aco five step process for reducing readmissions

FLAACOs Business Partners !

ACO Five-Step Process for Reducing Readmissions "

Marcy Rudowitz!Ph 904.485.0590!

Email [email protected]!


About FLAACOs!

FLAACOs is the premier professional organization for Accountable Care Organizations (ACOs) throughout Florida. ACOs are designed to incent

providers to work together to increase quality of care delivered to patients while significantly lowering overall medical costs. !

FLAACOs members are organized in a vibrant network of state affiliate groups that share FLAACOs goals in working on behalf of ACO professionals.

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Meet our Leadership Team"

Founding Members!§  Nicole Bradberry President, Orange Health Solutions and CEO, Orange Accountable Care!§  Rich Cassidy, MD Divisional VP, Chief Accountable Care Officer at Walgreens!§  Hymin Zucker, MD Palm Beach Accountable Care Organization!§  Mike Barrett VP Accountable Care Services, HealthCare Partners, IPA and HealthCare Partners, Management Services

Organization!§  Kelly A. Conroy, Executive Director at the Palm Beach Accountable Care Organization and South Florida Accountable Care!§  Joanne Ryan, CEO at Gatien & Associates and Board Member, Orange Accountable Care!§  Brenda Radke, CEO at Brevard Physicians Network and Executive Director Medical Practitioners for Affordable Care!§  Larry Jones, CEO at Physicians Collaborative Trust!§  Scott Backer, CEO at Baroma, INC!§  Balford Francis, Director of Managed Care and Network Development!§  Sheila Fuse, CEO at Primary Partners, LLC!§  Ben Shaker, Director at Orlando Health!§  Jennifer Endicott, VP of Clinical Integration at Orlando Health and Executive Director of Collaborative Care of Florida!§  Kristi R. Stovall, VP Marketing & Brand Management at Orange Health Solutions!


About the Reduction Program "

Mandated by the Affordable Care Act of 2010 (started Oct. 1, 2012) !§  Hospitalizations account for nearly one-third of the total $2 trillion spent on health care in the United States!§  About 20 percent of Medicare beneficiaries are readmitted to the hospital within 30 days of leaving, costing more than $15

billion annually!§  The reduction program, For the first year, the reimbursement penalty was limited to 1 percent, and the next year the cap

rose to 2 percent!§  For fiscal 2015, which starts Oct. 1, the maximum penalty is 3 percent!§  In the FY 2015, CMS has made refinements to the readmissions measures. Medicare has increased the number of

conditions on which hospitals are judged to five from three!§  Existing measures: pneumonia, heart attack and heart failure!§  New for 2015: hip/knee replacement and chronic obstructive pulmonary disease (COPD)!§  Medicare estimates the program will reduce payments to hospitals in fiscal 2015 by 0.2 percent, compared with 2014!


Influencing Factors"

Centers for Medicare and Medicaid Services reports 30-day readmission rates for heart attack, heart failure, and pneumonia. Payments to hospitals are linked to how well they perform on these measures, leading hospitals to focus on improving their rates. !!Factors Impacting Readmission !§  High percentages of residents who are Medicare beneficiaries, are unemployed, or have never been married is associated

with higher hospital readmission rates!§  Retirement destinations are generally associated with lower rates (possible reflection of higher socioeconomic status

among the Medicare population and a community geared toward caring for older people)!§  Higher numbers of general practitioners per capita were associated with lower readmission rates !§  Higher numbers of specialists were associated with higher readmission rates!§  Higher (as measured by multiple indicators) nursing home quality generally have lower readmissions !


Influencing Factors Continued"

Factors Impacting Readmission !§  Excluding the patient and family caregivers in assessing needs, identifying needed resources, and planning for

discharge -- leading to a poor understanding of what patients need to function in the home environment!§  Insufficiently understanding the patient’s functional ability, physical and cognitive health status, and social and

financial concerns, which may result in transfer to a care setting that is not appropriate for the patient’s needs!§  Failing to probe for unrealistic patient and family optimism to manage care at home!§  Not addressing the whole person (e.g., focusing on one clinical condition, missing underlying depression, social

needs, advanced illness, etc.)!§  Not addressing palliative care or end-of-life issues, including advance directives or planning beyond Do Not

Resuscitate (DNR) status!§  Failing to recognize or address medication errors and incomplete or lack of medication reconciliation!§  Labeling the patient as “noncompliant” and not recognizing the care team’s responsibility for facilitating the acquisition,

knowledge, and skills for patient self-care.!


Step 1 Care Coordination"

PCP as a Core Team Member!§  Enhanced primary care and behavioral health and care coordination!§  Reminder calls for preventive care!§  Multidisciplinary clinical team model, with all care authorization done by team!§  Behavioral health and physical health integration;!§  Physician identification of an adverse selection group;!§  Follow up on emergency room, hospital, and detox admissions;!§  Support groups;!§  Health education and promotion;!§  Nonclinician team members, nonclinician home visits and!§  Bilingual staff and clinicians!


Step 2 Patient Engagement"

Patients can reduce their chances of being readmitted by being engaged and informed:!§  Ask your doctor to explain the treatment plan you will use at home and get a written copy!§  Inform your doctor of all the medications including prescriptions and over the counter medicines that you take at home.!§  Schedule your follow-up doctor’s appointments before you leave the hospital !§  Make sure you have a transportation plan!§  Get your doctor’s name and phone number for and who to contact in case of an emergency after hours!§  Ask more than once for information about your medicines in terms you can understand!§  potential side effects of each medication and what to do if a side effect occurs!§  Make sure that any new medications the hospital doctor prescribes is covered by your insurance plan.!§  If you do not have insurance, work with hospital staff to find out about low cost or no cost ways of paying for your

medications and doctor visits!§  Learn about your condition and ask what symptoms might signal a change in health !§  Request printed information to help you manage your health and any symptoms!§  Make sure your doctor or nurse has answered your most important questions!


Step 3 Include Extended Family & Caregivers"

Involve the patient, their family, family caregiver(s), and community provider(s) as full partners in completing a needs assessment of the patient’s home-going needs. !§  The involvement of patients and family caregivers is an essential step in assessing the post-hospital needs of ALL hospitalized

patients!§  Engage in an in-depth conversation with patients and family members to provide opportunities for learning about the

comprehensive home-going needs of patients!

Provide Effective Teaching and Facilitate Learning !§  Involve all learners in patient education !§  Clinicians should utilize these open-ended statements or questions to discover contributing causes for unplanned admissions or

readmissions and worries about going home!§  Reader-friendly written materials!§  Focus on what the patient needs to know, delivered in easy-to-understand formats. !§  Easy-to-Read Written Materials!


Step 4 Ask the Right Questions"

Questions to Answer:!§  Where will the patient likely go after discharge?!§  Who will be providing the care—is this likely to be adequate or does the patient require a higher intensity of care?!§  What are the patient’s needs after discharge?!§  What are the potential discharge barriers?!

Why Ask Questions?!§  Patient not being able to get the prescription drugs or treatment needed following hospitalization!§  Patient may have had an underlying health condition that was not treated!§  Patient may develop a complication after discharge!§  Patient may not have had an adequate support system after discharge!§  Patient may not understand doctor’s instructions following discharge!


Step 5 "Post Hospital Care Follow-Up"

Post-Hospital Follow-Up Care presents a critical opportunity to address the conditions that precipitated the hospitalization or rehospitalization and prepare the patient and family caregivers for self-care activities. !§  Provide customized, real-time critical information to the next clinical care provider(s). !§  Strategies included single home visit, increased clinic follow-up, and home visits!§  Customized and structured discharge plan based on patient needs “reduces readmission rates!§  Give patient and family members a patient-friendly, post-hospital care plan which includes a clear medication list. !§  Review daily the patient’s medical and social risk for readmission and finalize the customized post-hospital follow-up plan. !§  Prior to discharge, schedule timely follow-up care and initiate clinical and social services as indicated from the identified

post-hospital needs and the capabilities of patients and family. !

Provide Real-Time Handover Communications!§  Give patient and family members a patient-friendly, post-hospital care plan which includes a clear medication list.!§  Provide customized, real-time critical information to the next clinical care provider(s).!


Reach Us!Florida Association of ACOs"

Marcy Rudowitz!Florida Association of ACOs!Ph 904.485.0590!Email [email protected]!Website www.flaacos.com!

aco five step process for reducing readmissions

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