Develop a readmissions reduction program that integrates people, process, and technology.

1. Integrating Care Transitions Strategies Through
Enterprise Process, People, and Technology
June 3, 2015

2. Integrating Care Transition Strategies
2
How to develop a readmissions reduction program that integrates people,
process, and technology
How to create consistent, effective readmission reduction strategies and
tactics for different service lines
How to deploy readmission reduction processes and technologies that work
internally and expand to external facilities and care teams
How to implement care team and management dashboards to track clinical,
financial, and outcome success
Copyright 2015 Digital Collaboration Solutions, LLC6-3-15
Learning Objectives

3. A consulting and services company that
provides care coordination, collaboration,
and patient/provider engagement solutions.
Care Coordination Collaboration Communications
HEALTHCARE
Process
People
Tech
DCS helps healthcare organizations improve care coordination and care team
engagement through process optimization, better collaboration, digital
communications, and use of innovative technology.
DCS combines in-depth experience
in healthcare, healthcare information
technology and patient/provider
engagement to deliver measurable
results and improved outcomes.
3Copyright 2015 Digital Collaboration Solutions, LLC6-3-15

4. Copyright 2015 Digital Collaboration Solutions, LLC 411-Mar-15
Root Causes of Ineffective Transitions of Care

5. Root causes of ineffective transitions of care
Accountability
Breakdowns
A survey at 101 Hospitals
revealed that 9% of
physicians have admitted to
“Turfing” patients.
Communications
Breakdowns
Discharge summaries reach
PCPs by the first follow-up visit
only 12% to 34% of such visits,
and then often lack key
information
Patient Education
Breakdowns
In a study of understanding
of discharge instructions in
patients > 65 years
54% did not accurately recall
instructions about their
follow-up appointment
The Joint Commission defines
three main areas of breakdowns
that are the root causes of
ineffective transitions of care
5Copyright 2015 Digital Collaboration Solutions, LLC6-3-15

6. Addressing Causes of Ineffective Transitions of Care
Balanced Performance
People
ProcessTechnology
Goals
&
Metrics
6Copyright 2015 Digital Collaboration Solutions, LLC6-3-15

7. Goals & Metrics
Which Measures are Critical to Your Healthcare Organization?
Measures
• Unplanned 30 Day Readmissions
• Quality Based Payment Reforms (QBPR)
• Physician Quality Reporting Initiative (PQRI)
• Meaningful Use Clinical Quality Measures (CQM)
• Hospital Acquired Conditions (HAC) Scores
• Press Ganey
• Joint Accreditation Commission
• CMS 30-day readmissions penalty
• Hospital Value Based Purchasing (HVBP)
• Medicare Spending per Beneficiary (MSPB)
• Hospital profitability
• Bad debt due to uninsured admissions and ER visits
• Under reimbursed Medicare & Medicaid
• Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS)
• Patient Activation Measure®
(PAM)
Care
Quality
Financial
Patient
Experience
7Copyright 2015 Digital Collaboration Solutions, LLC6-3-15

8. Readmissions Processes
86-3-15
Source: Readmission Reduction Guide, the Pittsburgh Regional Health Initiative (PRHI). January 2011
“…process-focused care is centered on the patient. It coordinates the work of
many care team members (including patients, physicians, nurses, midlevel
providers, lay caregivers, clinical educators, pharmacists, case managers, and
call-center personnel) to provide each patient with high-quality, efficient care
across time and across all venues of care.”
James M. Walker and Pascale Carayon From Tasks To Processes: The Case For Changing Health Information Technology To 67-477 Improve Health Care
Health Affairs, 28, no.2 (2009):467-477

9. Process Improvement Practices
Address Root Causes of Ineffective Transitions of Care
Accountability
Breakdowns
Clearly define &
document care transition
processes
Identify participants
Assign responsibility
Assess risks
Incorporate contingency
planning
Plan resource
requirements
Communications
Breakdowns
Clearly define & document
communications processes
Specify:
• What information should
be communicated
• To whom to communicate
• How to communicate
Enforce communications
timeframes
Clarify “hand-off”
communications (e.g.
acknowledgements)
Patient Education
Breakdowns
Integrate patient &
family education into
care transitions
Specify education
content
Enforce that education
occurs
Assign responsibility for
whom provides patient
education
9Copyright 2015 Digital Collaboration Solutions, LLC6-3-15

10. People
106-3-15
“Integrating hospital and outpatient care is key to reducing readmissions.
Formal or strong informal relationships between hospitals and local primary
care providers, heart clinics, nursing homes, home health care agencies, and
health plans appear to improve outcomes for patients at the four case study
hospitals. Close coordination between the hospitals and palliative care and
hospice programs—and efforts to understand and honor patients’ preferences
for end-of-life care—seem to reduce unwarranted and unwanted readmissions
as well.”

11. Readmissions Reduction Team
Key questions:
• Do you have the right people
involved for an integrated plan?
• What organizations do you need
to make a program successful?
Your readmissions initiatives must:
– Involve all participants
– Be broad-based within the
groups
– Be well planned
– Gain support of users
• Where is the “biggest
bang”?
11Copyright 2015 Digital Collaboration Solutions, LLC6-3-15
PatientNURSE
DOCTOR FAMILY
HOME CARE
PROVIDERS
POST-ACUTE
CARE/REHAB PHARMACY

12. Care Community Analysis
• What is the care community for your hospital or healthcare organization?
– Demographics
– Location of facilities and patients
– Are patients local or coming from far-away?
– Types of facilities
– Ownership
– Relationship to hospital
• What is the care community per service line?
– The same or different from the hospital overall?
• What is the care community for the patient?
– Who has responsibility for the patient?
• Outcome & care quality
• Patient experience
• Financially
– Don’t forget “informal” care community – family and friends
• What is the financial and business model
– Fee for service
– Bundled payments for “Episodes of Care”
– Shared risk/ACO
– Medicare – Value Based Purchasing
12Copyright 2015 Digital Collaboration Solutions, LLC6-3-15

13. You must align the people involved in
readmissions management
Copyright 2015 Digital Collaboration Solutions, LLC 136-3-15

14. Care Coordination Technology
What technologies are being used for care transitions?
• EHRs
• Hospital Information Systems (HIS)
• Care Coordination Systems
• Mobile Technology
• Portals
• Communication Technology
• Health Information Exchanges (HIEs)
And MANY others!
14Copyright 2015 Digital Collaboration Solutions, LLC6-3-15

15. Care Coordination Technology
• Technology is a valuable tool to improve transitions of care and
lower readmissions
• But it is critical the technology:
– Improve the processes
– Support the people involved
• Don’t use the “hot” new technology for its own sake.
• At the same time recognize that new technologies – like mobile
technology – are having an important impact
• Care coordination technologies are still immature
15Copyright 2015 Digital Collaboration Solutions, LLC6-3-15

16. Copyright 2015 Digital Collaboration Solutions, LLC 1611-Mar-15
How to create consistent, effective readmission
reductions strategies and tactics for different
service lines

17. Service Line Requirements
Different services have different post-acute requirements and
organizations
• Orthopedics is often very structured
– Treatment plans tend to be similar
– Orthopedics has different post-acute providers – like
physical therapy
• Cardiology is highly varied
– Broad range of diagnosis
– So care plans vary based on different patient needs
• COPD and PN are often co-morbidities in many services so
reducing readmissions is intertwined with care plan for primary
diagnosis
Transitions of care must take into account service lines and their
differences such as variants of processes.
Copyright 2015 Digital Collaboration Solutions, LLC 176-3-15

18. Understanding Service Line Needs
• Start with diagnosis subject to CMS
readmissions penalty
– AMI, HF, PN, COPD, THA, TKA
• Understand impact – by service line and
diagnosis
– Rate of readmissions
– Volume – hospitalizations and discharges
– Primary vs. secondary diagnosis
– Patient population characteristics – age,
co-morbidities, social-economic issues
– Severity of illness
– Impact on other measures – like MS-DRG
• Identify service line care team
– Typical treatment plans
– Post-acute providers
– Need for home care & family involvement
– Other resources required (e.g. home
oxygen)
18Copyright 2015 Digital Collaboration Solutions, LLC6-3-15
• Evaluate readiness for change
– Often varies by service
– Fit with current or past care transition
and readmission reduction program
– Employed vs. affiliated clinicians
– Owned vs. affiliated post-acute
institutions
– Relationships with post-acute
institutions
• Develop a priority list starting with “lowest
hanging fruit”

19. Copyright 2015 Digital Collaboration Solutions, LLC 1911-Mar-15
How to implement care team and management
dashboards to track clinical, financial, and outcome
success

20. Measures
• Unplanned 30 Day Readmissions
• Quality Based Payment Reforms (QBPR)
• Physician Quality Reporting Initiative (PQRI)
• Meaningful Use Clinical Quality Measures
(CQM)
• Hospital Acquired Conditions (HAC) Scores
• Press Ganey
• Joint Accreditation Commission
• CMS 30-day readmissions penalty
• Hospital Value Based Purchasing (HVBP)
• Medicare Spending per Beneficiary (MSPB)
• Hospital profitability
• Bad debt due to uninsured admissions and ER
visits
• Under reimbursed Medicare & Medicaid
• Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS)
• Patient Activation Measure®
(PAM)
Needed Data & Reports
• Readmission reduction
• Financial impact
• Service line impact
• Outcomes impact
• Patient satisfaction
• Quality scores
Care
Quality
Financial
Patient
Experience
20Copyright 2015 Digital Collaboration Solutions, LLC6-3-15

21. 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
216-3-15
Dashboard Should Include
• Executive summary of
readmission trends for all patient
populations
• Drill downs by hospitals, service
lines, nurse stations, physicians
down to patient detail
• 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.
Presentation at Healthcare Analytics Symposium July 14-16, 2014 by Gabriela Ramirez, PhD, MPH Corporate
Director, Enterprise Analytics, Clinical Analysis and Outcomes ORLANDO HEALTH
Dashboard Example

22. Dashboard Example – Summary Level
226-3-15
https://www.healthcatalyst.com/value-of-healthcare-dashboards

23. Dashboard Example – Transaction Level
23March 2015

24. Recommended Action Steps
Goals
• Analyze the data on readmissions and transitions of care to
define target improvements
Process
• Understand current processes and develop new ones
People
• Put together a multi-organization and multi-discipline team
Technology
• Identify and implement technology that enables achieving
improvements
Copyright 2015 Digital Collaboration Solutions, LLC 246-3-15

25. Michael Levinger
President & CEO
Digital Collaboration Solutions
mlevinger@thinkdcs.com
V: 781.307.7898
Skype: mlevinger
Twitter: @mlevinger
Questions & Answers