From Channeling to GRACE: Approaching Reduction in Readmissions
and Adverse Drug Events
Michael Wasserman, MD, CMDExecutive Director, Care Continuum
Health Services Advisory GroupSeptember 15, 2016
Quality Improvement Marathon
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Today’s Objectives
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Examine the Focus on Hospital
Readmissions
Review Medication Safety and
Adverse Drug Events (ADEs)
Discuss Care Coordination
Models
Medicare Spending
Hospitals 41₵
Pharmaceuticals 16₵
Medicare
$632 billion
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Contra Costa County ProgressAll-Cause, 30-Day Readmission Rate
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17.0%
2013
16.3%
2014
17.1%
2015
The ASAT data file representing calendar years (CYs) 2013–2015 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.
Group Discharged To Discharges ReadmissionsReadmission
Rate
Contra
Costa
Home 9,019 1,409 15.6%
Skilled Nursing
Facility (SNF)4,521 886 19.6%
Home Health
Agency (HHA)4,195 801 19.1%
Hospice 585 11 1.9%
Other 838 175 20.9%
Total 19,158 3,282 17.1%
State Total 724,776 134,427 18.5%
Contra Costa County Readmission Rate:Q1 2015–Q4 2015
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The ASAT data file representing Q1 2015 to Q4 2015 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.
Lost in Transition: Can We Find Our Way?
7 Creative Commons/Pixabay. http://pixabay.com/en/man-152231/
Doing things the same
way…
…will NOT reduce
readmissions.
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Hospital Readmission
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Internal Medicine vs. Geriatrics
Classic Internal Medicine Geriatric Medicine
Diagnosis Function
Treatment Quality of Life
Cure
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Evidence-based
medicine!
Evidence-based
medicine!
Evidence-based
medicine!
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Evidence-based
medicine!
Evidence-based
medicine!
Evidence-based
medicine!
Evidence-based
medicine!Evidence-
based medicine!
Hospital Complications
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Delirium
Infections
Adverse Drug Events
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)
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Just consider...
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How Do We Get to This Age?
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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 GullifordJAGS, 64:1,425–1,431, 2016
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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 RichJAGS, 64:1,475– 1,479, 2016
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Adverse Drug Events: National Picture
18Sources: Institute of Medicine, Agency for Healthcare Research and Quality and the National Institute of Health
AND
In older adultsADEs account for 30%
of emergency hospitalizations or readmissions
AgingMedicarepopulation
+
Increased need for medication safety and coordination of all
care transitions
+Visiting multiple providers =
multiple medications
Adverse Drug Events(ADEs) account for
1 3outof
Prolong hospital stays by
1.7 4.6to days
2MILLION/year
hospital stays affected
of all hospital adverse events
Moving from Volume…
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…To Value
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Bundled Payments
Accountable Care Organizations
Medicare Spending Per Beneficiary
Value-Based Purchasing
Penalties
CMS Support of Health Care Delivery System Reform (DSR)
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Historical StateKey Characteristics
• Producer-centered• Incentives for volume• Unsustainable• Fragmented care
Systems and Policies• Fee-for-Service (FFS)
payment systems
Evolving Future StateKey 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
Centers for Medicare & Medicaid Services
Result: Better care, smarter spending, and healthier people
© Eric A. Coleman, MD, MPH
Our healthcare system operates in “silos,” is setting centered―notpatient centered―and is incapable of reciprocal operation between organizations.
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Fragmentation
• Patients and families navigating unassisted
• Poor communication and lack of accountability
• Lack of quality improvement (QI)Infrastructure
24A Shih, K Davis, SC Schoenbaum, et al, The Commonwealth Fund Organizing the U.S. health
care Delivery System for high Performance. August 2008
Channeling Study
• Increased formal community service use
• Reduced unmet needs
• Improved satisfaction with life
• No reduction in nursing home use or costs
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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
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Integration of Care Coordination Into Primary Care
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We Don’t Need to Reinvent the Wheel
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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
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34%
29%
44%
53%
22%
HOSPITAL
HOSPITAL
EMERGENCY
SUB-ACUTE
SUB-ACUTE
GRACE Homebound Study
admissions
bed days
admissions
bed days
visits
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Acute Care of the Elderly (ACE) Unit
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Geriatric Approach to Care
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Geriatric Medicine (GeriMed) Philosophy of Care
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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.
GeriMed Philosophy of Care (cont.)
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Be sensitive to the patient’s financial condition.
Promote wellness.
Listen and communicate effectively.
Use a patient-centered approach to care and customer-focused approach to service.
Promote optimism and hope realistically.
Use a team approach to care.
ACE Unit Meta-Analysis
• Fewer falls (risk ratio [RR] = 0.51, 95% confidence interval [CI] = 0.29–0.88)
• Less delirium (RR = 0.73, 95% CI = 0.61–0.88)
• Less functional decline at discharge from baseline (RR = 0.87, 95% CI = 0.78–0.97)
• 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 = 0.68–0.99)
• Lower costs (WMD = $245.80, 95% CI = $446.23 to $45.38)
• More discharges to home (RR = 1.05, 95% CI = 1.01–1.10)
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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
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Where Have all the Geriatricians Gone?
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>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
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
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Coming to the End
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Cost of Preventable Adverse Events
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Fast Facts for Medication Management
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1Understanding and Improving Medication Reconciliation Between Hospitals and Nursing Homes—Patient Safety Risk and Cost in Care Transitions—Stratis Health http://www.stratishealth.org/documents/Stratis-Health-medication-reconciliation-white-paper-2014.pdf.
Fast Facts for Medication Management (cont.)
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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-06-11-00370. Pages 17-18. 2 http://www.stratishealth.org/documents/Stratis-Health-medication-reconciliation-white-paper-2014.pdf, table 1, page 4.
Business Case Study: Inappropriate Dosing
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• 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?
Take a guess on time and cost to
correct this issue.
Business Case Study: Workflow and Associated Costs
Task Profession Time Hourly Wage
Pharmacy consultant reviews order and identifies inappropriate dose
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 PharmacistPharm Tech
0.25 0.50
$56.01 $14.83
Nursing home processes the new order Unit ClerkRN
0.25 0.25
$16.80 $33.13
Nursing home destroys old medication RNRN witness
0.50 0.25
$33.13$33.13
3 hours/$108.47. That’s 1 patient and 1 medication!
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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%
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HSAG: Your Partner in Healthcare Quality
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• 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.
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
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Department of Health & Human
Services
CMS
HSAG’s QIN-QIO Responsibility
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HSAG is the Medicare QIN-QIO for California, Arizona, Florida, Ohio, and the U.S. Virgin Islands.
Nearly 25 percent of the nation’s Medicare beneficiaries
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Putting It All Together
Building Community Coalitions
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Community Model for Improvement
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Sustainable Community
• Engage community partners
• Create leadership structure
• Develop coalition charter
• Conduct root cause analysis
• Select interventions
• Evaluate interventions
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California Care Coordination Communities
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
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Questions
?????
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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.3-09082016-01
CMS Disclaimer
