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VIRGINIA HOSPITALS AND SKILLED NURSING FACILITIES: PARTNERS IN PREVENTING READMISSIONS

Amy Boutwell MD MPPDecember 12, 13, 14, 2017

Leesburg, Mechanicsville, Lynchburg, VA

WELCOMEAbraham Segres, April Payne

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FORMAT, AGENDAAmy Boutwell, MD, MPP

AGENDAYour goalCurrent effortsData/root causesWhat works?What will work for you?Measures to drive resultsHarvest ideas, prioritizeAction plan, report out

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YOUR GOALWhat is your specific readmission reduction goal?

What – for whom – by how much – by when?

READMISSION REDUCTION GOAL

20% reduction from baseline is aggressive but feasible

Often is achievable within 1-2 years

Trend monthly# readmissions % readmission rate

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DATA, ROOT CAUSES

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CommunityTotal # 

Hospital DCsTotal # of DCs Readmitted

Readmit Rate

Total # of Hospital DCs 

to SNFs

Total # of Hospital DCs to SNFs Readmitted

SNF Readmit Rate

LEAP 8,207 1,395 17.00 1,338 271 20.25

NOVA CTC 29,695 4,832 16.27 5,826 1,200 20.60

Aggregate 37,902 6,227 16.43 7,164 1,471 20.53

VA State 254,296 44,664 17.56 52,484 10,649 20.29

REGIONAL READMISSION RATES: LEESBURG AREA

• 1471 SNF readmissions in region• 4 per day (1251/365)• 1 fewer readmission per day 25% reduction

REGIONAL READMISSION RATES: RICHMOND AREA

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• 1251 SNF readmissions in region• 3‐4 per day (1251/365)• 1 fewer readmission per day 25+% reduction

Source: HQI

CommunityTotal # 

Hospital DCsTotal # of DCs Readmitted

Readmit Rate

Total # of Hospital DCs 

to SNFs

Total # of Hospital DCs to SNFs Readmitted

SNF Readmit Rate

EVCTP 36,631 6,198 16.92 6,906 1,425 20.63

HRCTC 37,171 6,870 18.48 8,326 1,763 21.17

RVA CTC 37,185 6,322 17.00 6,569 1,251 19.04

SRTC 9,167 1,852 20.20 1,504 373 24.80

Aggregate 120,154 21,242 17.68 23,305 4,812 20.65

VA State 254,296 44,664 17.56 52,484 10,649 20.29

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REGIONAL READMISSION RATES: LYNCHBURG AREA

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• 1628 SNF readmissions in region• 4‐5 per day (1251/365)• 1 fewer readmission per day 20% reduction

Source: HQI

CommunityTotal # 

Hospital DCsTotal # of DCs Readmitted

Readmit Rate

Total # of Hospital DCs 

to SNFs

Total # of Hospital DCs to SNFs Readmitted

SNF Readmit Rate

BRCC 14,187 2,382 16.79 3,670 685 18.66

CVTC 11,477 1,908 16.62 2,280 446 19.56

SCTC 8,551 1,594 18.64 2,259 497 22.00

Aggregate 34,215 5,884 17.20 8,209 1,628 19.83

VA State 254,296 44,664 17.56 52,484 10,649 20.29

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DAYS UNTIL READMISSION

Source: HQI

Consider the different causes of readmissions over 30 days:

• 0-5 days?

• 5-20 days?

• 20-30 days?

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Days Until Readmission from SNF Aggregate Communities (Jul2016‐Jun2017)

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DISCHARGE DXS LEADING TO READMISSION

What’s surprising? 246

68

64

56

55

52

50

40

34

34

0 50 100 150 200 250 300

Other sepsis

Cerebral infarction

Acute kidney failure

Hypertensive heart and chronic kidney disease

Heart failure

Fracture of femur

Other disorders of urinary system

Type 2 diabetes mellitus

Respiratory failure, not elsewhere classified

Osteoporosis with current pathological fracture

Top Principal Discharge Diagnoses Leading to a Readmission from SNFs in Aggregate Communities (Jul2016‐Jun2017)

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TOP READMISSION DXS

What’s surprising? 364

90

75

57

43

39

36

36

33

32

0 50 100 150 200 250 300 350 400

Other sepsis

Hypertensive heart and chronic kidney disease

Acute kidney failure

Respiratory failure, not elsewhere classified

Heart failure

Cerebral infarction

Other diseases of digestive system

Other disorders of urinary system

Other chronic obstructive pulmonary disease

Hypertensive heart disease

Top Principal Readmission Diagnoses from SNFs in Aggregate Communities (Jul2016‐Jun2017)

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ROOT CAUSES OF READMISSIONS

• 78M hospitalized for UTI; readmitted 1 day for altered mental status

• 69F hospitalized for back pain; readmitted 3 days after family called 911 from SNF

• 84F hospitalized for weakness; sent to ED 1 week after discharge for “bad labs”

• 89F hospitalized for pneumonia; readmitted 22 days later from home

ADDRESS THE ROOT CAUSES

Incomplete information about clinical status

Incomplete information about functional status

Incomplete information about behavioral health or “sundowning”

Missing hard copies of controlled substance prescription

Missing documentation of placement of tubes or lines (eg picc lines)

Delays in obtaining (rare, expensive) medications

Change in clinical status but not emergency

Patient/family dissatisfaction with the facility 

Readmissions following discharge from SNF to home 

Others?

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WHAT WORKS?

“PORTFOLIO OF STRATEGIES”

Improve standard care processes for all patients

Collaborate with cross-setting partners; ensure linkage

Provide enhanced services

Use data, analytics, flags, workflow prompts, automation, dashboards to support continuous improvement, ensure reliability, drive to results

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WARM HANDOFFS WITH “CIRCLE BACK” CALL

SNF Circle Back Questions (Hospital calls back SNF 3‐24h after d/c): Did the patient arrive safely?

Did you find admission packet in order?

Were the medication orders correct?

Does the patient’s presentation reflect the information you received?

Is patient and/or family satisfied with the transition?

Have we provided you everything you need to provide excellent care to the patient?

Key Lessons:• Transitions are a process (forms are useful, but need intent)

• Best done iteratively with communicationSource: Emily Skinner, Carolinas Healthcare System

WARM HANDOFFS WITH “CIRCLE BACK” CALLIMPLEMENTATION TIPS

Richmond, VA hospital and several partnering SNFs

• 1 point person RN made the post transfer calls

• Each SNF knew the name, contact of that 1 RN at the hospital

• The asked the 6 questions and followed up on all issues 

Key tips:

• Point person is key for fostering collaborative relationship

• RN provides “reminder” to floor RN, CM, MD about what was missing

• RN follows up with “issues here” and “issues there” 

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CIRCLE BACK: “IDEAS THAT WORK”IMPLEMENTATION EXAMPLE 

https://www.youtube.com/watch?v=SG28aJhs63s

“Anytime I discover an issue, I always follow up. When I started making the calls, I found issues 26% of the time; last month I only had issues 8% of the time” 

‐ Hospital RN

“6 simple questions are making a difference in the Richmond community” 

CO‐MANAGEMENT OVER TIME

• Dedicated Team: A Point Person

• ACO or Bundle clinical coordinator

• Co‐Management: Physical or Virtual Rounds in SNF 

• RN / NP to see patient, discuss plan with SNF staff

• Respond to changes in clinical status to manage in setting

• Weekly telephonic rounds ACO/bundle coordinator and SNF

• LOS, progress toward discharge goals, transitional care planning

• Tele‐medicine consults in SNF to manage on‐site 

• Direct admit back to SNF from home 

Took a while to develop collaborative rapport v. hospital “in‐charge”

No substitute for verbal communication and problem solving

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ED TREAT‐AND‐RETURN TO SNF 

2 hospital system, 20 ED docs, 17 PAs

• “Why are almost all SNF patients admitted?”

• “Patients only seen once a month”; “can’t do IVs”, etc

• “If they send them here they can’t take care of them” 

•Actions:• Asked ED clinicians “5 whys”

• Education: posted INTERACT SNF capability sheets in ED

• Simplicity: establish contacts, standard transfer information

•Results: increase in number of patients transferred from ED to SNF

Source: Dr Steven Sbardella, CMO and Chief of EDHallmark Health System Melrose, MA

# Treat-and-Return to SNF

ED TREAT-AND-RETURNIMPLEMENTATION TIPS

• Think twice: can this person return to the SNF?• Make it easy: Needs to be as easy to return to SNF as send “upstairs”

INTERACT tools available at: www.interact2.net

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BEST PRACTICES OF CROSS SETTING COLLABORATION

• Shared understanding of (best‐available) data

• Shared understanding of patients and caregivers’ perspective

• Shared understanding of “receivers” perspective

• Clearly identified specific, feasible improvement ideas

• Improvements are “hardwired” into new standard processes

• Regular meetings, joint problem‐solving

WHAT WILL WORK FOR YOU?

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MEASURES TO DRIVE RESULTSTrack implementation, not just outcomes – you will need to drive and

modify and innovate to get highly reliable implementation outcomes

PERCENT OF TARGET POPULATION SERVED

0

50

100

150

200

250

300

350

400

450

Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

Target Population

Target Population “Served” vs. Total Target Population

For hospitals: • # patients d/c to SNF• # “served”

For SNFs:• # patients admitted from hospital• # “served”

Close the gap! That takes focus, effort

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TIMELY CONTACT

For hospitals: • # patients d/c to SNF• # ”circle back” contact <48h• # contact <48h of d/c SNF to home

For SNFs:• # patients d/c to home• # contact <48h

Drive to goal >80% completed contact

PATIENT-FACING CONTACTS PER PATIENT

For hospitals: • # ”contacts” while in SNF• # contacts once d/c home

For SNFs:• # contacts once d/c home

Innovate: prioritize patient support, with same staff– that’s what helps

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HARVEST, PRIORITIZE

BRAINSTORM

• Do you have a clearly articulated readmission reduction goal? • Do you know you readmission data? • Have you analyzed the root causes of readmissions? • Do you review every readmission for root causes, opportunities for improvement? • Do you have a post-person relationship across settings? • Do you engage in warm handoffs or circle back?• Do you have a “portfolio of strategies” in place? • Do you have an operational dashboard to guide improvement work?

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Hard to Do --------Easy to Do

Low

Ben

efit

--

----

High

Ben

efit

ACTION PLAN

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ACTION PLAN

• Name of Plan• Action Steps

• What needs to happen, who will do it, by when?• ”Stakeholders”

• Who could stop progress, and how will you engage that person• Expected benefit

• What will be the benefit of completing this plan?• Measurement

• How will you measure what you did?

REPORT OUT

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THANK YOU FOR YOUR COMMITMENT TO REDUCING READMISSIONS

Amy E. Boutwell, MD, MPPAdvisor, VHHA Center for Healthcare Excellence

Physician Advisor, Cynosure Health for AHA/HRET HIINamy@collaborativehealthcarestrategies.com