JAMA Report Finds Community Collaboration Key to Reducing Hospitalizations and Rehospitalizations

 Posted by on January 23, 2013  1 Response »  Tagged with: , , , , , , , , , , ,
Jan 232013
 
Portrait of Dr. Joanne Lynn

By Dr. Joanne Lynn

The latest issue of JAMA features our paper describing   an exciting and successful initiative from the Centers for Medicare and Medicaid Services (CMS) and fourteen of its quality improvement organizations (QIOs).  Grounded in quality improvement methodology—plan-do-study-act–this unusual project offers many insights for those aiming to reduce avoidable readmissions.  And its raises a number of important question about how we measure progress in reducing readmissions. (For more on that topic, see our earlier MediCaring blog, http://medicaring.org/2013/01/07/readmissions-count-should-cms-revise-its-calculations/ )

A Medicare patient’s ability to receive successful treatment during care transitions from one setting to another has a crucial effect on the overall cost and efficiency of the Medicare system. Errors in information transfer, care planning or community support can cause hospitalizations, rehospitalizations and unnecessary costs to the Medicare program.

This project involved a three-year, community-based effort to improve the care transition process for fee-for-service Medicare beneficiaries. Participating QIOs facilitated cooperation among providers, health care facilities, and social services programs, such as Area Agencies on Aging. They centered their efforts around each community’s unique needs.   QIOs worked with communities to understand their own particular causes of readmissions, and to implement appropriate, evidence-based models to address them.  Communities analyzed results of the intervention along the way, and changed course to stick with interventions most likely to work.

The results, when compared to 50 comparison communities, showed significant reductions in hospitalizations and rehospitalizations, both by an almost 6% average, saving Medicare $3 million in hospitalization costs per average community per year.

This correlation has already led to new national efforts such as Partnership for Patients and the Community-based Care Transitions Program. In addition, in the 10th Scope of Work, all 53 QIOs are leading community projects nationwide (so far, in more than 400 communities).

This paper may be the first time one of America’s leading medical journals has published a report based on QI methods. Doing so represents a profound change in the openness of American medicine to learn not only what works for a patient, but works for the delivery system, too.

To learn more about this complex project, you can visit www.altarum.org/QIOpaper , a special website developed by Altarum Institute, in cooperation with the Colorado Foundation for Medical Care (CFMC), which led the work. The site features background material, links to print and online materials from JAMA (including control charts from the 14 communities), a top-ten list, a clever infographic, and videos of the lead authors discussing major findings and lessons learned.

key words: quality improvement, care transitions, CMS, CFMC, Joanne Lynn, readmissions, community coalitions, JAMA

Learning from Reviewing Readmissions: Tools You Can Use

 Posted by on August 8, 2011  No Responses »  Tagged with: , , , , , , ,
Aug 082011
 
Woman Organizing Files

A colleague asked an important question: Which tools are best for reviewing causes of readmissions? Two examples, from Georgia and New Jersey, are attached to this posting; many others can be found at www.cfmc.org/caretransitions. Georgia’s form requires starting from a patient/family interview review, and does not pull much from the record of the hospitalization. New Jersey’s form starts from the other direction – all pulled from charts, with just the contact information that enables an interview if someone undertakes it.  Each has targeted a certain set of issues — clear plan, medications, teach-back, advance directives, social problems, and so on.  Although the two forms overlap on many targets, on others they do not.

NJ_Readmission Chart Review tool

NEW_GA ReadmissionWorksheet
The Institute for Healthcare Improvement (IHI) has developed another useful form, which can be found on page 88 at this URL: http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImprovingTransitionstoReduceAvoidableRehospitalizations.aspx.  It “feels” more succinct, because it is set up to do 5 readmissions at a time and to focus upon themes.  But it also requires a more insightful reviewer, one who has thought about what it is that makes for rapid readmissions and what might work to make transitions bette

One way to get started is to simply review just a few charts of people who were readmitted to the hospital with which you are most familiar, and see what you most wanted to learn. You might start with the IHI form and then try filling out the other two to see what additional elements you might consider. Call a few patients or families, or, if that is not appropriate, call the main attending physician in the community. Try to gain some insight from the perspectives of people involved.
Keep track of the time it takes to do this review.  If you can get someone to pull the charts, the work to this point will take about two or three hours. Of the time involved, what seemed most productive and what was most illuminating?

Then put together your own form, starting with whichever one is most suited and adding or deleting the elements to end up with the ones that you found to be most useful.  Test that form on another two or three records, perhaps asking a colleague to do those (to learn what instructions are needed and whether another perspective identifies other things that are very important to include.
My prediction would be that you’ll find some remarkable stories–people in fragile condition whose community doctors did not really know they were out of the hospital or doctors who were unfamiliar with the patient’s situation and medications; people who could not afford the treatment prescribed; and people who simply greatly misunderstood what they were to do. (I recall the patient who told me about having to eat fresh vegetables for his heart – whereupon he opened a fresh can of peas every day!) Those stories will greatly help you galvanize the will to move ahead.  And you’ll have a process and form that you can persuade the quality improvement team at each hospital to do: Perhaps at large hospitals, five each week for four weeks and at small hospitals, five in the month.  Within a month, you’d have enough data and stories to build the endeavor, and continuing to collect the data provides rapid feedback about progress. Pick a lead intervention or two and get it tested and underway!

You are likely to find a certain sense of chaos– that there is a lot of “catch as catch can” processing with thorough unreliability on all sides. If this is the case, your coalition might well work on standardizing the process simply so that it is reliable.  You may find that the issues affecting the frail elders are different from those affecting younger populations– more complexity and fragility in the elders and more lack of access or barriers arising from mental illness in the younger.  Whatever you find, this is the “root cause analysis” that you’ll need to decide priorities and to apply for CCTP funds.

 

Key words: root cause analysis, reviewing readmissions, discharge record review, quality improvement tools, CCTP funding

Care Transitions Workbook Now Online

 Posted by on July 22, 2011  No Responses »  Tagged with: , , , , ,
Jul 222011
 

Community coalitions can be an effective way to engage diverse stakeholders in achieving common goals. Establishing such coalitions to address problems in care transitions is likely to be an essential tool for ensuring that such transitions become routinely good. Shortcomings in transitions today reflect larger, systemic problems that can best be addressed by community organizations working together. Indeed, no single organization will be able to resolve the broader issues, or work on its own to improve care transitions. It will truly take a village to make transitions safe, effective, and routine.

Many organizations around the country are looking to build coalitions that focus on care transitions. For many, similar experiences building community connections will enable them to establish and lead such coalitions. But many others will need guidance and support for learning the basics of coalition building, and for understanding issues specific to care transitions.

The Center for Eldercare and Advanced Illness has just posted a workbook, “It Takes a Village,” that offers  community leaders ideas and pointers for how to get started – and how to get going. It can be read in its entirety on the MediCaring.org website at: http://medicaring.org/it-takes-a-village/

The guide provides an overview of coalition building, ranging from recruiting partners to resolving governance. It describes what to consider when setting priorities for the work. Much of the text is devoted to issues of measurement – how will coalitions know that their work is improving patient care and experience? The guide explains how to usemeasurement to advance the coalition’s goals, how to find good data sources, and how to decide on what to measure. It provides very specific information on fixing care transitions, including how to fix the hospital discharge process and how to target rehospitalizations. Because care transitions have a major effect on very sick and vulnerable patients and families, the guide also includes ideas for how coalitions can coordinate their efforts with palliative care programs and services.

Community coalitions have proven effective at addressing diverse public health issues, from improving maternal and child health to creating healthier environments. Coalitions are defined by their focus on a particular issue, by their willingness to collaborate, and by their ability to bring a range of resources and perspectives to problem-solving. The guide offers a starting point – we hope you find it compelling and useful.

We’d like to hear about your experiences – what works for you and what doesn’t, where are your successes and what have been your challenges. Please join the dialogue by offering comments here, or emailing us at [email protected]. We look forward to hearing from you!

 

Key Words: care transitions, rehospitalization, readmission, quality improvement, coalition building, data sources, measurement

The Price is Right! Suggestions from current 3026 applicants

 Posted by on July 18, 2011  No Responses »  Tagged with: , , , , , , , , , ,
Jul 182011
 

As coalitions around the country move towards completing their application for Community-Based Care Transitions Program (CCTP; Section 3026 of the ACA), many teams will encounter difficulties in completing the proposal (see budget worksheet at: http://www.cms.gov/DemoProjectsEvalRpts/downloads/CCTP_ApplicationBudgetWorksheet.zip). Here are a few concerns and helpful suggestions raised during a recent meeting with potential 3026 applicants (from the IHI Triple Aim and ONC Beacon participants).

Regarding finance, the pricing is done on a per unit basis rather than a grant or contract basis that hospitals and community-based organizations (CBOs) might expect. Per unit pricing is just like any other Medicare service. Your program will submit a list of patients served each month and payment will go to the CBO. Some CBOs may find it helpful to confer with someone experienced in per unit pricing (i.e. experience in small business).

You will need to estimate what fixed and variable costs the intervention incurs, along with a reasonable estimation of the number of targeted beneficiaries eligible for your program. Having as precise an estimate as possible of this anticipated volume is crucial in arriving at the correct rate per eligible discharge. Keep in mind that having a lower than anticipated volume can lead to losses (because you incur fixed costs that you did not cover). The greater the volume, the more spread out your costs will be!

One way of improving your volume estimate is getting a good approximation for the acceptance rate into the program, which can be based on previous experience. Many programs initially have very high refusal rates, but usually you can decrease that over time. Although the budget worksheet does not include a place for an acceptance rate, you could modify your entry on Row B and then enter the explanation in an accompanying footnote.

“Not-to-exceed” budget is another aspect that might cause some confusion. Basically, your not-to-exceed budget is the money CMS will set aside for your entire program. Remember that the budget you are proposing is for five years. There might be changes in your program over this time period, only some of which you could predict. For example, you might be able to streamline your intervention over the first two years or you might predict an increase in patient volume. You could write in these predicted changes with a modification on Row M and then enter the explanation in an accompanying footnote. The aim of the program is to be integrated as a permanent part of Medicare, and to this end it allows and encourages learning throughout the program. However, the degree of flexibility is unknown.

Here is the link to the powerpoint presentation from the meeting on 7/12/11: http://medicaring.org/wp-content/uploads/2011/07/CCTP-Budget-Proposal.pptx

This is a collaborative effort and the above suggestions would not have been available if not for care transitions teams sharing their experience. So any comments, questions or modifications to our suggestions are encouraged. Please send your response to [email protected].

Key words: section 3026 applicants, Affordable Care Act (ACA), medicare, budget worksheet, financing, CCTP, care transitions, patient volume, rate per eligible beneficiary, IHI Triple Aim, ONC Beacon, community-based organizations

Tips on blended rate for 3026 applicants

 Posted by on July 11, 2011  No Responses »  Tagged with: , , , , , , , , ,
Jul 112011
 

Since many potential applicants are now figuring out how to use the financial template for Community-Based Care Transitions Program (CCTP) funding (as mentioned in our previous blog at: http://medicaring.org/2011/07/08/community-based-care-transitions-program-%e2%80%93-section-3026-funding/), here are some suggestions on mapping out a successful care transition model utilizing blended rate.  First, realize that all payments are to the Community-Based Organization, and must be paid “per eligible beneficiary.” Second, the worksheet provided by CMS must be used to convey the proposed blended rate (the worksheet can be found at: http://www.cms.gov/DemoProjectsEvalRpts/downloads/CCTP_ApplicationBudgetWorksheet.zip). You’ll need to have enough experience in providing care transition services to estimate your population and costs in order to be successful in getting the funding.

Some applicants might want to focus on a particular illness or transition type (e.g., to Skilled Nursing Facilities), but we would encourage you to consider taking all Medicare fee-for-service discharges, but then using a stratified model to deliver services and estimate financials. Using just one intervention on all patients (e.g., the Care Transitions Intervention at Dr. Coleman’s site at: http://www.caretransitions.org) will meet the terms of the solicitation. However, a more sustainable model seems to have you divide the target population into three groups: low-complexity transitions, medium-complexity transitions and high-complexity transitions. Then, estimate the N, the acceptance rate, and the total costs for each of the three populations over a year.  Remember that CMS has said that initial training of staff and trips to meetings in Baltimore are not included in the budget (they must be covered from other funds or from indirects).

If a community finds it appealing to stratify as we suggest, then the blended rate is set by the number of people in the population segment, the likely complete refusal rate, and the costs of serving this population. In order to be effective, you will want to drive down the refusal rate wherever possible, and again, experience will be helpful.

One possibility for increasing patient compliance is by creating a patient-centered and patient-friendly intervention by improving cultural competency of all staff workers. Getting endorsement of relevant community leaders could also help mitigate refusal rate. We also recommend incorporating maximum family input to optimize care transitions, and thereby, reducing not only avoidable hospital readmissions but also generating Medicare savings.

This piece was written in collaboration with Dr. Joanne Lynn.

 

We are very interested in your experience and thoughts – and in some real examples to share.  Please respond to this blog, or send along info to [email protected].

Key words: care transitions, blended rate, Medicare savings, 3026, Coleman model, hospital readmissions

Community-Based Care Transitions Program – Section 3026 funding

 Posted by on July 8, 2011  No Responses »  Tagged with: , , , , , , , , , , , ,
Jul 082011
 

Despite widespread interest in the $500 million budget allotted for Community-Based Care Transitions Program (CCTP) under the Affordable Care Act, many stakeholders are confused about the exact nature of the program. What does it aim to do? Who is eligible to apply for the funds?

Aim: CCTP aims to improve the reliability and effectiveness of care transitions as evidenced by reducing hospital readmissions. CCTP participants are paid to improve services targeted fee-for-service Medicare beneficiaries, the population requiring the most frequent care transitions. The backbone of the program in most places will be cooperation of service providers in a geographic community, since the participation and engagement of many stakeholders who share in the care of the area’s patients appears to be essential for sustained excellence.

Eligibility: To be eligible for funding, every applicant must have a minimum of one Community-Based Organization (CBO) and one hospital. While a hospital on CMS’s list of high readmission hospitals by state can lead a proposal, the payment will still go to the CBO, making lead authorship rather trivial (the CMS list can be found at: http://www.cms.gov/DemoProjectsEvalRpts/downloads/CCTP_FourthQuartileHospsbyState.pdf). Priority will be given to eligible entities participating in programs run by the Administration on Aging (AoA), or that serve the medically underserved, small communities, or rural areas.

Financing: Foremost, this is not a grant! Payment is based on a blended rate proposed in the response to the solicitation, paid “per eligible discharge” and heavily based on the type of intervention. The blended rate can reflect different costs for different categories of patients and can include such elements as ongoing supervision, monitoring, administrative costs, and so on. Most important, however, it does not include initial training: Sites must have some previous experience with care transitions, so they must have paid for initial training. CMS payment also cannot directly support travel expenses for attending the required meetings in Baltimore (the cost of this must come from some other source).

Applicants are required to use the worksheet provided by CMS (for a link to the worksheet see: http://www.cms.gov/DemoProjectsEvalRpts/downloads/CCTP_ApplicationBudgetWorksheet.zip). No payments will be made more than once in 6 months for each beneficiary. In other words, CMS will not pay for re-treatment of patients for whom first efforts to prevent rehospitalization failed. Keep in mind that, although the program will run for 5 years, the initial award is only for 2 years, with possibility of renewal annually thereafter.

Intervention: CCTP interventions must target Medicare beneficiaries who are at high-risk for readmissions, based on criteria provided by HHS, or for substandard care post-hospitalization. Interventions cannot duplicate already required services. You must be willing to participate in collaborative learning and redesign (including data collection). Finally, and not surprisingly, your intervention must save money overall, and show savings within two years. You can find a list of evidenced-based interventions at: http://www.amda.com/advocacy/Attachment_j-16.pdf

CMS’s measures so far include:

Outcome measures

  1. 30-d Risk-adjusted all-cause readmission rate (currently under development)
  2. 30-d unadjusted all cause readmission rate
  3. 30-d risk-adjusted AMI, HF, and Pneu readmissions

Process measures

  1. PCP follow-up within 7 days of hospital discharge
  2. PCP follow-up within 30 days of hospital discharge

“HCAHP items” – (note – includes more than HCAHPS)

  1. HCAHPS on medication info
  2. HCAHPS on discharge info
  3. Care Transitions Measure (3 – item, see http://www.caretransitions.org/documents/CTM3Specs0807.pdf)
  4. Patient Activation Measure (13-item, see    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361231/table/tbl1/)

 

Note: There are some areas where the solicitation is unclear or internally inconsistent. You should stay abreast of updated FAQs by subscribing to the email list at: https://service.govdelivery.com/service/subscribe.html?code=USCMS_626

Key words: hospital readmission, care transitions, 3026 funding, evidence-based intervenitons, patient activation measure, budget worksheet, financing, medicare beneficiaries, payment rate, CMS

Care Transitions Measurement 101

 Posted by on May 17, 2011  No Responses »  Tagged with: , , , , , , , , , ,
May 172011
 

Many improvement teams have real problems with measuring their progress – some never get around to measuring, and some never do anything else!  This presentation was set for the communities funded under the Beacon initiatives that are working to bring information exchange to care transitions, but you’ll find the pointers applicable to any intervention that your community might try.

You can download a PowerPoint presentation by clicking the following link:

caretransitionsmeasuresprimer (PowerPoint presentation)

Keywords: Beacon communities, care transitions, reasonable skeptic test, ten units of energy test, sure audience test, rehospitalization, best practices, Medicare, good care plans, near misses, targeting, nursing home residents, mentally ill, delirious, frail elderly, homeless, ESRD,  ”revolving door” patients, case reviews, Care Transitions Measure, avoidable readmission, HCAHPS, discharge planning, denominator problems, numerator problems