Posts Tagged ‘Reducing 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: Optimizing Post-Acute Care

October 17th, 2016 by Melanie Matthews

Seventy-five percent of hospital readmissions are preventable—more than $17 billion annually is wasted due to readmissions within 30 days, according to a new infographic by CareCentrix.

The infographic lists four keys to success in improving post-acute care and reducing readmissions.

Medicare's proposed payment rates and quality programs for skilled nursing facilities (SNFs) for 2017 and beyond solidify post-acute care's (PAC) partnership in the transformation of healthcare delivery. Subsequent to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), forward-thinking PAC organizations realized the need to rethink patient care—not just in their own facilities but as patients move from hospital to SNF, home health or rehabilitation facility.

Post-Acute Care Trends: Cross-Setting Collaborations to Align Clinical Standards and Provider Demands examines a collaboration between the first URAC-accredited clinically integrated network in the country and one of its partnering PAC providers to map out and enhance a patient's journey through the network continuum—drilling down to improve the quality of the transition from acute to post-acute care.

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HINfographic: Care Transitions Management 2.0

January 11th, 2016 by Melanie Matthews

Call it Care Transitions Management 2.0—innovative ideas ranging from recording patient discharge instructions to enlisting fire departments and pharmacists to conduct home visits and reconcile medications.

To improve 30-day readmissions and avoid costly Medicare penalties, more than one-third of respondents to the 2015 Care Transitions Management survey—34 percent—have designed programs in this area, drawing inspiration from the Coleman Care Transitions Program®, Project BOOST®, Project RED, Guided Care® and other models.

A new infographic by HIN examines how care transitions data is transmitted, which care transition is the most critical to manage and the top five discharge summary components.

2015 Healthcare Benchmarks: Care Transitions ManagementManagement of patient handoffs—between providers, from hospital to home or skilled nursing facility, or SNF to hospital—is a key factor in the delivery of value-based care. Poorly managed care transitions drive avoidable readmissions, ER use, medication errors and healthcare spend.

2015 Healthcare Benchmarks: Care Transitions Management, HIN's fourth annual analysis of these cross-continuum initiatives, examines programs, models, protocols and results associated with movement of patients from one care site to another, including the impact of care transitions management on quality metrics and the delivery of value-based care. Click here for more information.

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Infographic: Hospitals Overconfident, Unprepared To Reduce Readmissions

July 15th, 2015 by Melanie Matthews

While hospitals report they are confident in their ability to reduce readmissions, according to a new survey conducted by Q-Centrix, the percentage of hospitals penalized for readmissions has increased each year since CMS began imposing them.

The percentage of hospitals penalized for readmissions reached a high of 78 percent for FY 2015. Given the historical trend and the three additional diagnoses recently added, the percentage of hospitals penalized will likely be much higher than the 55 percent who reported that they expected to be penalized, according to an infographic produced by Q-Centrix on the survey results.

2014 Healthcare Benchmarks: Reducing Hospital Readmissions While great strides have been made in the reduction of 30-day all-cause hospital readmissions, CMS still penalized more than 2,200 hospitals in 2013 for exceeding 30-day readmission rates for heart failure, pneumonia and myocardial infarction. This year, CMS penalties extend to acute COPD and elective hip and knee replacements.

2014 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.

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13 Metrics on Care Transition Management

May 7th, 2015 by Cheryl Miller

Care transitions mandate: Sharpen communication between care sites.


Call it Care Transitions Management 2.0 — enterprising approaches that range from recording patient discharge instructions to enlisting fire departments and pharmacists to conduct home visits and reconcile medications.

To improve 30-day readmissions and avoid costly Medicare penalties, more than one-third of 116 respondents to the 2015 Care Transitions Management survey—34 percent—have designed programs in this area, drawing inspiration from the Coleman Care Transitions Program®, Project BOOST®, Project RED, Guided Care®, and other models.

Whether self-styled or off the shelf, well-managed care transitions enhance both quality of care and utilization metrics, according to this fourth annual Care Transitions survey conducted in February 2015 by the Healthcare Intelligence Network. Seventy-four percent of respondents reported a drop in readmissions; 44 percent saw decreases in lengths of stay; 38 percent saw readmissions penalties drop; and 65 percent said patient compliance improved.

Following are eight more care transition management metrics derived from the survey:

  • The hospital-to-home transition is the most critical transition to manage, say 50 percent of respondents.
  • Heart failure is the top targeted health condition of care transition efforts for 81 percent of respondents.
  • A history of recent hospitalizations is the most glaring indicator of a need for care transitions management, say 81 percent of respondents.
  • Beyond the self-developed approach, the most-modeled program is CMS’ Community-Based Care Transitions Program, say 13 percent of respondents.
  • Eighty percent of respondents engage patients post-discharge via telephonic follow-up.
  • Discharge summary templates are used by 45 percent of respondents.
  • Home visits for recently discharged patients are offered by 49 percent of respondents.
  • Beyond the EHR, information about discharged or transitioning patients is most often transmitted via phone or fax, say 38 percent of respondents.

Source: 2015 Healthcare Benchmarks: Care Transitions Management

Care Transition Management

2015 Healthcare Benchmarks: Care Transitions Management HIN's fourth annual analysis of these cross-continuum initiatives, examines programs, models, protocols and results associated with movement of patients from one care site to another, including the impact of care transitions management on quality metrics and the delivery of value-based care.

9 Hospital Discharge Communications Tactics to Curb Readmissions

January 27th, 2015 by Cheryl Miller

For heart failure patients making the transition from hospital to home, an effective discharge summary can mean the difference in whether the patient recovers quickly or returns to the hospital, according to two new studies from Yale School of Medicine researchers. To be effective, discharge summaries must have three key factors: they must be timely, be quickly forwarded to the outside physician, and contain detailed and useful information.

We asked the 116 respondents to the fourth annual Healthcare Intelligence Network’s (HIN) Reducing Hospital Readmissions Survey, conducted in December 2013, what hospital discharge communications tools they used to lower their readmissions rate. Following are their responses.

  • Follow-up with patient post-facility discharge by case managers embedded in our physician practices.
  • Improved communication between inpatient (hospital) care coordination and outpatient (medical group) services.
  • Follow-up appointments with the doctor and home care arrangements are made prior to discharge from the facility if appropriate. Discharge information with medications are sent to the doctor’s office by the facility doctor on discharge for availability on follow-up appointment.
  • Increased oversight of high-risk patients; increased communication among clinical teams and health providers.
  • We utilize a transitional care program to engage with patients while in facility and continue to follow with in-home visits on discharge to continue education and teach-back as well as monitor and oversee progress.
  • Post-acute touch (home health) within 24 hours of discharge; medication reconciliation, signs and symptoms education and scheduling primary care physician (PCP) office visit appointment.
  • All discharges are called by our nursing supervisor or other designee to determine their post-discharge status and ensure they keep their follow-up primary care appointment.
  • Reaching the patient within one to two days post-discharge. Assuring the patients have a follow-up appointment and transportation, understand discharge medications, red flag symptoms and who to call if necessary.
  • Follow-up in the home for 35 days post-transition to home.

Source: 2014 Healthcare Benchmarks: Reducing Hospital Readmissions

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

2014 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.

Hospitals: Chronic Disease Leading Cause of Avoidable ER Visits in 2014

December 4th, 2014 by Cheryl Miller

High utilizers continue to be responsible for the majority of avoidable emergency room (ER) visits, with chronic disease edging out pain management as the top complaint among this population, according to respondents to the third comprehensive survey on reducing avoidable ER visits, conducted in August 2014 by the Healthcare Intelligence Network (HIN). A total of 125 healthcare organizations described tactics employed; nearly one third (32 percent) of which were identified as hospitals/health systems. A sampling of this sector's results follows.

While the majority of hospitals/health systems were likely to have such a program in place (53 percent versus 69 percent of all respondents), of those that didn’t, just 25 percent planned a future program, compared to 47 percent of all respondents. Less than one half of hospital respondents (47 percent) felt that eased telehealth regulations would curb avoidable ER use.

This sector was twice as likely to find high utilizers generating the majority of avoidable ER visits (78 percent versus 31 percent of all respondents) and least likely to target Medicaid (10 percent versus 28 percent of all respondents). Chronic disease was the most frequently presented problem among this sector’s high utilizers (78 percent versus 54 percent).

In terms of patient level solutions, this sector was half as likely to utilize telephonic outreach (33 percent versus 60 percent), and twice as likely not to conduct follow-up phone calls with those discharged from the hospital (30 percent versus 15 percent). In terms of staff level solutions, this sector was more likely to use hospitalists (22 percent versus 10 percent for all respondents) and onsite educators/coaches (22 percent versus 11 percent for all respondents) and least likely to use disease-specific care coordination (11 percent versus 38 percent for all respondents). This sector was also least likely to notify PCPs of care gaps (22 percent versus 41 percent).

When asked to identify the greatest impact on overall ER efficiency, 70 percent of hospital respondents cited fast-tracking of non-urgent care, versus 33 percent of all respondents. Among the challenges of reducing avoidable ER visits, redirecting the non-urgent was considered a top obstacle for 3 percent of hospital/health system respondents, versus 18 percent of all respondents.

And 40 percent of this sector saw reductions in avoidable ER visits of between 0 to 5 percent, versus 26 percent of all respondents.

Source: 2014 Healthcare Benchmarks: Reducing Avoidable ER Visits

http://hin.3dcartstores.com/2014-Healthcare-Benchmarks-Reducing-Avoidable-ER-Visits-_p_4942.html

2014 Healthcare Benchmarks: Reducing Avoidable ER Visits delivers actionable metrics from 125 healthcare organizations on their efforts to foster appropriate use of hospital emergency departments. Enhanced with more than 50 easy-to-follow graphs and tables, this third edition of comprehensive data points presents year-over-year trends and best practices for engaging ER and hospital staff, primary care physicians, community providers and patients in reducing avoidable ED utilization.

6 Strategies Help Stem Hospital Readmissions, Streamline Processes and Care Transitions

February 27th, 2014 by Cheryl Miller

Development of post-acute partnerships with home health, skilled nursing facilities (SNFs) and hospice is emerging as a key strategy to stem hospital readmissions, according to new market data from the fourth annual Healthcare Intelligence Network (HIN) Reducing Hospital Readmissions Survey.

More than half of survey respondents participate in post-acute partnerships, with home health collaborations the most common (79 percent). These partnerships serve to streamline processes and care transitions, educate and align staff, and implement changes of value to patients, respondents say.

Looking at more conventional approaches, medication reconciliation and telephonic monitoring of patients post-discharge emerged as frontrunner strategies to curb readmissions. Moreover, the 2013 survey revealed significant upticks in the use of each tactic over 2012 levels: medication reconciliation is now conducted by 73 percent of respondents, versus 54 percent in 2012, while the use of telephonic monitoring jumped from 48 to 71 percent over the same 12-month period.

In other new data, almost half of respondents — 47 percent — aim programs at individuals already assessed at high risk for readmission as well as traditional Medicare (53 percent), Medicaid (28 percent) and high utilizer (23 percent).

Other key findings include the following:

  • Two-thirds of respondents to HIN’s December 2013 Readmissions e-survey have a program to reduce readmissions.
  • In a new metric from the 2013 survey, more than half — 52 percent — aim readmission reduction efforts at individuals with diabetes.
  • Case management is the most successful approach to curbing rehospitalizations, say 27 percent. The case manager retains chief responsibility for reducing readmissions, say 34 percent of respondents.
  • Heart failure remains the top condition targeted by programs, although a fifth already track readmissions for hip and knee replacements, a metric the Centers for Medicare and Medicaid Services (CMS) will examine more closely in 2015.

Excerpted from 2014 Healthcare Benchmarks: Reducing Hospital Readmissions.

3 Reasons Home Visits Critical During Care Transitions

February 20th, 2014 by Cheryl Miller

As far back as 2010, home visits were a vital component of the Durham Community Health Network (DCHN), a primary care case management program for Medicaid recipients who live in Durham County, NC, explains Jessica Simo, program manager with Durham Community Health Network (DCHN) for the Duke Division of Community Health. Conducted in three-month increments, and designed initially to better address Medicaid recipients' needs and link them to their medical homes, the face-to-face visits helped establish a level of trust between case manager and patient, eventually leading patients to better outcomes, including improving medication reconciliation.

Why are home visits so important? Number one, it is very challenging to observe problems that individual patients may have with adhering to their medication regimens if providers can’t see the medicines in the bottle in the patient’s home. You need to be available to count the medicines and ascertain definitively that they are not missing. Trying to do medication reconciliation over the phone is nowhere near as effective as being in a patient’s home.

Another reason home visits are more effective is that you can physically see what activities of daily living (ADL) or instrumental activities of daily living (IADL) deficits the patient may be experiencing in their natural environment. This is something you can’t directly observe within the confines of an exam room.

The engagement of family or other support persons is also important. Home visits are an excellent way to see somebody in their natural environment, find out who the support people are for the patient, have a comfortable discussion in their home about an individual plan of care and get the people who can assist with that on board.

For all of the previous reasons, home visits were critical to the DCHN pilot. It’s especially important in a medically complex patient population where there are frequent transitions, whether they be from the acute care setting, from any emergency department (ED) visit or back into the home from an assisted living facility.

Excerpted from 2013 Healthcare Benchmarks: Home Visits.

Targeting Heart Failure Readmissions with Telehealth Monitoring

January 30th, 2014 by Cheryl Miller

To further investigate gaps in care, Central Maine Medical Center expanded a team already focused on outcomes improvement for 30-day readmissions to include providers, nurses, home care and hospice. The resulting intervention incorporated home health visits supplemented with telehealth, explains Susan Horton, DNP, APRN, CHFN, executive director of Central Maine Heart and Vascular Institute. This innovative work also led to other home-based interventions that were not always restricted to individuals identified by Medicare as homebound.

About that time our home care and hospice group approached us. They had the opportunity to write a grant for telehealth monitors. They wanted to know whether Central Maine would support that application so that they could then target these telehealth monitors for our heart failure population.

We supported that grant, and they got it. However, that decision caused us to determine that we needed to be more strategic in our partnership with home care and hospice. From that, we developed a job description and hired a full time equivalent: 20 hours on the medical center payroll, and 20 hours on the home care and hospice payroll.

That’s where the home visit program really took off. We were able to say that whether Patient A meets Medicare criteria for homebound or not, home care would go into the patient’s home as a guest of Central Maine Medical Center. We explained to each patient at the time of discharge that we wanted to evaluate their home situation to make sure they were safe.

This was important because we are looking at all-cause readmissions. If a heart failure patient living in an unsafe situation trips and falls and gets readmitted with a head injury, that’s still going to be a black mark for heart failure readmission. It’s all-cause readmission. We felt that we needed to assess what was going on in the home. Who was there for the patient? What were they doing in terms of support? Could they take their medication? Did they have a scale? Could they read the scale? And we would offer telehealth.

Excerpted from: Guide to Home Visits for the Medically Complex.