From Channeling to GRACE: Approaching Reduction in Readmissions and Adverse Drug Events

Transcription

1 From Channeling to GRACE: Approaching Reduction in Readmissions and Adverse Drug Events Michael Wasserman, MD, CMD Executive Director, Care Continuum Health Services Advisory Group September 15, 2016

2 Quality Improvement Marathon 2

3 Today s Objectives Examine the Focus on Hospital Readmissions Review Medication Safety and Adverse Drug Events (ADEs) Discuss Care Coordination Models 3

4 Medicare Spending Hospitals 41 Pharmaceuticals 16 Medicare $632 billion 4

5 Contra Costa County Progress All-Cause, 30-Day Readmission Rate 17.0% 16.3% 17.1% The ASAT data file representing calendar years (CYs) was used for the analyses in this report. The ASAT data file is provided to HSAG by CMS. The ASAT data file includes Part-A claims for FFS beneficiaries.

6 Contra Costa County Readmission Rate: Q Q Group Discharged To Discharges Readmissions Contra Costa Readmission Rate Home 9,019 1, % Skilled Nursing Facility (SNF) Home Health Agency (HHA) 4, % 4, % Hospice % Other % Total 19,158 3, % State Total 724, , % 6 The ASAT data file representing Q to Q was used for the analyses in this report. The ASAT data file is provided to Health Services Advisory Group (HSAG) by the Centers for Medicare & Medicaid Services (CMS). The ASAT data file includes Part-A claims for Medicare Fee-for-Service beneficiaries.

7 Lost in Transition: Can We Find Our Way? 7 Creative Commons/Pixabay.

8 Doing things the same way will NOT reduce readmissions. 8

9 Hospital Readmission 9

10 Internal Medicine vs. Geriatrics Classic Internal Medicine Geriatric Medicine Diagnosis Treatment Function Quality of Life Cure 10

11 Evidencebased medicine! Evidencebased medicine! Evidencebased medicine! Evidencebased medicine! Evidencebased medicine! Evidencebased medicine! Evidencebased medicine! Evidencebased medicine! 11

12 Hospital Complications Adverse Drug Events Infections Delirium 12

13 Care Coordination A function that helps ensure that the patient s needs and preferences for health services and information sharing across people, functions, and sites are met over time. (National Quality Forum) 13

14 14 Just consider...

15 How Do We Get to This Age? 15

16 Are Medications Helpful in Older Adults? Mortality in Individuals Age 80 and Older With Type 2 Diabetes Mellitus in Relation to Glycosylated Hemoglobin, Blood Pressure, and Total Cholesterol S Hamada, M Gulliford JAGS, 64:1,425 1,431,

17 Are Medications Helpful in Older Adults? (cont.) Effect of Statin Therapy on Mortality in Older Adults Hospitalized With Coronary Artery Disease: A Propensity-Adjusted Analysis D Rothschild, E Novak, M Rich JAGS, 64:1,475 1,479,

18 Adverse Drug Events: National Picture Adverse Drug Events (ADEs) account for 1 out 3 of of all hospital adverse events Prolong hospital stays by to days hospital stays affected 2MILLION/year AND In older adults ADEs account for 30 % of emergency hospitalizations or readmissions Aging Medicare population+ multiple medications + Visiting = multiple providers Increased need for medication safety and coordination of all care transitions 18 Sources: Institute of Medicine, Agency for Healthcare Research and Quality and the National Institute of Health

19 Moving from Volume 20

20 To Value Bundled Payments Medicare Spending Per Beneficiary Value-Based Purchasing Penalties Accountable Care Organizations 21

21 CMS Support of Health Care Delivery System Reform (DSR) Historical State Key Characteristics Producer-centered Incentives for volume Unsustainable Fragmented care Systems and Policies Fee-for-Service (FFS) payment systems Result: Better care, smarter spending, and healthier people Evolving Future State Key Characteristics Patient-centered Incentives for outcomes Sustainable Coordinated care Systems and Policies Value-based purchasing Accountable Care Organizations (ACOs) Episode-based payments Medical homes Quality/cost transparency 22 Centers for Medicare & Medicaid Services

22 Our healthcare system operates in silos, is setting centered not patient centered and is incapable of reciprocal operation between organizations. Eric A. Coleman, MD, MPH 23

23 Fragmentation Patients and families navigating unassisted Poor communication and lack of accountability Lack of quality improvement (QI) Infrastructure 24 A Shih, K Davis, SC Schoenbaum, et al, The Commonwealth Fund Organizing the U.S. health care Delivery System for high Performance. August 2008

24 Channeling Study Increased formal community service use Reduced unmet needs Improved satisfaction with life No reduction in nursing home use or costs 25

25 Mathematica Policy Research: Elements of Care to Reduce Repeat Hospitalizations Face-to-face care coordinator contact with patients Face-to-face care coordinator contact with physicians Evidence-based patient education Management of care setting transitions Facilitation of communications across providers Medication management 26

26 Integration of Care Coordination Into Primary Care 27

27 We Don t Need to Reinvent the Wheel 28

28 Geriatric Resources for Assessment and Care of Elders (GRACE) Program Nurse practitioner/social worker (NP/SW) team overseen by a geriatrician Focus on geriatric conditions and medication management Provides recommendations for care and resources for implementation and follow-up Incorporates proven care transition strategies Provides home-based and proactive care management Integrates with community resources and social services Develops relationships through longitudinal care 29

29 GRACE Homebound Study 34% 29% 44% 53% 22% HOSPITAL HOSPITAL SUB-ACUTE SUB-ACUTE EMERGENCY admissions bed days admissions bed days visits 30

30 Acute Care of the Elderly (ACE) Unit 31

31 Geriatric Approach to Care 32

32 Geriatric Medicine (GeriMed) Philosophy of Care Focus on function. Focus on managing chronic disease(s) and developing chronic care treatment models. Identify and manage psychological and social aspects of care. Respect patients dignity and autonomy. Respect cultural and spiritual beliefs. 33

33 GeriMed Philosophy of Care (cont.) Be sensitive to the patient s financial condition. Promote wellness. Listen and communicate effectively. Use a patient-centered approach to care and customerfocused approach to service. Promote optimism and hope realistically. Use a team approach to care. 34

34 ACE Unit Meta-Analysis Fewer falls (risk ratio [RR] = 0.51, 95% confidence interval [CI] = ) Less delirium (RR = 0.73, 95% CI = ) Less functional decline at discharge from baseline (RR = 0.87, 95% CI = ) Shorter length of hospital stay (weighted mean difference [WMD] = 0.61, 95% CI = 1.16 to 0.05) Fewer discharges to a nursing home (RR = 0.82, 95% CI = ) Lower costs (WMD = $245.80, 95% CI = $ to $45.38) More discharges to home (RR = 1.05, 95% CI = ) 35

35 Program for All-Inclusive Care of the Elderly (PACE) All Medicare and Medicaid services through single delivery point Targeted to frail elderly with a host of chronic care needs Provider-based model of care Participants at the center of the plan of care developed by an interdisciplinary team Full continuum of preventive, primary, acute, rehabilitative, and long-term care services Comprehensive care in a fiscally responsible manner for families, healthcare providers, government programs, and others that pay for care Historically staffed by geriatricians 36

36 Where Have all the Geriatricians Gone? >660,000 practicing physicians in U.S. <7,000 board certified geriatricians Number of geriatricians decreasing annually No medical school admission focus Minimal focus during first three years of medical school Lack of positive mentoring opportunities Poor reimbursement >85 years old is most rapidly growing demographic 37

37 What Can We Do? 1. Recognize the value of the geriatric approach to care 2. Recognize the value and importance of geriatricians 3. Develop education and training programs that geriatricize our existing clinical workforce 4. Institute models of care that are based on the geriatric approach to care 38

38 Coming to the End 39

39 Cost of Preventable Adverse Events 40

40 Fast Facts for Medication Management 41 1 Understanding and Improving Medication Reconciliation Between Hospitals and Nursing Homes Patient Safety Risk and Cost in Care Transitions Stratis Health pdf.

41 Fast Facts for Medication Management (cont.) 42 1 Department of Health and Human Services Office of Inspector General. Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries. Daniel R. Levinson Inspector General February 2014 OEI Pages table 1, page 4.

42 Business Case Study: Inappropriate Dosing Take a guess on time and cost to correct this issue. A 76-year-old female patient is discharged from hospital to nursing home with an order for Ambien 10 mg at bedtime. Sedative/hypnotics with significant side effects Staff- or person-centered treatment? Was it ever necessary? 44

43 Business Case Study: Workflow and Associated Costs Pharmacy consultant reviews order and identifies inappropriate dose Task Profession Time Hourly Wage Pharmacist 0.25 $56.01 Nursing home generates request to change order RN 0.25 $33.13 Physician writes new order for new medication Physician 0.25 $92.95 Physician office faxes new order to nursing home Unit Clerk 0.25 $16.80 Pharmacy processes and fills the new order Nursing home processes the new order Nursing home destroys old medication Pharmacist Pharm Tech Unit Clerk RN RN RN witness hours/$ That s 1 patient and 1 medication! $56.01 $14.83 $16.80 $33.13 $33.13 $

44 Another Risk Group for Readmissions: Patients on High-Risk Medications (HRMs) HRMs Anticoagulants Diabetic agents Opioids Of patients readmitted within 7 days of discharge, 396 were on HRMs More than 1 out of 4 = 28% 46

45 HSAG: Your Partner in Healthcare Quality HSAG is California s Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO). QIN-QIOs in every state and territory are united in a network administered by CMS. The QIN-QIO program is the largest federal program dedicated to improving health quality at the community level. 47

46 What is a QIN-QIO? Funded by CMS Dedicated to improving health quality at the community level Ensures people with Medicare get the care they deserve and improves care for everyone Department of Health & Human Services CMS 48

47 HSAG s QIN-QIO Responsibility Nearly 25 percent of the nation s Medicare beneficiaries HSAG is the Medicare QIN-QIO for California, Arizona, Florida, Ohio, and the U.S. Virgin Islands. 49

48 Putting It All Together 50

49 Building Community Coalitions 51

50 Community Model for Improvement Sustainable Community Engage community partners Create leadership structure Develop coalition charter Conduct root cause analysis Select interventions Evaluate interventions 52

51 California Care Coordination Communities 53

52 Power of Collaboration: Key Advantages Create a holistic view of the problem Identify the most relevant and effective solutions Leverage our collective resources Amplify influence to generate results Align initiatives across the community to scale results 54

53 Questions????? 55

54 Thank you! Michael Wasserman, MD, CMD

55 CMS Disclaimer This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for California, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. CA-11SOW-C