Acknowledgements The Health Research & Educational Trust (HRET), an affiliate of the American Hospital Association (AHA), is dedicated to transforming health care through research and education. This guide was funded by The Commonwealth Fund and The John A. Hartford Foundation. HRET would like to express our sincere gratitude to the following important contributors who attended a workshop to discuss how to spread and implement strategies to reduce avoidable readmissions: David Acker, JD Maulik Joshi, DrPH Canton-Potsdam Hospital Health Research & Educational Trust American Hospital Association Anne-Marie J. Audet, MD, MSc The Commonwealth Fund Mary Jane Koren, MD, MPH The Commonwealth Fund Amy Berman, RN The John A. Hartford Foundation, Inc. Nancy Landor, MS Healthcare Association of New York State Amy Boutwell, MD, MPP Institute for Healthcare Improvement Joe McCannon Institute for Healthcare Improvement Bram B. Briggance, PhD Briggance Consulting Captain Matthew T. McKenna, MD, MPH The Centers for Disease Control and Prevention Jane Brock, MD, MSPH Colorado Foundation for Medical Care Anne Mutti, MPA Medicare Payment Advisory Commission Eric A. Coleman, MD, MPH Care Transitions Program Mary Naylor, RN, PhD University of Colorado NewCourtland Center for Transitions and Health University of Pennsylvania School of Nursing Matthew E. Fitzgerald, DrPH American College of Cardiology Kate O’Malley, RN, MS California HealthCare Foundation Irene Fraser, PhD Agency for Healthcare Research and Quality Awo Osei-Anto, MPP Health Research & Educational Trust David N. Gans, MSHA Medical Group Management Association Carol Raphael, MPA Visiting Nurse Service of New York Gavin W. Hougham, PhD The John A. Hartford Foundation, Inc. Kim Streit, MBA, MHA Florida Hospital Association Brian Jack, MD Boston University School of Medicine Mark V. Williams, MD Northwestern University Stephen F. Jencks, MD, MPH Feinberg School of Medicine Consultant in Healthcare Safety and Quality Charlotte Yeh, MD AARP Services, Inc. Suggested Citation Osei-Anto A, Joshi M, Audet AM, Berman A, Jencks S, Health Care Leader Action Guide to Reduce Avoidable Readmissions. Health Research & Educational Trust, Chicago, IL. January 2010. Contact Information: Awo Osei-Anto, MPP, at Health Research & Educational Trust hanto@aha.org © 2010 Health Research & Educational Trust Executive summary Reducing avoidable hospital readmissions is an opportunity to improve quality and reduce costs in the health care system. This guide is designed to serve as a starting point for hospital leaders to assess, prioritize, implement, and monitor strategies to reduce avoidable readmissions. Steps for hospital leaders to reduce avoidable readmissions Recognizing that hospitals may be at different points in the process, this guide follows a four-step approach to aid hospital leaders in their efforts to reduce avoidable readmissions. The four steps are: 1 Examine your hospital’s current rate of readmissions. 2 Assess and prioritize your improvement opportunities. 3 Develop an action plan of strategies to implement. 4 Monitor your hospital’s progress. Major strategies to reduce avoidable readmissions This guide is meant to address readmissions that are avoidable and not all readmissions. Many readmissions, in fact, could represent good care; such as those that are part of a course of treatment planned in advance by the doctor and patient, or readmissions that are done in response to trauma or a sudden acute illness unrelated to the original admission. Neither public policy nor hospital actions should deter these readmissions from occurring. Instead, this guide is meant to better equip hospitals to address the readmissions that are unplanned and potentially the result of missteps in care either during the hospitalization or in the period immediately following the hospitalization. Hospitals should focus on these potentially avoidable readmissions to see if they can act – or they can encourage others to act - in such a way as to reduce their occurrence. This document suggests strategies that hospitals could pursue at different stages of the care continuum to reduce avoidable readmissions. The strategies on the tables below are the foundational actions in the different interventions to reduce avoidable readmissions. Table 1: During Table 2: At Discharge Table 3: Post- Hospitalization Discharge  Risk screen patients and  Implement  Promote patient self tailor care comprehensive discharge management  Establish communication planning  Conduct patient home with primary care physician  Educate patient/caregiver visit (PCP), family, and home using ―teach-back‖  Follow up with patients care  Schedule and prepare for via telephone  Use ―teach-back‖ to follow-up appointment  Use personal health educate patient/caregiver  Help patient manage records to manage about diagnosis and care medications patient information  Use interdisciplinary/multi-  Facilitate discharge to  Establish community disciplinary clinical team nursing homes with networks  Coordinate patient care detailed discharge  Use telehealth in patient across multidisciplinary instructions and care care team partnerships with nursing  Discuss end-of-life home practitioners treatment wishes 2 Health Care Leader Action Guide to Reduce Avoidable Readmissions Why readmission rates matter Hospitals’ avoidable readmission rates have come under close scrutiny by payers and policymakers because of the potential of high savings associated with them. According to a recent study, unplanned readmissions cost Medicare $17.4 billion in 2004.i The study found that 20 percent of Medicare fee-for-service patients were readmitted within 30 days of discharge. In addition to having financial implications, avoidable readmissions are increasingly viewed as a quality issue by payers, health care organizations, and patients, with some research showing that readmission rates may be correlated with quality of care. ii Not all readmissions are entirely preventable, and thus, constitute a quality issue. However, a portion of unplanned readmissions that are related to the original reason for admission could be prevented by taking actions that address the processes that led to the readmission. Certain patient-level factors such as patient demographics (elderly, dually eligible Medicare enrollees), clinical conditions (cardiovascular conditions, stroke, and depression), race, and gender may be predictors of readmissions.iii The strategies proposed in this guide directly or indirectly address these factors. Addressing the issue of potentially avoidable readmissions requires “Success in reducing readmissions a community approach with input from various actors across the lies in effectively partnering to not continuum of care. Better health care outcomes are not only only achieve better outcomes but dependent on receiving better care in the hospital, but increasingly, also to reduce the fragmentation on receiving better care at home. The current fragmentation of and lack of support that so often the US health care system makes this a challenging concept. While comes with transitions between most of the efforts to reduce avoidable readmissions focus on providers and care settings.” factors that are often outside of the hospital’s control— - Amy Berman, Program empowering patients, consumers, families, and caregivers to Officer, The John A. navigate their way around community support services and organize their care at home—there are still actions that hospitals Hartford Foundation can take to make a difference. Hospital leaders will also benefit from positioning their organizations to succeed in the face of financial penalties and other payment reforms suggested in recent legislative proposals to address avoidable readmissions. The step-by-step actions in this guide provide a springboard for hospital leaders to proactively address avoidable readmissions. Steps for hospital leaders to reduce avoidable readmissions Several interventions have been developed to reduce avoidable readmissions. Whereas some interventions are supported by a robust evidence-base, others require evidence to support their effectiveness in reducing avoidable readmissions. A detailed chart of these interventions is included in Table A in the Appendix. Recognizing that not every hospital has the resources or need to implement the entire suite of strategies recommended by the interventions, we identified the crosscutting strategies in these interventions that hospitals could implement. Even though there is no evidence supporting the ability of individual strategies to reduce avoidable readmissions, each of these strategies could help address the underlying reasons for readmissions such as improper transitions and lack of communication between care providers and patients. Health care leaders may need to implement several of these strategies or augment the actions that are already underway in their facilities to see a reduction in avoidable readmissions. The steps for hospital leaders included in this guide are: 1 Examine your hospital’s current rate of readmissions. 2 Assess and prioritize your improvement opportunities. 3 Develop an action plan of strategies to implement. 4 Monitor your hospital’s progress. 3 Health Care Leader Action Guide to Reduce Avoidable Readmissions 1 Examine your hospital’s current rate of readmissions. First, hospitals need to compile information on their readmission rates. Payers, legislators, and other health care stakeholders are focusing on readmissions data as evidenced by the reporting of 30-day readmission rates for heart attacks, heart failure, and pneumonia on Hospital Compare (www.hospitalcompare.hhs.gov). Knowing the readmission rates and trends in their facilities could aid hospital leaders to better target strategies for reducing them. One approach for gathering data is for hospitals to track and review data on patients being readmitted to their facility. In areas where the data is available, hospitals may also want to review other hospitals’ readmissions data provided by state agencies and local payers. Hospitals could examine readmissions data for the following trends:  Readmission rates for different conditions: To the extent feasible, examine readmission rates by diagnosis and significant co-morbidities, and look for correlation with the patient’s severity.  Readmission rate by practitioners: Examine the rates by physician to determine if the patterns of readmissions are appropriate or if any type of practitioner is associated with unexpected readmissions.  Readmission rates by readmission source: Examine the rates by readmission source (for example, home, nursing home, etc.) to determine the places from which patients are most often being readmitted.  Readmission rates at different time frames: Examine readmissions within a given time period such as 7, 30, 60, and 90 days. Examining a shorter timeframe may bring to light issues more directly related to hospital care or flaws in the process of transitioning the patient to the ambulatory setting. Examining the longer timeframe may reveal issues with follow-up care and patients’ understanding of self care. To supplement the internally and externally reported data on readmissions, health care leaders and practitioners should seek “Hospitals are constantly assessing to more deeply understand readmissions in their facilities. An and improving quality of care and effective way of doing this is to review the charts of a few implementing better patient safety patients who have been admitted repeatedly from various systems that are transparent to the sources. In reviewing the charts, hospitals should follow the community. The growing interest in trajectory of patient’s care to understand why the patient was hospital readmissions will provide us readmitted and what could have been done to prevent the opportunities to both improve the readmission. Analyzing individual cases of readmitted patients will help health care leaders and front line clinical staff to quality of care and reduce costs.” understand the underlying failures that occurred in the care - Rich Umbdenstock, President process and also witness firsthand the detrimental impact of the & CEO, American Hospital readmission. Association In addition to the analyses recommended above, hospitals should examine the impact of avoidable readmissions on their finances, specifically, the current revenues and costs associated with readmissions. Recent legislative proposals seek to reduce payments to hospitals that have relatively high readmissions rates for certain conditions and establish a pilot program to test bundling payments for an episode of care, combining payment for initial and subsequent hospitalizations. Understanding the financial implications of readmissions will better position hospitals for future legislation tying reimbursement to readmissions and for potential reductions in revenues resulting from decreased readmission rates. Specifically, hospitals could examine whether reducing avoidable readmissions would affect their volume and potentially alter patient-mix. 2 Assess and prioritize your improvement opportunities. Once hospital leaders determine the rates and trends of avoidable readmissions in their facilities, the second step is to prioritize their areas of focus. The prioritization process should capitalize on immediate opportunities for improvement for the hospital. Hospital leaders may follow one or more of the following approaches: Focus on specific patient populations: If it is identified that readmissions rates are especially high for certain conditions or for specific patient populations, hospitals could focus on those conditions or patient populations. For example, for older adults who tend to be multiply co-morbid, hospitals could institute a more rigorous risk- assessment process to determine and address risk factors upon admission and at discharge. 4 Health Care Leader Action Guide to Reduce Avoidable Readmissions Focus on stages of the care delivery process: Similarly, if it is identified that patients are readmitted for the same reasons, it could point to areas for improvement in the care delivery process. For example, discharge processes could be strengthened to include a component of patient/caregiver education to empower them to take charge of their care post-discharge. Focus on hospital’s organizational strengths: Hospitals could also address the issue of readmissions by harnessing the resources available to them. For example, hospitals serving ethnically diverse patients could harness the language skills of a multilingual staff in communicating care plans or discharge instructions to patients and caregivers. Similarly, a facility with a comprehensive electronic health record system could use the components of the system to coordinate patient care in their efforts to reduce readmissions. Focus on hospital’s priority areas and current quality improvement initiatives: Mandatory and voluntary quality improvement programs in which hospitals are currently involved could serve as a vehicle for prioritizing readmissions focus. As identified in Table B in the Appendix, several past and current quality improvement programs include a redesign of fundamental care processes that could be harnessed to concurrently reduce readmissions. By reviewing hospitals’ current priorities, leaders could seamlessly incorporate readmissions goals into existing initiatives and assess progress. 3 Develop an action plan of strategies to implement. A detailed chart of some interventions that have been successfully implemented in various clinical settings is included in Table A in the Appendix.iv To facilitate hospital leaders’ understanding of these interventions to reduce readmissions, the third step of this guide attempts to synthesize the foundational strategies in the interventions. The strategies are summarized in Tables 1, 2, and 3 on the following page. To effectively implement the strategies identified in the three tables, hospitals may need to involve key stakeholders in the care delivery process: patients, physicians, pharmacists, social services, nutritionists, physical therapists, and the community. Getting the health care team on board to address the issue “Rehospitalization is a system issue and the problem does not lie with Since practitioners drive health care delivery, their active one organization or one provider, participation is needed in strategies to reduce avoidable but with the community and the readmissions. In some cases, hospitals may have to identify and local health care system. Addressing overcome barriers to interdisciplinary/multidisciplinary care this issue will require organizations practices. Hospitals may also need to circumvent misalignment and providers to work together.” of hospital and physicians’ incentives to obtain physician buy-in on the hospital’s quality improvement goals. A proven approach - Anne-Marie Audet, VP, The for engaging practitioners is to pull together a core team of Commonwealth Fund hospital staff (physicians, nurses, quality specialists, case managers, and pharmacists) to champion the hospital’s work on readmissions, and then roll out the efforts to the medical staff. Developing community connections to eliminate barriers to successful care transitions Addressing the issue of avoidable readmissions requires hospitals to build partnerships with other health care providers as well as with public and private support groups in their communities. These partnerships will help facilitate the transition of patients back into the community by leveraging partners to ensure continuity of care for patients following hospitalization. Partners are able to ensure that the next care provider is aware of the patient’s status and care information, and to direct at-risk patients such as low-income populations and elderly or frail patients to needed care following hospitalization. Community partners are also sometimes equipped to address non-medical factors that could lead to readmissions such as behavioral, health literacy, and cultural issues. In places where these partnerships already exist, hospitals could focus on strengthening and maximizing their benefit. Engaging patients, families, and caregivers in addressing the issue Even though patients and their families are active participants in the health care system, their feedback is often not sought in addressing health care delivery issues. Successfully reducing readmissions rates may depend on patients’ 5 Health Care Leader Action Guide to Reduce Avoidable Readmissions ability to understand three things: their diagnosis, the care they receive, and their discharge instructions. Hospitals could successfully engage patients in care delivery by establishing hospital-based patient advisory councils or by partnering with existing patient advocacy groups. v Patients’ ability to engage in their care is influenced by several factors such as their clinical, physical, and emotional status, the support system available to them, their ability to organize care and medications, and language and cultural barriers. Patients’ families and caregivers could be effectively engaged in patient care to help overcome some of these behavioral, cultural, and literacy factors. Another proven strategy to improving patients’ health literacy is the use of the ―teach-back‖ technique. Practitioners, families, and caregivers can be assured of patients’ level of comprehension by asking them to repeat or demonstrate what they have been told. Major strategies to reduce avoidable readmissions The strategies in the three tables below are organized by the level of effort required to implement them. In general, implementation will require process changes in hospitals. However, strategies requiring ―low effort‖ can be implemented using the hospital’s existing resources. ―Medium effort‖ strategies may require hospitals to acquire additional resources, especially human resources, while ―high effort‖ strategies may necessitate the installation of complex and sometimes costly systems. In addition to considering the level of effort involved in implementing these strategies, health care leaders should also consider the value conferred by these strategies. The amount of effort required to implement a strategy may not correspond with its value in health outcomes and cost savings. For example, a multisite randomized controlled trial found that coordinating patient care across a multidisciplinary care team, a high effort activity, coupled with other activities, demonstrated annual average savings of $4,845 per patient after accounting for the cost of the intervention.vi High effort systems, such as, telehealth, electronic medical records, and remote monitoring could also be leveraged to achieve several patient safety and quality improvement goals, therefore warranting the higher initial investment. The strategies are grouped by the stages of care where they can be applied as presented in Tables 1, 2, and 3 below:  Table 1: During hospitalization  Table 2: At discharge  Table 3: Post-discharge Using the priority areas identified in the previous steps, hospital leaders can check off strategies in the tables below that their facilities can focus on to reduce their rates of avoidable readmissions. Table 1: During Table 2: At Discharge Table 3: Post- Hospitalization Discharge  Risk screen patients and tailor  Implement  Promote patient self care comprehensive discharge management  Establish communication with planning  Conduct patient home PCP, family, and home care  Educate patient/caregiver visit  Use ―teach-back‖ to educate using ―teach-back‖  Follow up with patients patient about diagnosis and  Schedule and prepare for via telephone care follow-up appointment  Use personal health  Use  Help patient manage records to manage interdisciplinary/multidisciplina medications patient information ry clinical team  Facilitate discharge to  Establish community  Coordinate patient care nursing homes with networks across multidisciplinary care detailed discharge  Use telehealth in patient team instructions and care  Discuss end-of-life treatment partnerships with nursing wishes home practitioners 6 Health Care Leader Action Guide to Reduce Avoidable Readmissions Upon admission and during hospitalization, opportunities exist for hospitals to enhance the care that patients receive to facilitate discharge planning and post-discharge care. The strategies identified in Table 1 are primarily hospital-based and can be performed by nurses, physicians, caseworkers, or other hospital staff. Table 1: During Hospitalization—Strategies to Prevent Readmissions vii Strategies Level of Actions Selected Interventions that Use Strategiesviii Effort □ Risk screen Low Proactively determining and responding Colorado Foundation for Medical Care and Partners(Care patients and tailor to patient risks Transitions Intervention (CTI)) care Guided Care Tailoring patient care based on HealthCare Partners Medical Group evidence-based practice, clinical Heart Failure Resource Center guidelines, care paths, etc. INTERACT John Muir Health (CTI) Identifying and responding to patient Kaiser Permanente Chronic Care Coordination needs for early ambulation, early Novant Physician Group Practice Demonstration Project nutritional interventions, physical Project BOOST therapy, social work, etc. Summa Health System Transitional Care Model Transitions Home for Patient with Heart Failure: St. Luke’s Hospital Visiting Nurse Service of New York □ Establish Low PCP serving as a core team member of Commonwealth Care Alliance: Brightwood Clinic communication patient care delivery team Guided Care with PCP, family, Project BOOST and home care Family or home care agency is informed Transitional Care Model of patient care process and progress Visiting Nurse Service of New York □ Use ―teach-back‖ Low Clinician educating patient about Novant Physician Group Practice Demonstration Project to educate patient diagnosis during hospitalization Project BOOST about diagnosis and Re-Engineered Discharge/RED care STAAR Transitional Care Model □ Discuss end-of-life Medium Discussing terminal and palliative care Blue Shield of California treatment wishes plans across the continuum Evercare™ Care Model St. Luke’s Hospital Transitions Home for Patient with Heart Failure: St. Luke’s Hospital Transitional Care Model □ Use Medium Team including complex care manager, Commonwealth Care Alliance: Brightwood Clinic interdisciplinary/ hospitalists, SNF physician, case Guided Care multidisciplinary managers, PCPs, pharmacists, and HealthCare Partners Medical Group Kaiser Permanente clinical team specialists Chronic Care Coordination Transitional Care Model Team including bilingual staff and clinicians (where needed) □ Coordinate patient High Using electronic health records to Commonwealth Care Alliance: Brightwood Clinic care across support care coordination Guided Care multidisciplinary Home at Home care team Using transitional care nurse (TCN) (or Sharp Reese-Stealy Medical Group similar role) to coordinate care Transitional Care Model Visiting Nurse Service of New York 7 Health Care Leader Action Guide to Reduce Avoidable Readmissions The actions identified to be performed at discharge could also be performed by other practitioners such as the primary care provider, home health agencies, long term care facilities, as well as caregivers, and community social networks for patients. Hospitals could however initiate these actions at discharge as described on Table 2 below. Table 2: At Discharge—Strategies to Prevent Readmissions ix Strategies Level of Actions Selected Interventions that Use Effort Strategiesx □ Implement comprehensive Medium Creating personalized comprehensive care Project BOOST discharge planning record for patient, including pending test Re-Engineered Discharge/RED results and medications STAAR Transitional Care Model Hospital staff communicating discharge summary to PCP or next care provider Reconciling discharge plan with national guidelines and clinical pathways Providing discharge plan to patient/caregiver Reconciling medications for discharge Standardized checklist of transitional services □ Educate patient /caregiver Medium Reviewing what to do if a problem arises St. Luke’s Hospital using ―teach-back‖ Guided Care Focusing handoff information on patient and John Muir Health family Re-Engineered Discharge/RED STAAR St. Luke’s Hospital Transitional Care Model Transitions Home for Patient with Heart Visiting Nurse Service of New York □ Schedule and prepare for Medium Transmitting discharge resume to outpatient Care Transitions Program (CTI) follow-up appointment provider Colorado Foundation for Medical Care and Partners(Care Transitions Making appointment for clinician follow-up Intervention (CTI)) John Muir Health (CTI) Re-Engineered Discharge/RED Sharp Rees-Stealy Medical Group St. Luke’s Hospital Transitional Care Model Visiting Nurse Service of New York □ Help patient manage Medium Managing patient medication with help of a Care Transitions Program (CTI) medication transition coach Colorado Foundation for Medical Care and Partners(Care Transitions Intervention (CTI)) St. Luke’s Hospital John Muir Health(CTI) Project BOOST Re-Engineered Discharge/RED Transitions Home for Patient with Heart Transitional Care Model Visiting Nurse Service of New York □ Facilitate discharge to nursing Low–High Using standardized referral form/transfer form Evercare™ Care Model homes with discharge STAAR instructions and partnerships Using nurse practitioner in nursing home Summa Health System with nursing homes setting Transitional Care Model 8 Health Care Leader Action Guide to Reduce Avoidable Readmissions Maintaining community connections is especially important for strategies of interventions implemented post- discharge to reduce avoidable readmissions. Practitioners serving a predominant subset of patients such as the elderly or immigrants could benefit from community partnerships with outpatient physician offices, nursing homes, and home health agencies in their efforts to reduce avoidable readmissions through the strategies identified in Table 3 below. Table 3: Post-Discharge—Strategies to Prevent Readmissions xi Strategies Level of Actions Selected Interventions that Use Strategiesxii Effort □ Promote patient self Low Using tools to help patient Care Transitions Program (CTI) management manage care plan post- Guided Care discharge Transitional Care Model Visiting Nurse Service of New York □ Conduct patient Medium Conducting home and Care Transitions Program (CTI) home visit nursing home visits Colorado Foundation for Medical Care and Partners(Care Transitions immediately after discharge Intervention (CTI)) and regularly after that Commonwealth Care Alliance: Brightwood Clinic HealthCare Partners Medical Group Home Healthcare Telemedicine Hospital at Home St. Luke’s Hospital Transition Home for Patients with Heart Failure: St. Luke’s Hospital Transitional Care Model Visiting Nurse Service of New York □ Follow up with Medium Calling 2–3 days after Care Transitions Program (CTI) patients via discharge to reinforce Colorado Foundation for Medical Care and Partners(Care Transitions telephone discharge plan and offer Intervention (CTI)) problem solving Commonwealth Care Alliance: Brightwood Clinic Evercare™ Care Model Offering telephone support Kaiser Permanente Chronic Care Coordination for a period post-discharge Project BOOST Re-Engineered Discharge/RED Calling to remind patients of Sharp Rees-Stealy Medical Group preventive care St. Luke’s Hospital STAAR Transitional Care Model Transition Home for Patients with Heart Failure: St. Luke’s Hospital Visiting Nurse Service of New York □ Use personal health High Including information on Care Transitions Program (CTI) records to manage patient diagnosis, test Colorado Foundation for Medical Care and Partners patient information results, prescribed John Muir Health (CTI) medication, follow-up Re-Engineered Discharge/RED appointments, etc. on PHR □ Establish community High Developing public/private Community Care North Carolina networks partnerships to meet Guided Care patients needs Summa Health System Transitions Home for Patient with Heart Failure: St. Luke’s Hospital □ Use telehealth in High Monitoring patient progress Heart Failure Resource Center patient care through telehealth, e.g., Home Healthcare Telemedicine electronic cardiac John Muir Health monitoring, remote patient Sharp Rees-Stealy Medical Group telemonitoring 9 Health Care Leader Action Guide to Reduce Avoidable Readmissions 4 Monitor your hospital’s progress. The key to sustaining efforts to reduce readmissions is for hospital leaders to monitor their facilities’ progress. This fourth step is especially critical since this guide is structured to encourage hospitals to pick individual strategies to implement. Monitoring the hospital’s progress will inform hospital leaders of the efficacy of these strategies and perhaps guide them in implementing additional strategies. Monitoring the hospital’s progress should be done regularly, as determined by hospital leadership, and focus on the trends identified in step 1 of this guide:  Readmission rates for different conditions  Readmission rate by practitioners  Readmission rates by readmission source  Readmission rates over different time frames. Finally, to sustain organizational efforts on reducing avoidable readmissions, data on readmissions could be included in the key quality indicators tracked and reported to hospital boards, other quality committees, and front line clinical staff. In addition to monitoring progress made in reducing avoidable readmissions, hospitals should also monitor possible unintended consequences from efforts aimed at reducing readmissions. 10 Health Care Leader Action Guide to Reduce Avoidable Readmissions Appendix Table A: Selected List of Interventions to Reduce Preventable Readmissions Organized by Level of Supporting Evidence xiii,xiv,xv Organization & Intervention Target Population Actions Included Key Players Where xvi Interventions with Very Strong Evidence of Reduction in Avoidable Readmissions Boston Medical Center Patient education; comprehensive Nurse discharge Hospital and Re-Engineered Discharge/RED All adult BMC patients discharge planning; AHCP; post-discharge advocate, clinical home (phone http://www.bu.edu/fammed/projectred/ phone call for medication reconciliation pharmacist only) Care Transitions Intervention (CTI); Care Transitions Program Community-dwelling patients 65 medication self-management; patient- Transitions coach Home http://www.caretransitions.org/ and older centered record (PHR); follow-up with physician; and risk appraisal and response Evercare™ Care Model Patients with long-term or Primary care and care coordination; NP http://evercarehealthplans.com/about_ Nurse practitioner or Home and advanced illness, older patients care in nursing home; personalized care evercare.jsp%3bjsessionid=NNDDDJJF care managers nursing home or those with disabilities plans MEBB Care coordination; risk assessment; Transitional Care Model (TCM) High-risk, elderly patients with development of evidence-based plan of Transitional care nurse Hospital and http://www.transitionalcare.info/ chronic illness care; home visits and phone support; (TCN) home patient and family education Interventions with Some Evidence of Reduction in Avoidable Readmissionsxvii Primary care and behavioral health care Nurses, nurse coordination; reminder calls for preventive practitioners, mental Commonwealth Care Alliance: Low-income Latinos with care; multidisciplinary clinical team; follow- health and addiction Community Brightwood Clinicxviii disabilities and chronic illnesses up; health education and promotion; counselors, support support groups; bilingual staff; non-clinician service staff home visits Local network of primary care providers: Community Care North Carolina DM for asthma, HF, diabetes; ED; Medicaid patients Primary care providers Community http://www.communitycarenc.com/ pharmacy initiatives; case management for high-risk/ high-cost patients Heart Failure Resource Center Advanced practice Home and Outpatient care for chronically Evidence-based clinical care protocols; http://www.innovativecaremodels.com/c nurse and physician (for outpatient ill patients with heart failure remote patient telemonitoring are_models/15 consultation) setting Home Healthcare Telemedicine Recently discharged with Telemedicine nurse and Telehealth care; telemonitoring; in-home http://www.innovativecaremodels.com/c congestive heart failure or traditional home health Home visits, are_models/18/key_elements COPD nurse Kaiser Permanente Chronic Care Patients with four or more Multidisciplinary chronic care team; needs- Specially trained nurses, Hospital and Coordination chronic illnesses; recently based care plans; patient communications licensed clinical social long-term care Organization & Intervention Target Population Actions Included Key Players Where http://www.innovativecaremodels.com/c discharged; high ED utilization or via phone workers settings are_models/13/overview recently discharged from a SNF IHI Transition Home for Patients with Admission assessment for post-discharge Multidisciplinary team, Heart Failure: St. Luke’s Hospital Patients with congestive heart needs; teaching and learning; early post- including nurses, Hospital and http://www.ihi.org/IHI/Programs/Strateg failure acute care follow-up; patient and family- clinicians, and hospital home icInitiatives/TransformingCareAtTheBed centered handoff communication executives side.htm Implement Comprehensive, Organized Medicine Provided Across a Seamless Novant Physician Group Practice System (COMPASS); for providers: Demonstration Project Medicare fee-for-service evidence-based practice standards, http://www.cfmc.org/caretransitions/file Physicians, staff Community beneficiaries education and inpatient to outpatient s/Care%20Transitions%20presentation systems; For patients: chronic and %202%2008b.pdf preventive care guidelines, education, and disease management Promising Interventions Requiring Additional Data xix Guided Care Patient self-management; care http://www.cfmc.org/caretransitions/file Patients 65 or older deemed to coordination; patient/caregiver education; Primary care s/Ouslander%20Care%20Transitions% be high risk for hospitalization or Specially trained nurses access to community services; evidence- offices 20Call%20Presentation%20030308.p other cost-intensive care based ―care guide‖ df Patients over 65 years old Hospital at Home requiring hospital admission for Daily physician visits; care coordination; http://www.innovativecaremodels.com/c Registered nurse Home COPD, CHF, cellulitis, or multidisciplinary team are_models/20 community-acquired pneumonia INTERACT http://www.cfmc.org/caretransitions/file Nurses, physicians, Care paths, communication tools, Hospital and s/Ouslander%20Care%20Transitions% Nursing home patients nurse practitioners, advance care planning tools , risk appraisal nursing home 20Call%20Presentation%20030308.p physician assistants df Project BOOST Medication reconciliation; general http://www.hospitalmedicine.org/Resour assessment of preparedness (GAP); teach- Multidisciplinary care Hospital and Older adults ceRoomRedesign/RR_CareTransitions/ back; patient/caregiver education; team home CT_Home.cfm communication; phone follow-up Other Relevant Interventionsxx Blue Shield of California Complex patients with advanced ParadigmHealth team, Patient education; care coordination; end- Patient-Centered Management illness. Piloted with CalPERS including case manager Home of-life management in seven care domains (PCM)xxi enrollees in Northern California and team manager, both Organization & Intervention Target Population Actions Included Key Players Where nurses, and MD consultant Colorado foundation for Medical Care (CFMC) Elderly clinic patients, medical Hospital visit, home visit, and follow-up Transitions coaches Hospital and Care Transitions Intervention (CTI), beneficiaries who have been calls by coach, focusing on the four CTI (nurses) home pilot project hospitalized pillars http://www.cfmc.org/ Uses risk assessment to stratify Self-management and health education; HealthCare Partners Medical Group patients and match to four levels complex case management; high-risk Multiple interdisciplinary Hospital, http://www.healthcarepartners.com/ of programs; special programs clinics; home care management; disease staff members home, SNFs for frail patients management John Muir Physician Network Transforming Chronic Care (TCC) Transition coaches, case Eligible frail patients—most have CTI; complex case management; disease Hospital and Program managers, both with http://www.johnmuirhealth.com/index.ph heart failure, COPD, or diabetes management home multiple backgrounds p/chronic_care_referral_program.html Continuity of Care Unit (CCU); Telescale CCU: nurse case Sharp Rees-Stealy Medical Group High-risk patients, including all Hospital and for HF patients; Transitions program for manager; Transitions: http://www.sharp.com/rees-stealy/ discharged from hospital or ED home those near end-of-life nurse St. Luke’s Hospital, Cedar Rapids, IA Patient education using ―teach-back‖; Transitions Home for Patients with Advanced practice Hospital and Heart failure patients in pilot home visit; post-discharge phone call; Heart Failure nurse, staff nurses home outpatient classes http://www.innovations.ahrq.gov/conten t.aspx?id=2206 Hospital-based care Hospital, State Action on Avoidable Enhanced assessment of post-discharge team, representatives home, and Rehospitalizations (STAAR) needs; enhanced teaching and learning; from skilled nursing other post- http://www.ihi.org/IHI/Programs/Str All patients enhanced communication at discharge; facilities, home health acute/long- ategicInitiatives/STateActiononAvoi and timely post-acute follow-up agencies, patients, family term care dableRehospitalizationsSTAAR.htm caregivers, etc. setting Interdisciplinary teams, Low-income frail elders with Risk appraisal; integrated medical and Hospital, Summa Health System, Akron, OH including RN care chronic illnesses in community- psychosocial care based on Naylor and home, PCP http://www.summahealth.org/ manager, APN, AAA based long-term care Coleman models office visits staff, etc. Visiting Nurse Service of New York Risk assessment with stratified Hospital (for Nursing Home patients post- NPs; home nurses; (VNSNY) interventions; self-management support, some patients) hospitalization home health aides http://www.vnsny.org/ etc. and home Linking readmissions strategies to other national efforts Hospitals may currently be or previously have been involved in care delivery and patient safety initiatives that could serve as vehicles for implementing strategies to reduce preventable readmissions. By coordinating efforts in various priorities, hospitals are able to reap the most benefit for their investment, avoid duplicative work, and minimize burden on practitioners as they strive to improve the care that they deliver. The following table outlines strategies in some of the initiatives that could facilitate implementation of strategies to reduce avoidable readmissions: Table B: Linking Readmissions Strategies to Current National Strategies Initiative Description Overlap with Readmissions Strategies AHA Hospitals in Pursuit of Topic Areas:  Risk screening of patients & tailored care Excellence (HPOE)xxii  Care coordination—focus on the discharge process and care  Establishing communication with PCP transitions to reduce readmissions  Use of interdisciplinary/ multidisciplinary team  Reduce hospital-acquired conditions such as:  Care coordination o surgical infections and complications; central line-associated  Patient education blood stream infections; methicillin-resistant Staphylococcus  Comprehensive discharge planning aureus; clostridium difficile infections; ventilator-associated  Patient /caregiver education using ―teach-back‖ pneumonia; catheter-associated urinary tract infections; adverse  Scheduling and preparing for follow-up appointment drug events from high-hazard medications, and pressure ulcers  Discussions about end-of-life treatment wishes  Implement health information technology (HIT)—focus on  Facilitate discharge to nursing homes leadership and clinical strategies to effectively implement HIT  Home visit  Medication management—use of HIT and performing  Follow-up call medication reconciliation  Medication management  Promote patient safety  Personal health records  Patient throughput—improving patient flow in ED, OR, and ICU  Establishing community networks  Patient self management IHI Campaigns (100K and 5 Components for the 100K Lives campaign:  Risk screening of patients & tailored care Million Lives campaigns)  Deploy Rapid Response Teams  Care coordination  Deliver Reliable, Evidence-Based Care for Acute  Patient education Myocardial Infarction  Comprehensive discharge planning  Prevent Adverse Drug Events (ADEs) by implementing  Patient /caregiver education using ―teach-back‖ medication reconciliation  Medication management  Prevent Central Line Infections  Prevent Surgical Site Infections  Prevent Ventilator-Associated Pneumonia Initiative Description Overlap with Readmissions Strategies Principles for the 5 Million Lives campaign (plus principles from 100K Lives campaign:  Prevent Harm from High-Alert Medications (focus on anticoagulants, sedatives, narcotics, and insulin)  Reduce Surgical Complications  Prevent Pressure Ulcers  Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) infection  Deliver Reliable, Evidence-Based Care for Congestive  Heart Failure…to avoid readmissions  Get Boards on Board so that they can become far more effective in accelerating organizational progress toward safe care Joint Commission Speak Current initiatives:  Patient education Up™ initiatives  Help Prevent Errors in Your Care  Patient /caregiver education using ―teach-back‖  Help Avoid Mistakes in Your Surgery  Information for Living Organ Donors  Five Things You Can Do to Prevent Infection  Help Avoid Mistakes With Your Medicines  What You Should Know About Research Studies  Planning Your Follow-up Care  Help Prevent Medical Test Mistakes  Know Your Rights  Understanding Your Doctors and Other Caregivers  What You Should Know About Pain Management  Prevent Errors in Your Child’s Care Patient-Centered Medical Characteristics of the Patient-Centered Medical Home(PCMH):  Establishing communication with PCP Home (PCMH) xxiii  Personal physician—for each patient  Use of interdisciplinary/ multidisciplinary team  Physician directed medical practice—has collective  Care coordination responsibility for the ongoing care of patients  Patient education  Whole person orientation—includes care for all stages of life;  Comprehensive discharge planning acute care; chronic care; preventive services; and end-of-life care  Scheduling and preparing for follow-up appointment led by personal physician.  Discussions about end-of-life treatment wishes  Care is coordination—across all elements of the health care  Facilitate discharge to nursing homes system (subspecialty care, hospitals, home health agencies, nursing  Follow-up call homes) and the patient’s community (family, public and private  Medication management community-based services).  Personal health records Initiative Description Overlap with Readmissions Strategies  Quality and safety—includes the following:  Establishing community networks o care planning process  Patient self management o Evidence-based medicine and clinical decision-support tools o Active patients and families participation o Information technology o Patients and families participate in quality improvement activities at the practice level. Enhanced access—used through open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff Contact Information for Some Interventions 1. Care Transitions Program http://www.caretransitions.org/ Eric A. Coleman, MD, MPH The Division of Health Care Policy and Research 13611 East Colfax Avenue, Suite 100 Aurora, CO 80045-5701 Phone: 303-724-2523 Fax: 303-724-2486 2. Project RED (Re-Engineered Discharge) http://www.bu.edu/fammed/projectred/index.ht ml Brian Jack, MD Principal Investigator Brian.Jack@bmc.org 3. Project BOOST (Better Outcomes for Older adults through Safe Transitions) http://www.hospitalmedicine.org/ResourceRoo mRedesign/RR_CareTransitions/CT_Home.cfm Mark V. Williams, MD, FHM Principal Investigator Advisory Board Co-Chair Professor & Chief, Division of Hospital Medicine Northwestern University Feinberg School of Medicine Chicago, IL BOOST@hospitalmedicine.org 4. Transitional Care Model http://www.transitionalcare.info/ Mary D. Naylor, PhD, RN, FAAN Marian S. Ware Professor in Gerontology Director, NewCourtland Center for Transitions & Health University of Pennsylvania School of Nursing Claire M. Fagin Hall, 3rd Floor (RM341) 418 Curie Boulevard Philadelphia, PA 19104-4217 naylor@nursing.upenn.edu i Jencks, Stephen F., Williams, Mark V., and Coleman, Eric A. and disability. Results of the Brightwood Center 2009. Rehospitalizations among Patients in the Medicare Fee- intervention. Journal of Disability Policy Studies. for-Service Program. N Engl J Med 360 (14):1418-1428. 2008;18(4):197-204. ii Benbassat, J., Taragin, M. 2000. Hospital readmissions as a xix Boutwell, A. Griffin, F. Hwu, S. Shannon, D. Effective measure of quality of health care: advantages and limitations. Interventions to Reduce Rehospitalizations: A Compendium of Archives of Internal Medicine 160 (8):1074-1081. 15 Promising Interventions. Cambridge, MA: Institute for iii Minott, J. Reducing Hospital Readmissions. 2008. Healthcare Improvement; 2009. AcademyHealth. Accessed online at: xx Interventions based on one or more of the models http://www.academyhealth.org/files/publications/Reducing_H described in the other categories ospital_Readmissions.pdf on December 17, 2009. xxi Sweeney, L. Halpert, A., Waranoff, J. Patient-centered iv Boutwell, A. Griffin, F. Hwu, S. Shannon, D. Effective management of complex patients can reduce costs without Interventions to Reduce Rehospitalizations: A Compendium of 15 shortening life. American Journal of Managed Care. February Promising Interventions. Cambridge, MA: Institute for 2007. Healthcare Improvement; 2009. xxii American Hospital Association. About Hospitals in Pursuit of v Leonhardt K, Bonin K, Pagel P. Guide for Developing a Excellence. Accessed at http://www.hpoe.org/about on Community-Based Patient Safety Advisory Council. Prepared by 10/28/2009. Aurora Health Care, Wisconsin. AHRQ Publication No. 08- xxiii Joint Principles of the Patient Centered Medical Home. 0048. Rockville, MD: Agency for Healthcare Research and Developed by AAFP, AAP, ACP, and AOA. Accessed at Quality. April 2008. Accessed on 11/16/2009 at: http://pcpcc.net/node/14 on 10/28/2009. http://www.ahrq.gov/qual/advisorycouncil/advisorycouncil.pdf vi Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684. vii Not all of the actions listed for this particular strategy may correspond to the resource intensity identified. viii The interventions listed here, though not comprehensive, represent some of the commonly used and referenced. interventions for reducing avoidable readmissions. Details on the intervention are listed on Table 1 in the Appendix. ix Not all the actions listed for this particular strategy may correspond to the resource intensity identified x The interventions listed here, though not comprehensive, represent some of the commonly used and referenced interventions for reducing avoidable readmissions. xi Not all the actions listed for this particular strategy may correspond to the resource intensity identified xii The interventions listed here, though not comprehensive, represent some of the commonly used and referenced interventions for reducing avoidable readmissions. xiii Kanaan, S.B. Homeward Bound: Nine Patient-Centered Programs Cut Readmissions. California Healthcare Foundation; 2009. xiv Information on this table is culled from the California HealthCare Foundation publication, Homeward Bound: Nine Patient-Centered Programs Cut Readmissions, and supplemented with other resources. xv The interventions listed here, though not comprehensive, represent some of the commonly used and referenced interventions for reducing avoidable readmissions. xvi Boutwell, A. Griffin, F. Hwu, S. Shannon, D. Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions. Cambridge, MA: Institute for Healthcare Improvement; 2009. xvii Boutwell, A. Griffin, F. Hwu, S. Shannon, D. Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions. Cambridge, MA: Institute for Healthcare Improvement; 2009. xviii Bachman SS, Tobias C, Master RJ, Scavron J, Tierney K. A managed care model for Latino adults with chronic illness