Posts Tagged ‘Hospital Readmissions’

Infographic: Stopping the Revolving Door of Short-Term Readmissions

April 10th, 2017 by Melanie Matthews

Transitioning eligible patients to hospice can help hospitals avoid Medicare's 30-day readmission penalty, according to a new infographic by VITAS.

The infographic examines how hospice can reduce readmission rates and increase patient satisfaction.

Reducing SNF Readmissions: Quality Reporting Metrics Drive ImprovementsA tri-county, skilled nursing facility (SNF) collaborative in Michigan is holding the line on hospital readmission rates for the three competitive health systems participating in the program.

Henry Ford Health System, Detroit Medical Center and St. John's Providence, along with the state's Quality Improvement Organization (QIO), MPRO, developed standardized quality reporting metrics for 130 SNFs in its market. The SNFs, in turn, enter the quality metrics into a data portal created by MPRO.

During Reducing SNF Readmissions: Quality Reporting Metrics Drive Improvements, a 45-minute webinar on May 11th at 1:30 p.m. Eastern, Susan Craft, director, care coordination, family caregiver program, Office of Clinical Quality & Safety at Henry Ford Health System, will share the key details behind this collaborative, the impact the program has had on her organization's readmission rates along with the inside details on new readmission reduction target areas born from the program's data analysis.

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Infographic: The Impact of Medication Reconciliation on Readmission Rates

July 18th, 2016 by Melanie Matthews

Medication reconciliation programs, in which pharmacists review patients' medication regimens and provide adherence counseling during the patient's transition from hospital to home, reduced ths risk of hospital readmission by 50 percent and helped avoid unnecessary healthcare costs, according to a new study from the CVS Health Research Institute.

A new infographic by CVS highlights the survey findings, including details on the impact of medication non-adherence on readmission rates and how a pharmacist intervention reduced readmission risks.

Medication Management: Using Clinical Pharmacists To Complete Comprehensive Drug Therapy Management Post Discharge in High-Risk PatientsA clinical pharmacist-driven medication management effort at Novant Health identifies patients at high-risk for readmissions or ED visits related to adverse drug events. Using a combination of medication reconciliation, pharmacotherapy review, and patient education, Novant Health's clinical pharmacists are working to reduce preventable readmissions by optimizing medication regimens and removing barriers to adherence among these high-risk patients.

During Medication Management: Using Clinical Pharmacists To Complete Comprehensive Drug Therapy Management Post Discharge in High-Risk Patients a 45-minute webinar on February 3rd, now available for replay, Rebecca Bean, director, population health pharmacy, Novant Health, shares her organization’s medication management approach and why a clinical pharmacist is key to the program’s success.

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Infographic: Medicaid Readmission Rates

February 19th, 2016 by Melanie Matthews

Many hospitals are working hard to lower readmissions among Medicare patients. But another patient group—adults covered by Medicaid—have readmission rates that are just as high, or even higher, than Medicare patients, according to 2012 data from AHRQ, illustrated in a new infographic.

The infographic compares 30-day readmission rates for Medicare and Medicaid patients for acute myocardial infarction, congestive heart failure, pneumonia, and hip and knee replacement.

Asked by its C-suite to quantify contributions of its multidisciplinary care team for its highest-risk patients, AltaMed Health Services Corporation readily identified seven key performance metrics associated with the team. Having demonstrated the team's bottom line impact on specialty costs, emergency room visits, and HEDIS® measures, among other areas, the largest independent federally qualified community health center (FQHC) was granted additional staff to expand care management for its safety net population.

Care Coordination of Highest-Risk Patients: Business Case for Managing Complex Populations chronicles AltaMed's four-phase rollout of care coordination for dual eligibles—a population with higher hospitalization and utilization and care costs twice those of any other population served by AltaMed.

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Infographic: Reducing Readmissions Through Patient Education

December 18th, 2015 by Melanie Matthews

The importance of care transitions in improving patient safety is illustrated by recent data released by The Joint Commission on sentinel events compiled from January 2014 to October 2015.

The data show a total of 197 sentinel events—from suicide to falls to wrong site surgery—and the root causes included failures in patient communication (127 incidents), patient education (26 incidents) and patient rights (44 incidents). The majority of the patient education failures were related to not assessing the effectiveness of patient education or not providing education. The patient rights failures included absent or incomplete informed consent, and lack of the patient's participation in their care.

In response to these findings, the Joint Commission released an infographic to help healthcare providers in their efforts to reduce patient readmissions and improve the discharge process.

Providers who signed on for San Francisco Health Network's Care Transitions Task Force shared not only a professional passion for care transitions work but also the belief that care transitions responsibility should be spread across the healthcare continuum. And once the SFHN task force mined a 'black box' of administrative data buried in more than 60 siloed databases across its health network, continuum-wide care transition improvement seemed attainable.

Data-Driven Care Transition Management: Action Plans for High-Risk Patients documents how SFHN's deep data dive triggered the development of a data dashboard, a hospital discharge database and a set of uniform standards and practices that have streamlined care transitions within its safety net population.

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Behavioral Health Diagnoses Can Inflate Readmissions Rates, Hinder Self-Management

April 9th, 2015 by Cheryl Miller

Preliminary data from a Care Transitions Task Force found that when patients with behavioral health diagnoses are excluded from readmissions rates, those rates fall by nearly 4 percent, says Michelle Schneidermann, MD, task force member and Associate Clinical Professor of Medicine for the division of hospital medicine at the University of California, San Francisco, and Medical Director of the San Francisco Department of Public Health, Medical Respite and Sobering Center. Part of the reason for this is this patient population's inability to follow through on self-management instructions once they leave the hospital.

Question: Among your discharge patients there’s a number of behavioral health diagnoses. Are there any considerations, or challenges to this patient population during care transitions, and any unique follow-up that your organization is doing?

Response: (Dr. Michelle Schneidermann) Yes, this patient population provides a very distinct challenge. The patients are challenged by so many other competing priorities, in addition to having a significant and severe mental health disorder, that it interferes with their ability to organize and follow through with the self-management requirements we place on them when they leave the hospital and their ability to manage chronic illness in general. So, from the patient perspective, it’s incredibly difficult.

From the systems perspective, although we are an integrated network health system, there are limitations on the number of outpatient behavioral healthcare clinics and providers. Plus, we don’t always have providers who are culturally concordant or language concordant, although the network is trying very hard to make that happen.

One of the things we’re working on right now is to tease out what our readmission rate looks like when we pull out all patients who have a behavioral health code. Just initial, very crude, back of the envelope calculations show a significant difference in our readmission rate.

When patients with behavioral health diagnoses are included, our hospital-wide, 30-day all-cause readmission rate is around 12 percent. When you remove patients with the behavioral health diagnosis, the readmission rate goes down to about 8.5 or 9 percent. Again, preliminary data, but it shows you the impact that this patient population has on readmissions and tells the story about the challenges that they personally face when they’re leaving the hospital.

cross-continuum care transitions
Dr. Michelle Schneidermann completed her primary care internal medicine training at UCSF and joined the UCSF faculty in 2003, where she is a member of the Division of Hospital Medicine at San Francisco General Hospital (SFGH). Through her inpatient clinical work and work with ambulatory programs, she has been able to directly witness the successes and challenges of patients’ transitions and generate feedback to the providers and systems that manage their care.

Source: Cross-Continuum Care Transitions: A Standardized Approach to Post-Acute Patient Hand-Offs

Risk Stratification Targets the High-Risk, Curbs Utilization Across Continuum

February 19th, 2015 by Cheryl Miller

Preventive care and utilizing hospital and discharge information are critical for stratification, say a number of thought leaders from organizations like Humana, Adventist Health, Taconic Professional Resources, Monarch Healthcare (a Pioneer ACO), and often lead to improved clinical and financial outcomes. Here, some advice from these thought leaders.

Across the healthcare continuum, improved clinical and financial outcomes at organizations like Humana, Adventist Health, Taconic Professional Resources, Monarch Healthcare (a Pioneer ACO), and Ochsner Health System were preceded by rigorous risk stratification of populations served.

“Humana encourages preventive care, and we are trying to prevent the most costly interventions by making sure we address things before they become big problems,” notes Gail Miller, vice president of telephonic clinical operations in Humana’s care management organization, Humana Cares/SeniorBridge. “It is successful so far. We have been able to reduce hospitalizations from what we expected by about 42 percent. We have been able to decrease our hospital readmission rate to 11 percent.”

Hospital admission and discharge information is critical for stratification, adds Annette Watson, RN-BC, CCM, MBA, senior vice president of community transformation for Taconic Professional Resources. “Depending on the model in a primary care practice (PCP), if a physician is not the admitting physician—if the admission is from a specialist, hospitalist, or through the ER—it cannot be assumed the PCP has the admission and discharge information. People may think physicians know about their patients being in the hospital, but that is not always the case.”

“Our first step in launching Monarch’s Pioneer ACO program was to develop a population disease profile in risk stratification analysis,” contributes Colin LeClair, executive director of accountable care at Monarch HealthCare. “With the help of Optum Actuarial Solutions, we identified the eight most prevalent and costly conditions in our population. We then identified the largest cohort of high-risk patients best suited for Monarch’s care management programs. Ultimately we isolated the top 6 percent of high-risk patients with a diagnosis of diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or renal disease and found that of those patients, 6 percent account for 43 percent of total medical cost across the entire population. That analysis resulted in us targeting about 1,200 high-risk patients who have a similar constellation of issues.”

“You want to look at your high utilizers of care, because they’re using a great deal of care,” concludes Elizabeth Miller, RN, MSN, vice president of care management at White Memorial Medical Center, part of Adventist Health. “There’s potential for decreasing procedures, tests, ED visits, hospitalizations.”

Source: 2014 Healthcare Benchmarks: Stratifying High-Risk Patients

http://hin.3dcartstores.com/2014-Healthcare-Benchmarks-Reducing-Hospital-Readmissions_p_4786.html

2014 Healthcare Benchmarks: Stratifying High-Risk Patients captures the tools and practices employed by dozens of organizations in this prerequisite for care management and jumping-off point for population health improvement—data analytics that will ultimately enhance quality ratings and improve reimbursement in the industry's value-focused climate.

Infographic: Why Care Coordination Matters

January 23rd, 2015 by Melanie Matthews

As a result of poor coordination of care, one in five Medicare patients is readmitted within 30 days of discharge from the hospital, according to a new infographic by Primaris.

The infographic also examines the level of post-discharge care for Medicare beneficiaries who are re-admitted and the cost of these readmissions.

Scalable Models in Health Risk Stratification: Results from Cross-Continuum Care Coordination Health risk stratification is scalable—whether grouping diabetics in a single practice without an EMR or drilling down to an ACO's subset of medication non-adherent diabetics with elevated HbA1cs who lack social supports. That's the experience of Ochsner Health System, whose scaling and centralization of risk stratification and care coordination protocols across its nine-hospital system drive ROI and improve clinical outcomes and efficiency.

Scalable Models in Health Risk Stratification: Results from Cross-Continuum Care Coordination explores Ochsner's approach, in which standardized scripts, tools and workflows are applied along the care continuum, from post-hospital and ER discharge telephonic follow-up to capture of complex cases for outpatient management.

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Infographic: 7 Cities with Highest Readmission Rates

September 22nd, 2014 by Melanie Matthews

The seven cities with the highest hospital readmission rates include: Chicago, Brooklyn, Philadelphia, Baltimore, Manhattan, Boston and Los Angeles, according to a new analysis by Kaiser Health News, depicted in an infographic by Becker's Healthcare.

Nineteen hospitals in Chicago exceeded the national average readmission rate. The infographic details how many hospitals in each of the other cities exceeded the average.

7 Cities with Highest Hospital Readmission Rates

2014 Healthcare Benchmarks: Reducing Hospital Readmissions2014 Healthcare Benchmarks: Reducing Hospital Readmissions documents the latest key initiatives and partnerships to reduce readmissions by patients with these costly conditions and others by more than 100 healthcare organizations. This 60-page report, now in its fourth year, for the first time provides details on partnerships with post-acute care to reduce readmissions from these care sites.

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5 Barriers to Optimal Care in the Post-Acute Setting

January 22nd, 2014 by Jessica Fornarotto

Summa Health System's care coordination network of skilled nursing facilities (SNFs) is working to decrease fragmentation, length of stay and unnecessary readmissions while improving outcomes of care. Mike Demagall, administrator of Bath Manor & Windsong Care Center, a participant in this network, identified five barriers to patient care that originated in the acute care setting.

First, we found a lack of quality information received upon transfer from an acute care to a nursing facility and the lag time in identification of post-acute bed availability. The social worker was calling or faxing information to a facility, and the facility took up to 24 hours to respond as to whether a bed was available. That person may have been ready that day; instead it postponed that discharge another day.

We also had barriers to the patient’s acceptance of the need for post-acute care. Social workers and care coordinators at the bedside tell them when it is time for rehabilitation.

The next barrier was family expectations. Does the family feel that they need to go to the nursing home? The hospital staff and the insurers had to spot the appropriate levels of care. One of the concerns we had was, 'Is this going to send a lot of our patients — our referrals — to home healthcare and decrease our referrals by participating in this?' That happened to not be the case at all.

There was still a lack of knowledge and respect toward long-term care (LTC). All the discharge planning individuals, which were the case manager nurses and social workers, were able to tour the facility. Each facility had the opportunity to present their services and what they do. That helped with the overall cohesion of the group, and it moved this project forward.

There was also a lack of quality information received from the nursing facilities on the transfer to an emergency department (ED). That was information that we needed to get back, just as we were asking for information as those residents were coming in.

Excerpted from: 7 Patient-Centered Strategies to Generate Value-Based Reimbursement

SNF Community Partnership Shores Up Accountable Care

October 1st, 2013 by Jessica Fornarotto

To support ACO construction, industry thought leaders advise hospitals to monitor what goes on across its care continuum and to partner with facilities it discharges its patients to most often to reduce 30-day readmissions. A prime example is the skilled nursing facility (SNF) network coordinated by Summa Health System, discussed here by Carolyn Holder, manager of transitional care for Summa Health System, and Michael Demagall, administrator of Bath Manor & Windsong Care Center.

(Carolyn Holder) We have been working on a pilot model for accountable care. Accountable care is the focus on primary care wellness in population health. Patients and families need to be actively engaged in this process. It coincides with having the right level of care provided to the patient where they need it, and that is what we are talking about with accountable care. You need partnering relationships between hospitals and physicians and through all levels of care to be able to support that individual in their wellness or illness effectively.

What is the value of this care coordination that worked in the accountable care model of care? It relates to the Triple Aims and looking at providing safe, patient-centered, timely care. We are collaborating to do that with our partner facilities. We have been working at improving health and patient populations in communities. Patients in this situation need rehab, so they have had some functional impairments and frailty. We are trying to get them back to their optimal level of function. To do this, we partner with our SNFs to support that level of care and lower the per capita cost of healthcare.

We also work with community-based long-term care. That has certainly not taken away from any of our nursing facilities any patients that are appropriate or keeping them in the optimal function that they would want.

(Mike Demagall) Through this development of the ACO on the skilled nursing side in working with the hospitals, one thing we focused on was the key indicator comparisons for our 2010 data.

Along with the hospital, we will provide standardized numbers of information that we can get back, that we are going to be held accountable for from the SNF side. The hospital knows what we do is safe and efficient, patient-centered and equitable for everybody involved. As we move forward with the ACO through care coordination, we will look at numbers and information that we can share as a community with the health system so they know what the facilities are doing. There are many reasons that is done, but one of the greatest accomplishments is everybody working together.

Out of 39 homes in the county, the collaboration has been incredible. Initially there was some hesitation, but the collaboration has moved forward, and we are not afraid to share that information. The information is blocked and as we provide information back, it will be blocked from other members except for the hospital, who knows who those numbers are. However, from my facility, I may see a readmission rate at one facility lower than ours although we have the same type of case mix index. I need to look at our facility and ask, “What can we do to get better? What are they doing that we aren’t?” Therefore, everybody gets better as a group, and that is ultimately the goal of the community and the health population in the community we serve.