Integrating Care Transitions Strategies Through Enterprise Process, People, and Technology

Integrating Care Transitions Strategies Through Enterprise Process, People, and Technology

June 3, 2015

Integrating Care Transition Strategies

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How to develop a readmissions reduction program that integrates people, process, and technology

How to create consistent, effective readmission reduction strategies and tactics for different service lines

How to deploy readmission reduction processes and technologies that work internally and expand to external facilities and care teams

How to implement care team and management dashboards to track clinical, financial, and outcome success

Copyright 2015 Digital Collaboration Solutions, LLC 6-3-15

Learning Objectives

A consulting and services company that provides care coordination, collaboration,and patient/provider engagement solutions.

Care Coordination Collaboration Communications

HEALTHCARE

Process

People

Tech

DCS helps healthcare organizations improve care coordination and care team engagement through process optimization, better collaboration, digital communications, and use of innovative technology.

DCS combines in-depth experience in healthcare, healthcare information technology and patient/provider engagement to deliver measurable results and improved outcomes.

3Copyright 2015 Digital Collaboration Solutions, LLC 6-3-15

Copyright 2015 Digital Collaboration Solutions, LLC 411-Mar-15

Root Causes of Ineffective Transitions of Care

Root causes of ineffective transitions of care

Accountability Breakdowns

A survey at 101 Hospitals revealed that 9% of physicians have admitted to “Turfing” patients.

Communications Breakdowns

Discharge summaries reach PCPs by the first follow-up visit only 12% to 34% of such visits, and then often lack key information

Patient Education Breakdowns

In a study of understanding of discharge instructions in patients > 65 years54% did not accurately recall instructions about their follow-up appointment

The Joint Commission defines three main areas of breakdowns that are the root causes of ineffective transitions of care


Addressing Causes of Ineffective Transitions of CareBalanced Performance

Goals&

Metrics


Goals & MetricsWhich Measures are Critical to Your Healthcare Organization?

Measures• Unplanned 30 Day Readmissions • Quality Based Payment Reforms (QBPR)• Physician Quality Reporting Initiative (PQRI) • Meaningful Use Clinical Quality Measures (CQM) • Hospital Acquired Conditions (HAC) Scores• Press Ganey• Joint Accreditation Commission

• CMS 30-day readmissions penalty• Hospital Value Based Purchasing (HVBP)• Medicare Spending per Beneficiary (MSPB)• Hospital profitability• Bad debt due to uninsured admissions and ER visits• Under reimbursed Medicare & Medicaid

• Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

• Patient Activation Measure® (PAM)

Care Quality

Financial

Patient Experience


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Readmissions Processes

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Source: Readmission Reduction Guide, the Pittsburgh Regional Health Initiative (PRHI). January 2011

“…process-focused care is centered on the patient. It coordinates the work of many care team members (including patients, physicians, nurses, midlevel providers, lay caregivers, clinical educators, pharmacists, case managers, and call-center personnel) to provide each patient with high-quality, efficient care across time and across all venues of care.”

James M. Walker and Pascale Carayon From Tasks To Processes: The Case For Changing Health Information Technology To 67-477 Improve Health Care Health Affairs, 28, no.2 (2009):467-477

http://www.chqpr.org/downloads/PRHI_Readmission_Reduction_Guide.pdf

Process Improvement Practices

Address Root Causes of Ineffective Transitions of Care

Accountability Breakdowns

Clearly define & document care transition processes

Identify participants

Assign responsibility

Assess risks

Incorporate contingency planning

Plan resource requirements

Communications Breakdowns

Clearly define & document communications processes

Specify:• What information should

be communicated• To whom to communicate• How to communicate

Enforce communications timeframes

Clarify “hand-off” communications (e.g. acknowledgements)

Patient Education Breakdowns

Integrate patient & family education into care transitions

Specify education content

Enforce that education occurs

Assign responsibility for whom provides patient education


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People

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“Integrating hospital and outpatient care is key to reducing readmissions.

Formal or strong informal relationships between hospitals and local primary

care providers, heart clinics, nursing homes, home health care agencies, and

health plans appear to improve outcomes for patients at the four case study

hospitals. Close coordination between the hospitals and palliative care and

hospice programs—and efforts to understand and honor patients’ preferences

for end-of-life care—seem to reduce unwarranted and unwanted readmissions

as well.”

Readmissions Reduction Team

Key questions:• Do you have the right people

involved for an integrated plan? • What organizations do you need

to make a program successful?

Your readmissions initiatives must:– Involve all participants– Be broad-based within the

groups– Be well planned– Gain support of users

• Where is the “biggest bang”?


PatientNURSE

DOCTOR FAMILY

HOME CARE PROVIDERS

POST-ACUTE CARE/REHAB PHARMACY

Care Community Analysis• What is the care community for your hospital or healthcare organization?

– Demographics– Location of facilities and patients– Are patients local or coming from far-away?– Types of facilities– Ownership– Relationship to hospital

• What is the care community per service line?– The same or different from the hospital overall?

• What is the care community for the patient?– Who has responsibility for the patient?

• Outcome & care quality• Patient experience• Financially

– Don’t forget “informal” care community – family and friends

• What is the financial and business model– Fee for service– Bundled payments for “Episodes of Care”– Shared risk/ACO– Medicare – Value Based Purchasing


Copyright 2015 Digital Collaboration Solutions, LLC 13

You must align the people involved in readmissions management

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Care Coordination Technology

What technologies are being used for care transitions?• EHRs• Hospital Information Systems (HIS)• Care Coordination Systems• Mobile Technology• Portals• Communication Technology• Health Information Exchanges (HIEs)

And MANY others!


Care Coordination Technology

• Technology is a valuable tool to improve transitions of care and lower readmissions

• But it is critical the technology:– Improve the processes– Support the people involved

• Don’t use the “hot” new technology for its own sake. • At the same time recognize that new technologies – like mobile

technology – are having an important impact• Care coordination technologies are still immature



How to create consistent, effective readmission reductions strategies and tactics for different service lines


Service Line RequirementsDifferent services have different post-acute requirements and organizations • Orthopedics is often very structured

– Treatment plans tend to be similar– Orthopedics has different post-acute providers – like

physical therapy• Cardiology is highly varied

– Broad range of diagnosis– So care plans vary based on different patient needs

• COPD and PN are often co-morbidities in many services so reducing readmissions is intertwined with care plan for primary diagnosis

Transitions of care must take into account service lines and their differences such as variants of processes.

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Understanding Service Line Needs

• Start with diagnosis subject to CMS

readmissions penalty

– AMI, HF, PN, COPD, THA, TKA

• Understand impact – by service line and

diagnosis

– Rate of readmissions

– Volume – hospitalizations and discharges

– Primary vs. secondary diagnosis

– Patient population characteristics – age,

co-morbidities, social-economic issues

– Severity of illness

– Impact on other measures – like MS-DRG

• Identify service line care team

– Typical treatment plans

– Post-acute providers

– Need for home care & family involvement

– Other resources required (e.g. home

oxygen)18Copyright 2015 Digital Collaboration Solutions, LLC 6-3-15

• Evaluate readiness for change

– Often varies by service

– Fit with current or past care transition

and readmission reduction program

– Employed vs. affiliated clinicians

– Owned vs. affiliated post-acute

institutions

– Relationships with post-acute

institutions

• Develop a priority list starting with “lowest

hanging fruit”


How to implement care team and management dashboards to track clinical, financial, and outcome success

Measures• Unplanned 30 Day Readmissions • Quality Based Payment Reforms (QBPR)• Physician Quality Reporting Initiative (PQRI) • Meaningful Use Clinical Quality Measures

(CQM) • Hospital Acquired Conditions (HAC) Scores• Press Ganey• Joint Accreditation Commission

• CMS 30-day readmissions penalty

• Hospital Value Based Purchasing (HVBP)

• Medicare Spending per Beneficiary (MSPB)

• Hospital profitability

• Bad debt due to uninsured admissions and ER visits

• Under reimbursed Medicare & Medicaid

• Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

• Patient Activation Measure® (PAM)

Needed Data & Reports

• Readmission reduction• Financial impact• Service line impact• Outcomes impact• Patient satisfaction• Quality scores

Care Quality

Financial

Patient Experience


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Data Used for Dashboard

Dashboard uses commonly available patient visit and billing data such as • In-house patient list • Current LOS • Patient acuity • Billing diagnosis codes • Visit type, such as, Inpatient, outpatient

or ED • DRG • Payer information • Clinical service • Patient location in the hospital • Physician information

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Dashboard Should Include• Executive summary of

readmission trends for all patient populations

• Drill downs by hospitals, service lines, nurse stations, physicians down to patient detail

• A risk scoring algorithm based on the LACE model provides daily risk stratified reports showing all in-house patients sorted by their risk level for readmission.

Presentation at Healthcare Analytics Symposium July 14-16, 2014 by Gabriela Ramirez, PhD, MPH Corporate Director, Enterprise Analytics, Clinical Analysis and Outcomes ORLANDO HEALTH

Dashboard Example

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Dashboard Example – Summary Level

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https://www.healthcatalyst.com/value-of-healthcare-dashboards

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Dashboard Example – Transaction Level

March 2015


Recommended Action Steps

Goals

• Analyze the data on readmissions and transitions of care to define target improvements

Process

• Understand current processes and develop new ones

People

• Put together a multi-organization and multi-discipline team

Technology

• Identify and implement technology that enables achieving improvements

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Michael LevingerPresident & CEODigital Collaboration [email protected]: 781.307.7898Skype: mlevingerTwitter: @mlevinger

Questions & Answers

Integrating Care Transitions Strategies Through Enterprise Process, People, and Technology

Health & Medicine

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