© Pathway Health, 2013

Best Practice Model for Reducing Unnecessary Hospital Transfers Explore quality patient outcomes with the right guide

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Table of Contents Introduction 2

Problem Statement 2

The Pathway Solution – Best Practice Model 3

Summary 6

Introduction In 2010, $17.4 billion Medicare dollars were spent on hospital readmissions within 30 days. One quarter of the patients readmitted to the hospital within 30 days of discharge were from skilled nursing facilities with the remaining from the community. On October 2012, the Hospital Readmission Reduction Program (HRRP), a part of the March 2010 Affordable Care Act, became effective. Medicare will recover payments from hospitals for unnecessary readmissions within 30 days of discharge if the patient was discharged with a diagnosis of acute myocardial infarction (AMI), pneumonia and congestive heart failure (CHF). Urinary tract infections (UTI) and sepsis are also areas that are being discussed for future tracking.

Problem Statement Nearly 18 percent of hospitalizations of Medicare beneficiaries are the result of the readmission of patients discharged from the hospital within the previous 30 days. Many of these readmissions are avoidable with better discharge planning and follow-up care. (Source: http://www.whitehouse.gov) To improve this situation, hospitals will receive bundled payments covering not just the hospitalization, but care for the 30 days after the hospitalization. Hospitals with high rates of readmission will be paid less if patients are re-admitted to the hospital within the same 30-day period. So what does the HRRP mean for the post-acute provider? Hospitals will now align with post-acute providers that are proficient and clinically competent in managing these disease states.

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Post-acute providers will need to implement a best practice approach including a review of organizational readiness, strategic alliances, and a proactive review of system processes and outcome management for AMI, CHF, pneumonia, as well as UTI and sepsis. Hospitals will now actively seek post-acute providers that can manage patients effectively. Hospitals will seek out providers that can:

• implement programs and systems that will ensure clinical competency to effectively manage these disease states;

• demonstrate the ability to pick up on subtle changes before they become crisis situations;

• institute competent interventions when there is a decline in patient status.

The Pathway Solution: Best Practice Model With budget cuts, regulatory demands, staffing issues and higher acuity residents/patients, alignment with key partners and resources is imperative for the post-acute provider to be successful. The Pathway Health Best Practice Model for avoidable hospital transfers combines our recommended implementation of proactive solutions, utilizing key industry thought leaders and standards of practice. This model approach provides an integrated, systematic solution to ensuring proper disease state management.

Our resources prepare post-acute providers to demonstrate synchronized systems of care. Quality care begins long before a new patient/resident is admitted into your care. Our focus is to empower the clinical team to be the eyes, ears, and voice of the patient/resident. Identification of subtle changes in condition is critical for positive care outcomes. The Pathway Health Best Practice Model for avoidable hospital transfers combines the implementation of INTERACT II Tools with expert support, resources, field experts, industry leading benchmarks, educational programs and information technology providing early detection of changes in condition, clinical processes and systems that stabilize and improve resident health while improving financial outcomes for providers. Our expertise includes best-in-class services, partnership alignment and resources to avoid unnecessary hospital transfers. Pathway Health Best Practice Model Implementation Resources

Practical Guidance

The Pathway Rehospitalization Reduction Assessment© The Pathway Best Practice Model provides expert navigation and guidance to keep your team and operations moving in the right direction. This comprehensive assessment provides direction and guidance as your organization prepares for its critical role in the Hospital Readmissions Reduction Program (HRRP). Post-acute

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providers need to have a solid road map for care transitions that identify and assess changes in patient status, including appropriate clinical management of new admissions, communication, documentation and trending of conditions that will trigger a potential hospital readmission. The Pathway Rehospitalization Assessment© provides an in depth review of your organizations readiness for the rehospitalization initiative.

• The preadmission process • Clinical system integration

including INTERACT II and care outcomes

• Clinical competency • Documentation and

care tracking systems • Risk Management and

QAA integration • Review of strategic alliances

and communication strategies

Onsite, customized Rehospitalization Reduction Consultation and Training that is geared to guide your team to keep on the right path.

Tools for an Integrated, Systematic Approach

Rehospitalization Reduction Toolkit©

As post-acute providers embark on the journey towards reducing avoidable hospital transfers, implementation of key strategic initiatives is critical to an organization’s success. This comprehensive Toolkit provides practical, step-by-step guidance for organizations as they implement a solid rehospitalization plan. From policies to resources to education – this Toolkit is an essential piece of equipment for post-acute care leaders. This toolkit provides leadership and clinicians with the tools they need to keep on the right path.

• Pathway’s proprietary PATH system for front line nursing staff and the interdisciplinary team. PATH focuses on how to responsibly Pass it on, Act on it, Talk about it and Handle it. Our systems work compatibly with the INTERACT II system and reinforce the importance of every member of the team.

• Tracking and trending tools • Tips to extend length of stay and

reduce unnecessary hospitalizations • Change in Condition resources • Communication, documentation

and reporting tools • Educational pathways

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Knowledge and Resources

Webinars, Onsite Training and Classroom Education

For post-acute leaders, clinicians and the Interdisciplinary Team to enhance their skills to conquer disease state management challenges and the rehospitalization journey.

• Rehospitalization and operational impact

• Pre-admission screening • Admission process and

evaluation of the assessment to develop the plan of care

• Management of disease states • Accurate assessment skills and

interpretation of the assessment to pick up on subtle changes

• Implementation of interventions based off of the assessment

• Implementation strategies for INTERACT 3.0 within your processes

• Trends analysis and benchmarking data

• Communications with front line staff

• On-going assessment and care planning

• Communication, documentation and reporting

• Strategies for the marketplace and referral sources

Strategic Partnerships

Quality Outcome-Driven Focus Organizational data, outcomes and benchmarks are key! Post-acute provider performance will be measured as the rehospitalization reduction journey continues. Pathway Health experts will work with you and your team to customize an outcome driven focus which reviews your current data, evaluates performance per industry benchmarks while establishing a practical guide to increase performance and quality outcomes. Industry data shows that the average nursing facility, assisted living or home care resident has a complicated disease profile, many with one primary disease and up to eight secondary diseases or afflictions. Over 70% of re-hospitalizations are due to the progression of secondary or new diseases.

Summary Alignment with key partners and resources is imperative for the post-acute provider to be successful in the era of Health Care Reform. Pathway’s Best Practice Model for avoidable hospital transfers provides an integrated, systematic solution to ensuring proper disease state management. It is vital providers engage experts and industry leaders who have aligned best-in-class services, partnership alignment and resources to avoid unnecessary hospital transfers. Learn more about Pathway Health’s solutions for avoidable hospital transfers at www.pathway-readmissions.com.

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