Potentially Avoidable Readmissions Workgroup Update

Bree Collaborative

March 27, 2013

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Outline of Today’s Meeting

•Update on Bree Collaborative request to WSHA and Qualis to semi-publicly publish 30-day, all-cause data

•Update on activities to promote endorsement of the concept of WSHA and partners’ tool kit

•Present summary of stakeholder interviews & Discuss future ideas for Bree role in reducing avoidable readmissions

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Background information on Data Request• Qualis & WSHA partnering to provide reports to hospitals on

readmission rates and patterns, approximately every 6 months▫ Medicare FFS and CHARS (“all-payers”)▫ Description of data and data analytics in meeting packet

• Reports intended to support QI efforts by hospitals and others to improve care transitions and reduce hospital admissions

• Results are shared with individual hospitals – hospitals see their own performance and how they compare to peers; aggregate reports available to public (not individual hospitals’ performance)

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Request to Publish 30-day, All-Cause Avoidable Readmissions

•Part of Strategy #2 - Measurement, transparency, and reporting (in a semi-public manner)

•At 1/31 meeting, Bree approved Steve Hill sending a letter to Qualis and WSHA requesting that they publish 30-day, all-cause readmissions results

•Bree Readmissions workgroup collaborated on draft letter; final letter sent February 1st

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Request in Letter

• Publish 30-day, all-cause readmission results, by hospital, in a semi-public manner, starting with the next WSHA/Qualis Hospital Readmission Report

• Semi-public = Publish data on public websites but do not advertise or publish data in an aggressive manner

• Publish results until all-cause data becomes available from the Puget Sound Health Alliance and CMS in 2013 – the later two are nationally vetted, more utility to inform benefit design

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Responses to Request

• Qualis response: working with CMS to secure approval and publish these data; if CMS deems data confidential, each hospital will need to give permission (response letter sent on 2/8)

• WSHA response: currently available data is not risk-adjusted and therefore would be inaccurate and misleading – will not publish more data until CMS releases new measure in July (response letter sent on 3/6)

• Opportunity for comments from Qualis and WSHA

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Endorsement of WSHA Tool KitIn January 2013, the Bree Collaborative formally endorsed the concept of the WSHA tool kit and acknowledged that preventing avoidable readmissions requires:

1. A community-wide approach▫ Hospitals cannot solve this problem alone▫ Requires active engagement from primary care, home health,

hospice, community organizations, etc.2. Standardization

▫ Every one doing it their own way has led to the chaos that exists today; patients are the ones that suffer

▫ Providers have patients in multiple hospitals▫ Variation in practice makes it very difficult for community-

based providers to engage w/ hospitals

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Promotion of Bree Endorsement of Concept of WSHA Tool Kit, Cont’d

• Letter to the Editor published in Seattle Times, 2/26 about the importance of standardization and a community-wide approach

• Next Steps:▫ Write Op-Ed and/or Letters to the Editor in response to

readmission articles published in Washington newspapers (not labor/resource intensive)

▫ Send letters to all hospitals, county medical societies, WAFP, and others PAR workgroup will develop list and scope out key messages

Other ideas? Does the Bree agree with this approach?

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Bree Collaborative & Avoidable Readmissions

Summary of Stakeholder Interviews & Discussion of Bree’s Future Role

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Outline of Presentation

•Review the readmissions problem & efforts in WA state

•Recap the Bree Collaborative’s work in this area

•Present findings from stakeholder interviews▫Barriers to readmissions problem and potential

solutions▫Potential role(s) of the Bree in this area

•Present and discuss straw person proposal for next steps

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Readmissions Problem• Potentially avoidable readmissions (PAR) are common and costly

events

• Readmission may indicate poor quality of care

• Result of our highly fragmented system and inability to coordinate care for patients during times of transitions of care and across the health care continuum – lack of clear roles, responsibilities, accountability

• Historically, health care system rewards avoidable readmissions (until recently)

• Socio-economic factors are a big driver of readmissions

• WA readmissions causes differ by population▫ Medicare - Diabetes (25%)▫ Medicaid - Psychosis (35%)

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Efforts in WA

• WSHA (and many partners: Puget Sound Health Alliance, WSMA)▫State- Wide Readmissions Committee▫Smooth Transitions Tool Kit

• State (DSHS and HCA)▫Health homes for Medicaid, persons with public

insurance• Home Care Association of Washington• Leading Age Washington• Olympic Agency on Aging• Qualis Health• PeaceHealth• Others! Lots!

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Bree Collaborative Topic Selection, Sept 2011 - RECAPTopic: Reducing preventable hospital readmissions

8 topics presented; each Bree members was asked to rank each topic – good first topic; good topic but not first; and not a good topic for the Bree

Out of 17 Bree Collaborative members surveyed:▫ 14 voted for readmissions as a good first topic▫ 2 voted for readmissions as a good but not first topic▫ 1 voted this is not a good topic for the Bree

OB and Appropriate ED Use, along with reducing preventable hospital readmissions received the most votes for a good first topic

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PAR Workgroup ‘Charge’ - RECAP

•Formed a workgroup Summer 2012 •Recommend strategies to reduce Potentially

Avoidable Readmissions (PARs)•Expected final work product – Report, to be

adopted by the Bree Collaborative•Report to contain strategies in 3 general areas:

1. Alignment/support local readmission opportunities

2. Measurement, transparency, and reporting (in a semi-public manner)

3. New accountable payment models that align payment with quality/value

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PAR Work to Date – RECAP

• Held 7 meetings; meets every 4 weeks

• Workgroup members: Susie Dade, Sharon Eloranta, Joe Gifford, Mary Gregg, Tony Haftel, Bob Mecklenburg, Kerry Schaefer, Peter Valenzuela

• Narrowed focus: reduce all-cause avoidable readmissions (not disease-specific)

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PAR Work to Date, Cont’d – RECAP

1. Alignment/support local readmission opportunities▫ At 1/31 meeting, Bree Collaborative approved

workgroup recommendation to recognize that “WSHA and its community partners are on the right track of developing a standardized tool kit and process that both hospitals and community providers can use to reduce the rate of readmissions”

▫ Letter to the Editor printed in the Seattle Times on 2/26 about the importance of standardization and a community-wide approach

2. Measurement, transparency, and reporting (in a semi-public manner)

▫ Requested Qualis and WSHA semi-public 30-day, all-cause readmissions, by hospital

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PAR Work to Date, Cont’d – RECAP

3. New accountable payment models that align payment with quality/value

▫APM subgroup has met 6 times to develop a total knee and total hip replacement warranty and bundle model

▫Goal: Bundled payment goes live on January 1, 2014

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Challenges so far…

•Has not had a chair since August

•Workgroup composition, no ‘clinical’ expert in readmission –additional expertise needed

•No clear charter/purpose/scope too broad

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Purpose of Stakeholder Interviews

To help “scope” readmissions work and identify where Bree can make meaningful contributions

•ID top 3 barriers to reducing readmissions

•ID strategies to reduce readmissions

•Role of Bree – how can Bree make a meaningful contribution to reducing readmissions

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Diverse Sampling of Stakeholders Invited & Interviewed

• 20 individuals statewide invited • More than 10 interviewed

▫A few members of the PAR workgroup, and additional Bree members

▫A least one member of each stakeholder group: purchaser, payer, hospital, provider

▫WSMA and WSHA▫State Reps – DSHS and HCA▫Medicaid Managed Care organization▫Mental Health community organization

Note: Long-term care community rep did not respond

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Top Barriers to Reducing Avoidable Readmissions

• Community does not have a shared sense of responsibility for the problem – what’s the role of payers? PC? Home health workers? Who is accountable for what?

• No business case for hospitals – lack of financial incentives to change

• Not easy to define avoidable vs. unavoidable readmissions

• Mental health system – diagnoses and lack of care before inpatient

• Lack of organizational capacity

• Inter and intra-organizational barriers – hard to work across systems

• A lot of work being done, but in individual silos – not one table with everyone at the table

• State’s role unclear – not one point person

• Primary care/outpatient providers not engaged in the process, at the table

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Improvement Strategies – What the Evidence says Works

•No silver bullet

•Evidence shows multiple interventions, simultaneously can reduce readmissions

•Most strategies are hospital-centric, not community-wide

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Recommended Roles for Bree• Note: Only a few people had time or ideas

• Top idea: Lead financial and payment reform discussions and recommendations▫ “Follow the Money” – help expose where the incentives are▫ Incentives, preferential contracting, patient-centered medical

home, global payment

• Top idea: Augment Advanced Planning – how to inculcate into the process

• Convene/facilitate a community conversation, since the Bree is a multi-stakeholder group, on behalf of the state▫ State needs to lead efforts – work on recommendations for

state role in the issue

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Other recommended Roles for Bree, Cont’d

•“Allow payment for pre-discharge appointment”

•“Help create a Health Information Exchange”

•“Recommend discharge standards across the state”

•“Implement CMS Readmission Penalties to WA Medicaid”

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Questions to Consider

•Adding value vs. duplication

•Do proven, evidence-based strategies exist?

•Can Bree make meaningful contributions in this area?

•If Bree is going to do anything, is this an appropriate area given limited resources and attention? Or is another area more appropriate to switch attention to?

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Straw Person Based on Recommendations

Narrow the scope: After tool kit pilot results are known, focus on payment reform/financial incentives recommendations to facilitate implementation and standardization Examples: Discharge checklists, advanced

planning Submit final report by end of summer PAR workgroup recommend ID additional experts

to join workgroup & chair to Bree

Questions? Other Ideas?