Managing Readmissions: The Key to Impacting Your Bottom Line

Dr. Jyoti KamalChief Data ScientistHealth Care DataWorks

A Division of Fathom®

Sherrie SmithConsultantMaestro Strategies

Readmissions Issue Overview Readmissions Reduction Policies Readmissions Reduction Strategy

• Visibility into current state• Ability to identify high risk patients and disease groups• Plan intervention programs for high risk patients• Ability to monitor progress

Other Drivers of Readmission Reductions• Root Cause Analysis: Actionable Information• Process Changes• Getting Results

Recap

Presentation Outline

Higher rates of readmissions has become a quality of care issue at many hospitals and health systems

Readmissions are contributing to the high cost of care Nearly 1 in 5 patients are readmitted within 30 days Analysis of Medicare claims data shows 75% of these readmissions are

preventable Excessive readmissions are costing CMS 17.5 billion dollar annually CMS ruling in 2009 to make readmission rates publically available as a way to

incentivize hospitals to pay more attention to care coordination had little effect on reducing readmissions. In fact readmission rates went up as hospitals had no financial incentives to reduce readmissions

Readmissions Overview

CMS is instituting new rulings and stricter penalties for readmissions

In accordance with the Affordable Care Act, new CMS rulings are aimed at improving quality of care, reducing readmissions and lowering Medicare spending

The Readmissions Reduction Program became effective October 1, 2012• Unlike the budget neutral VBP, CMS aims to recover millions of dollars through

readmission penalties• In FY 2013, CMS recovered $280M in readmission penalties (only .3% of CMS

reimbursements)

Penalties based on reductions of base operating DRG payment amount• FY 2013: 1% reduction• FY 2014: 2% reduction• FY 2015: 3% reduction

Readmission Penalties

Managing Readmissions Strategy

To avoid financial penalties, and provide cost-effective care hospitals must implement strategies to manage readmissions:

Provide visibility into current state of readmissions

Analyze planned and unplanned readmissions for both medical and surgical service lines to identify problem areas for focus

Identify patients at high risk for readmissions through predictive algorithms

Monitor and intervene with patients at high risk of readmission while they are still in house• Create care coordination plans

• Engage patient and family in education programs for medication and nutrition management

• Ensure proper discharge planning and instructions

• Coordinate follow up calls and appointments

• Coordinate home care

Observe readmissions trends for the AMI, HF, and pneumonia populations, both for Medicare and non-Medicare patients to ensure effectiveness of the interventions

Solutions for Readmissions Management

How do we enable these strategies? As a first step we need data that can be readily accessed without manual extraction or

intervention An automated data collection and integration process

The data should be modeled and curated to ensure accuracy, consistency and reliability There should be a presentation layer through which this data can be consumed and

analyzed. It should be intuitive to navigate with drill down capabilities to provide– Retrospective reviews of data as part of performance improvement initiatives for

readmissions– Predictive algorithms to assess the likelihood of readmission before patients are

discharged so hospitals have the ability to intervene while the patient is still in-house

– Detail information for root cause analysis and insights into the operations

Empowerment to make process changes

The solution we are going to discuss today is a dashboard from HCD’s KnowledgeEdge suite of tools.

The dashboard includes two areas of focus:

Provide an executive summary of readmission trends for all patient populations with drill downs by hospitals, service lines, nurse stations, physicians down to patient detail

• Allows tracking and monitoring of patients readmitted within any time period within 30 days or beyond for deeper visibility into the hospital operations and problem areas

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.

• Action worklists present opportunities for timely intervention and care coordination Can be filtered for Medicare population

Can be also be filtered by hospital, nurse station, working diagnosis

Readmissions Management Dashboard

The LACE model used in the dashboard calculates a risk score for all in-house patients by associating points to each of the attributes listed below

The output of the calculation is a score between 1 and 17

LACE Scoring Model

L= Length of Stay in the hospital for the current admissionA= Acuity of the current admission (urgent or emergent)C= Comorbidities derived from the billing diagnosis in the last one yearE= ED Visits in the last six months

Risk Levels and Interventions

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

Data Integration and Automation

Readmissions DashboardReadmissions Risk DashboardHigh Risk Patient Work List

Readmissions Management Dashboard

Readmission Management Dashboard

Daily LACE Readmissions Dashboard

Daily LACE Readmissions Dashboard

Provides daily risk stratified reports, by LACE score or DRG, showing in-house patients at high risk for readmission

LACE Risk Level Drill Down

2

LACE Risk Level Drill Down

2

Individual component scores of how LACE score was calculated

Profile of patient with this risk level

Worklist that includes all patients with this risk level. Can be exported to Excel for Care Coordinators

2

Readmissions Summary

Readmissions Summary

Visits broken down by Planned and Unplanned admissions by medical and surgical Service Line

Out of the box, tile colors are based on CMS benchmarks but can be configured to customer specific criteriaFilter on 2, 7, 14, or

30 day readmissions

Provides tracking and monitoring of readmission trends and statistics across the hospital or health system

Readmissions Patient Drill Down

Readmissions Patient Drill Down

Index admission details

Patient visit historyCurrent or most recent visit details

HCD’s KnowledgeEdge Readmission Management Module helps hospitals gain visibility into its operations.

Integrates a predictive algorithm, providing daily readmission risk stratification

Provides action worklist for timely intervention and care coordination

Monitors readmission trends to help identify problem areas and promote accountability

Helps reduce readmissions and penalties by providing information for root cause analysis to make necessary process changes

DRAFTDashboard Summary

Multiple Components of a Readmission Reduction Program

Root Cause Analysis (RCA) includes

• Identification of high risk patients

• Identification of other drivers Ineffective processes Staff skills and

knowledge Post-acute care

providers Community dynamics

Identifying high risk patients is also a tool used daily to mitigate known potential readmissions

Actionable Information

Now that you know which patients require what level of intervention…

Processes must be implemented to act on the information• Who has overall responsibility for each patient?• Do you create a new position for “transitional care managers”?• Who makes post-discharge phone calls to the patient (if that is an intervention you

selected)?– Do you have scripts / decision trees to address types of calls?– Do you intervene when a call results in more actionable information? How?– Do you track how many services you arrange post-discharge (i.e., home health,

hospice) to quantify benefit to the patient AND the hospital ?

• Do you provide feedback of information you learn to appropriate hospital staff to make process changes as needed (patient teaching, medication management,

discharge, etc.)?

Getting Results

• Charter teams to drive the initiative (i.e., project team, chronic disease teams, multi-provider teams, etc.)

• Identify and collaborate with key community leaders to address community related issues

• Train teams and key staff members in the principles and tools of problem solving, identifying and mitigating latent and active errors, conducting an effective RCA, etc.

• Conduct RCA to identify drivers of readmissions (patients, processes, providers, community, etc.)

• Use HCD KnowledgeEdge™ Readmissions Management Dashboard to identify and manage high risk patients

• Implement interventions based on RCA findings (evidence-based interventions, home-grown interventions—or both)

• Collect performance data, track results and make adjustments to processes as needed

• Celebrate your improvement!

• Real Example: Located in New Jersey is a 250+ bed hospital having several Joint Commission Centers of Excellence—A good hospital

• Because of their high readmission rate– They received the maximum 1% penalty (FY2013)

– Resulting in a loss in Medicare payment of $446,000

Penalty Number of Hospitals

Percentage of Hospitals

No penalty 1,134 33.8%

Up to 1% 2,054 61.1%

1% - 2% 153 4.5%

2% 18 0.6%

Total 3,359 100%

Financial Impact of Penalties

Statistics from Inpatient Prospective Payment System Fiscal Year 2014 Final Regulation

Source: American Hospital Association

Recap

Process changes

With Encounter and Encounter billing as the foundational sources for data integration, dashboard can be easily deployed to provide at a glance view of readmission trends and identify areas of opportunity

Easy Implementation

Better care coordination. Engaging patients in education programs and their own health by timely follow ups and calls

Daily worklists for high and moderate risk patients allows care to be appropriately focused and coordinated between physicians, specialists, social workers, nurses, families and patients

Improved Care

Information for root cause analysis to make process changes

Improved Communication

Improved Outcome Cost Savings

Improved quality of care leading to better patient and staff satisfaction, reduced readmission and patient days, and millions of dollars in savings.

For more healthcare marketing information & insight,

visit the Fathom Health Blog.

QUESTIONS?Dr. Jyoti Kamal

jyoti.kamal@hcdataworks.com

Sherrie Smithsmith@maestrostrategies.com