Readmission Partnership Between Acute Care and

Post-Acute Care

Melissa Suzuki, MSW Regional UR Case Manager Specialist Commonwealth Care of Roanoke (CCR) Amanda Melvin, MSW Referral Development Coordinator Radford Health & Rehab Center The Woodlands Health & Rehab Center

Acute Care Readmission Statistics

Retrieved from: https://www.hcup-us.ahrq.gov/reports/infographics/HCUP-hospital-readmission-infographic-final.pdf

Acute Care Readmission Statistics by Payer

Retrieved from: https://www.hcup-us.ahrq.gov/reports/infographics/HCUP-hospital-readmission-infographic-final.pdf

• Established in the 2010 Affordable Care Act, allows the CMS to withhold inpatient prospective payments to short-term acute hospitals with excessive readmissions for certain conditions.

• Study published in the Annals of Internal Medicine, concluded that hospital readmissions across the U.S. indeed declined starting with the ACA, and that moreover, hospitals with the highest readmission rates before 2010 improved the most in the years following.

Readmissions Reduction Program

Carilion Roanoke Memorial Readmissions

• The Centers for Medicare & Medicaid Services will withhold $2.6 million of Roanoke Memorial’s payment for fiscal year 2017

• Roanoke Memorial receives about $303 million a year in revenue from Medicare and $96 million from Medicaid.

• The penalty is about $1.2 million less than this year, reflecting improvements that began a couple of years ago.

• Roanoke Memorial is among 19 out of Virginia’s 79 hospitals that were penalized.

Source: http://www.roanoke.com/business/news/feds-issue-million-penalty-to-carilion-roanoke-

memorial/article_469ac3a0-f825-5ad0-9308-701318112ba5.html

Decreasing readmissions

• Roanoke Memorial began to show improvements in its readmission rate in 2015

• Greater improvement came by having social workers begin to work with at-risk patients from the time they enter the emergency department to make sure they have support once they leave.

Programs in place at Carilion Roanoke Memorial Hospital to prevent readmissions

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Care Management Department made up of :

-Social Workers (MSW) -Case Managers (RN) -Utilization Management -Central Resource Center -CARES Department

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LACE Score used within Care Management

Lace Score:

00-55 = Low Risk for Readmission

56-75 = Moderate Risk for Readmission

76-90 = High Risk for Readmission

Preventing Readmissions in Acute Care

• Daily Rounding with Interdisciplinary Team Based Approach

• Biopsychosocial Assessments on all Patients

• Daily charting requirements in Epic

• Discharge instructions discussed with patient/nurse

Evolent Health Partners with Carilion Clinic

• Evolent Health partners with leading health systems to drive value-based care transformation.

• Providing clinical, analytical and financial capabilities, Evolent helps physicians and health systems achieve superior quality and cost results.

• Evolent's approach breaks down barriers, aligns incentives and powers a new model of care delivery resulting in meaningful alignment between providers, payers, physicians and patients

• SOURCE: Evolent Health

CRMH HEART SURGERY PATIENT

• Beginning Summer 2017, all recent cardiac surgery patients discharged from Carilion Roanoke Memorial Hospital (CRMH) will be wearing this bracelet.

• The bracelet will remind patients or caregivers to call the Cardiothoracic Surgery Service ANYTIME they have a question OR an urgent need that takes them to an Emergency Department, Urgent Care Center, or Doctor’s Office.

Quarterly Skilled Facility Meeting

• Skilled Nursing Facility Representatives/Administrators meet to discuss readmission trends and collaborate on identifying additional ways to prevent readmissions

Impact of Readmissions

• Multiple readmissions have been associated with: – Increase cost of healthcare dollars (estimated $17.4 billion annually)

– Deterioration in overall health status

– Increased risk for medical errors

– Increased risk of duplication of services, testing, etc..

• Research has shown that majority of readmissions are preventable – These are associated with indicators of substandard care during the initial

admission such as; poor resolutions of the main problem, unstable therapy at discharge, and inadequate post discharge care

• Additional research has shown that some readmissions can be prevented by implementing effective patient education, predischarge assessments, and appropriate aftercare services

Safe Transitions: A method to help reduce readmissions

• Brief History and Key Factors

• Definition and Purpose

• Prior to Admission

• Day of Admission

• During Skilled Stay

• Week of Discharge

• Day of Discharge

• Post Discharge

Brief history and Key Factors

• Large majority of serious medical errors involve miscommunication during the hand-off between medical providers

• Improving transitions between care venues has been identified as an important strategy in helping to decrease readmission rates, improve patient health, enhance patient care quality and safety, reduce inefficiencies, and lower costs

• Unsatisfactory care transitions increase the probability of a decline in health status, thus increasing likelihood of a readmission

• Key factors or root causes behind failed care transitions: – Lack of provider coordination and information sharing

– Lack of follow up from physicians and other caregivers

– Lack of patient/caregiver knowledge and empowerment

– Accountability breakdowns

Definition and Purpose

• Safe Transitions: to provide a seamless handoff or discharge from subacute back to home or lower level of care in the community.

• Purpose:

– improve post discharge patient outcomes

– reduce hospital readmission rates

– reduce possible adverse reactions

– improve health

– maintain patient in community longer

– improve quality of life for patient and families

More Definitions and Purpose

7 Key components for a Safe Transition to occur:

– Leadership Support

– Interdisciplinary Collaboration

– Early Identification of Patients at Risk

– Transitional Planning from Day 1

– Medication Management

– Patient and Family Engagement

– Transfer of Information

Prior to Admission

• Meet with patient and family at hospital

• Gather relevant information from Case Manager

• Discussions w/patient and family – Set the expectations (short stay v. LTC)

– Determine safe transition goal

– Identify any potential barriers and address

(i.e. copay concerns, lack of support, etc..)

• Schedule TBAA

• Complete Admission packet if able

• Collect any POA/Advance Directive paperwork

• Introduce Safe Transitions booklet

Initial Admission to Center

• Orient patient/family to center, provide Welcome Packet, escort them to their room, ensure they get settled in

• Admission assessments should be completed within first 24-48 hours – Nursing Admission Assessments and Skilled Care notes – Therapy evaluations – Social Work Admission assessment – Activities assessment – Dietary assessment and preferences

• TBAA held within first 72 hours – Interdisciplinary attendance and engagement is critical – Reiterate expectations of stay – Develop plan of care with input from patient/caregiver – Review goals of patient – Identify barriers to obtaining goals and how they will be addressed

During Skilled Stay

• Weekly UR meeting

• PPS/Clinical Reimbursement management daily

– Critical to providing the right level of care throughout the stay

• Continue to analyze discharge plan and identify barriers and record these along the way

• Utilize Safe Transition form if patient has appointments

• Daily clinical meeting

– Analyze patient progress, changes in condition, etc.

Week of Safe Transition

• Finalize Discharge Plan

• Review medications with patient/family

• Schedule follow up appointments with PCP and specialists as indicated

• Ensure patient/caregiver education has been completed and utilize Teach Back method to gauge level of understanding

• Arrange follow up services

– HHC

– DME

– Community resources

Day of Safe Transition

• Provide patient/family with completed Discharge folder

– Contact info for HHC company

– Contact info for social worker or center

– Educational material about diagnosis

– Med list

– Discharge instruction form

• Review med list with patient/family again. Give them the opportunity to ask questions.

• Inform patient/family that they may be able to return within 30 days if they decline or don’t manage well once home, instead of going to hospital

Post Safe Transition

• Social Service staff completes follow up call within initial 24-48 hours after patient has left facility – Big topics to focus on:

– Ensure patient was able to obtain meds

– Home Health services started

– Verify/confirm any scheduled follow up appointments

– Discuss any concerns patient/family has experienced since leaving the center

– Reiterate option to readmit back to center within 30 days if they experience a decline or are not able to manage at home

– Reiterate if they have any questions to feel free to reach back out to the center

• Additional follow up calls performed as needed, best practice after the initial call is to complete additional calls around 7days, 14days, and 30days. – Coordinate information sharing and additional calls with downstream providers like

HH if possible

Questions?

Resources

• Healthcare Cost and Prevention and Utilization Project

– HCUP Statistical Briefs #153 and #154: http://www.hcup-us.ahrq.gov/reports/statbriefs/statbriefs.jsp

– SOURCE Evolent Health http://evolenthealth.com

• Suzanne DelBoccio, MS, RN, CENP, FACHE; Debra F Smith, MSW, LCSW, CCM; Melissa Hicks MSN, RN-BC; Pamela Voight Lowe, MSN, RN, CPHQ, NE-BC; Joy E Graves-Rust; Jennifer Volland, DHA, RN, MBB, CPHQ, NEA-BC, FACHE; Sarah Fryda, BA, MS. Successes and Challenges in Patient Care Transition Programming. Online J Issues Nurs. 2015; 20(3). www.Medscape.com 4/26/2016

• Improving Care Transitions: A Strategy for Reducing Readmissions. The Center for Improving Value in Health

Care, 2012

• Transitions of Care: The need for a more effective approach to continuing patient care. The Joint Commission

Center for Transforming Healthcare, 2012