & Hoffman, 2010; CMS, 2013)
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Goal: Reduced Hospital Readmissions
Trying to Find a Solution……
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Readmissions…not just the costResearch on readmissions
Effect on Individual & Family↑ need for institutionalization
↑ co‐morbidities
Death
Emerging Models and TrendsPPACA—many models being tested
Transitional Care ModelsColeman and Naylor
Self‐Management Education Interventions Lorig and Wheeler
Coordinated Care InterventionsCMS Demos
Disease ManagementPatient Centered Medical Home: Dr. Wagner’s Model
(AHRQ, 2012)
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Focus on Preventing ReadmissionsProject REDProject BOOSTProject BOOSTIHI Readmissions CollaborativeProject BRIDGECommunity Care demonstration projectChronic Care demonstration projectNavigator demonstration projectg p jACO formation
Bundled Post AcuteOthers…
Care TransitionsCare Transitions
“The movement patients make betweenThe movement patients make between healthcare practitioners and settings as their condition and care needs change during the
course of chronic or acute illness”
…Dr. Eric ColemanMultiple transitionsCritical: Hospital to Home
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Transitional CareIdentification of Risk
BOOST (Better Outcomes for Older Adults)BOOST (Better Outcomes for Older Adults)Why are people readmitted?Who gets readmitted?What are the risk factors?Can we address these and reduce the readmission rate?
BOOST developed as transitional care tool for hospitals
Can be useful in home care
(Hansen, n.d.)
BOOST…Why
50% never see their doctor prior to being readmittedreadmitted70% of patients readmitted after surgery
Chronic medical condition is cause72% have medication problemsHeart Failure one of leading causes
37% d itt d f HF i37% readmitted for non‐HF issuesOther issues—
Lack of understanding related to discharge instructions
(Hansen, n.d.)
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BOOST…Who?What do these patients have in common?
The 8 P’s1. Problem medications2. Psychological (stress, depression, mental illness)3. Principal diagnosis (CA, DM, COPD, HF, CVA)4. Polypharmacy (on multiple medications)5. Poor health literacy6. Patient support lacking6. Patient support lacking7. Prior hospitalizations8. Palliative care9. Not a P…Mary added‐‐ Falls(Hansen, n.d.)
BOOST…GoalIdentify risk factors prior to discharge
I t t t i t d i kIncorporate strategies to reduce riskPolicy and process development
Accountability
Improved discharge planning and communication
Improve transition to next levelp
(Hansen, n.d.)
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Transitional CareHospital to home presents highest risk for readmissionreadmission
All transitions are important
Appropriate level of careCommunity services
Coordination
Communication
Patient choice
Principles of chronic disease management
End‐of‐Life ConsiderationsFinancial Burden
27% of the Medicare budget in final year of lifeg yAverage payments of about $28,000
Personal IssueRight to self‐determinationHow do you envision the end of your life? In the ICU?ICU?
Advance Decision MakingWho prompts this discussion?
(Shugarman, Lorenz, & Lynn 2005)
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Further Thoughts: Wellness
Wellness is an active process through which people become aware of, and make choices toward, a more successful
existence.
(National Wellness Institute, n.d.)
Wellness
Wellness is a conscious, self‐directed and evolving process of achieving full potential
Wellness is multi‐dimensional and holistic, encompassing lifestyle, mental and spiritual well‐being, and the environment
Wellness is positive and affirmingWellness is positive and affirming
(National Wellness Institute, n.d.)
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WellnessComprised of Six Dimensions—
IntellectualSpiritualEmotionalPhysicalOccupationalSocial
Other definitions include: financial, environmental, mental and medical2 broad categories: Mental and Physical
(National Wellness Institute, n.d.)
Wellness and AgingFinal Thoughts
How does this pertain toHow does this pertain to our population and why
is this important?
Can a person be chronically p yill and advanced in age and still be “well”?
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Thank you!Thank you!mary‐newberry@riversidehealthcare.net
ReferencesAgency for Healthcare Research & Quality [AHRQ]. (2012). Reducing avoidable hospital readmissions. Retrieved from http://www.ahrq.gov/news/kt/red/readmissionslides/readslide20.htmAnderson, G. (2010). Chronic care: Making the case for ongoing care. Retrieved from Robert Wood Johnson Foundation website: http://www.rwjf.org/pr/product.jsp?id=50968Centers for Disease Control and Prevention [CDC]. (2011). Chronic disease prevention and health promotion. Retrieved from http://www.cdc.gov/chronicdisease/index.htmhealth promotion. Retrieved from http://www.cdc.gov/chronicdisease/index.htmDeVol, R., & Bedroussian, A. (2007, October). An unhealthy America: the economic burden of chronic disease. Retrieved from Milken Institute website: http://www.milkeninstitute.org/publications/publications.taf?function=detail&ID=38801020&cat=ResRepExperience Corps. (n.d.). Fact sheet on aging of America. Retrieved October 1, 2012, from http://www.experiencecorps.org/images/pdf/Fact%20Sheet.pdfHansen, L. (n.d.). Project BOOST: Patient readmission risk and the "8P" risk assessment. Retrieved September 15, 2012, from http://www.ihatoday.org/uploadDocs/1/boostapril28.pdfHermes, S. A. (2010, October 21). The hazards of hospitalization [PowerPoint slides]. Kl i il R M Fl t h K & J i B M (2008) R d i f ti l d li iKleinpeil, R. M., Fletcher, K., & Jennings, B. M. (2008). Reducing functional decline in hospitalized elderly. Rockville, Maryland.Shugarman, L. R., Lorenz, K., & Lynn, J. (2005). End‐of‐life care: An agenda for policy improvement. Clinics in Geriatric Medicine, 21(1), 255‐272. Stone, J., & Hoffman, G. (2010, September). Medicare Hospital readmissions: issues, policy options and the PPACA. Retrieved from Congressional Research Service [CRS] website: http://www.crsdocuments.comSuter, P., Hennessey, B., Harrison, G., Fagan, M., Norman, B., & Suter, W. N. (2008). Home‐based chronic care: an expanded integrative model for home health professionals. Home Healthcare Nurse, 26(4), 222‐228.