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Guide to Reducing Medicare Readmissions, Vol. II
Healthcare Intelligence Network, June 2011, Pages: 120
Reimbursement models shaped by the Patient Protection and Affordable Care Act reward the reduction of fragmented care and unwarranted utilization. Much avoidable use of healthcare services is attributed to Medicare beneficiaries.
The Guide to Reducing Medicare Readmissions, Vol. II examines innovative interventions to reduce preventable admissions, rehospitalizations and ER visits by high-utilizing Medicare beneficiaries. This guide looks at four multidisciplinary collaborative interventions aimed at key factors fueling readmissions in this population — and that support an accountable care vision.
The profiled programs are designed to shore up the critical patient handoffs of hospital-to-home and hospital-to-skilled nursing facility (SNF); identify functional decline in the elderly (a harbinger of high utilization); and enlist the help of community pharmacists in improving medication adherence. They are the result of innovation by HealthCare Partners Medical Group, Fallon Community Health Plan, Summa Health System, Highmark, University of Pittsburgh School of Pharmacy and Rite Aid pharmacies.
This guide also provides a complete set of 2011 benchmarks in reducing readmissions from nearly 100 healthcare organizations.
Applying the best practices contained in the Guide to Reducing Medicare Readmissions, Vol. II will help organizations to improve the health of their populations, enhance the patient experience of care and rein in costs associated with avoidable utilization.
Executive Editor’s Note
Chapter 1: 2011 Benchmarks in Reducing Readmissions
Executive Summary
Key Findings
Methodology
Respondent Demographics
Analysis of Responses
Continued Emphasis on Hospital Discharge
New Challenge for 2010: Health Literacy a Top Barrier
The Hospital Perspective
The Long-Term Care Perspective
Future Programs
Comparison of 2009 Data to 2010 Data
Respondents in Their Own Words
Most Effective Readmission Reduction Strategy
Additional Comments on Reducing Hospital Readmissions
Conclusion
Responses to Questions
Part I: Overall Survey Responses
Figure 1: Respondents with Programs to Reduce Readmissions
Figure 2: Targeted Populations
Figure 3: Targeted Conditions
Figure 4: Patient Identification Tools
Figure 5: Readmission Prevention Strategies
Figure 6: Steps Performed at Hospital Discharge
Figure 7: Primary Program Responsibility
Figure 8: Program-Related Reduction in Hospital Readmissions
Figure 9: Program ROI
Figure 10: Reduced Payment for 30-Day Readmissions
Figure 11: Barriers to Reducing Readmission Rates
Figure 12: Planning Program in Next 12 Months
Figure 13: No Program: Barrier to Program Launch
Figure 14: Respondent Demographics
Part II: Responses from Hospitals
Figure 15: Hospitals: Targeted Populations
Figure 16: Hospitals: Targeted Conditions
Figure 17: Hospitals: Patient Identification Tools
Figure 18: Hospitals: Readmission Prevention Strategies
Figure 19: Hospitals: Steps Performed at Hospital Discharge
Figure 20: Hospitals: Primary Program Responsibility
Figure 21: Hospitals: Reduction in Hospital Readmissions
Figure 22: Hospitals: Program ROI
Figure 23: Hospitals: Reduced Payment for 30-Day Readmissions
Figure 24: Hospitals: Barriers to Reducing Readmissions
Part III: Responses from Long-Term Care
Figure 25: Long-term Care: Targeted Populations
Figure 26: Long-term Care: Targeted Conditions
Figure 27: Long-term Care: Patient Identification Tools
Figure 28: Long-term Care: Readmission Prevention Strategies
Figure 29: Long-term Care: Steps Performed at Discharge
Figure 30: Long-term Care: Primary Program Responsibility
Figure 31: Long-term Care: Reduction in Hospital Readmissions
Figure 32: Long-term Care: Program ROI
Figure 33: Longterm Care: Reduced Payment for 30-Day Readmits
Figure 34: Longterm Care: Barriers to Reducing Readmissions
Reducing Hospital Readmissions Benchmark Survey Tool
Chapter 2: Identifying Functional Decline
Identifying Functional Decline in Chronic Care Patients To Reduce Preventable Healthcare Utilization
Key Program Components
Using Referrals to Target Patients
Implementing a Collaborative Structure
Evolving Program Strategies
Addressing Socialization and Isolation
Administrative Coordination and Group Gatherings
Overcoming Program Challenges
Assessing Outcomes and Calculating ROI
Chapter 3: Improving SNF-Hospital Handoffs
Improving Transitions of Care Between Skilled Nursing Facilities and Hospitals
Developing a Care Coordination Network
Deciding on Developing a Care Coordination Network
Staffing and Implementing a Care Coordination Network
What Does the Care Coordination Network Accomplish
Barriers to Patient Care
Formulating Solutions to Barriers
Transfer Form for Post-Acute to the ED
Measuring Outcomes Between Facilities
Calculating Readmission Rate
Formation and Development of an ACO
Chapter 4: Multidisciplinary Post-Discharge Support
Reducing Readmissions Through Multi-Disciplinary Post-Discharge Support
Staffing the Discharge Team
Tools to Increase Efficiency, Reduce Hospitalization Rates
Using Predictive Modeling to Risk-Stratify
Care Transitions and the Continuum of Care
Centralizing Patient Needs
High Risk Programs and Clinics
Advanced Care Planning
Redesigning the Medical Home
Information Systems Connectivity
Keys for Success
Chapter 5: Improving Medication Adherence
Improving Medication Adherence Benchmarks Through Community Pharmacist Intervention
Identifying Top Issues for Medication Adherence
Pennsylvania Collaborative Project
Training Rite-Aid Pharmacists
ASPIRE: Providing Pharmacy Metrics
Surveys to Increase Medication Adherence
The Brief Intervention
Communicating Effectively with Patients
Secret Weapon: Patient Feedback
Utilizing Proficiency Checklists & Technical Assistance
Collaborating with Highmark
Chapter 6: Q&A
Tools to Identify High-Risk Patients
Predictive Modeling Tools
Diagnosing Dementia
Services for Non-Qualifying Patients
Telehealth Organizations: Collecting Patient Information
Engaging PCPs and Specialists
Number of Referrals per Month
Patient Engagement Strategies
Risk-Sharing Between Organizations
Patient Exclusion Criteria
Out- Versus In-Program Patients
Program Data Results
Reviewing Predictive Modeling
Medication Adherence and Therapy
Typical Home Visit
Screening Tools to Assess Depression
Working with Caregivers to Set Goals
Enhancing the Home Run Program
Sharing Information between SNF and Hospital
Physician Interaction with Patients in SNFs
Sharing Preferred Provider Information with Patients
Giving Patients a Provider Choice
SNF Specializations
CHF Transition Protocol
Future Program Enhancements
Selecting Patients for Intensive Post-Discharge Support
Supporting Medication Reconciliation
In-Home Transitions Versus Telephonic Management
Socioeconomic Status of Patients
Staffing the Home Care Model
Emphasizing Quality Over Scores
Home Care Manager Caseload
Ensuring Care at the Post-Discharge Clinic
Three Key Elements of Medication Adherence
Phase II: Targeting Patients
Private Consulting Area
Barriers to Protecting Patient Privacy
Defining Brief Intervention
Key Performance Indicators for Pharmacies
Expanding Outside the United States
Training Pharmacists
Driving Improvement by Data Sharing
Pharmacy Benefits
Measuring Adherence
Using Claims Data to Target Patients for Interventions
Prescription Wait Time
Payment of Pharmacists
Glossary
About the Speakers
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