PCORI and Stroke Outcomes

Presented to the Southeast Chapters of ARNApril 7, 2016

Wrightsville Beach, NC

Terrie Black DNP, MBA, CRRN, FAHA

Clinical Assistant Professor

University of Massachusetts, Amherst

Nurse Reviewer – The Joint Commission

Speaker Disclosure Statement

Terrie Black has no industry relationships to disclose

Learning Objectives

1.List 3 reasons for monitoring stroke outcomes from a quality perspective

2.Discuss factors impacting stroke outcomes

3.Describe an evidence-based care intervention for transitions to help reduce stroke readmissions

Why Monitor Stroke Outcomes?

Primary Incentives

• National Quality Strategy (NQS)

• Quality Indicator Reporting / Report cards / P4P

• Informed choice for consumers / Value based purchasing

• Accreditation / Certification status

• IMPACT Act

Other Pertinent Activities in the Field

• CMS Technical Expert Panels (TEP)

• Potentially Preventable Readmission / Discharge to Community

• Stroke Quality Measures Work Groups

• American Academy of Neurology (AAN)

• National Quality Forum (NQF)

National Quality Strategy: to improve the

quality of American healthcare

• Better care

• Healthy People/Healthy Communities

• Affordable care

Quality Indicators

• National Quality Forum (NQF) provides HHS and

CMS input regarding the quality & performance

measures currently under consideration for use in

federal programs

National Quality Strategy

Regulatory, Health Policy & Quality Cycle

NQF

CMS

Proposed RuleFinal Rule

Implementation

Comment on

Measures Under

Consideration

Comment on

Proposed Rule

(usually 60 day

period)

Comment on

Final Rule

(usually 60 day

period)

What constitutes Quality Care?

Institute of Medicine’s (IOM) report Crossing the Quality Chasm: A New Health System, for the 21st Century:

Safe Planned and managed to prevent harm to patients from medical or administrative errors.

Effective Based on scientific knowledge, and executed well to maximize their benefit.

Timely Patients receive needed transitions and consultative services without unnecessary delays.

Patient-centered Responsive to patient and family needs and preferences.

Efficient Limited to necessary referrals, and avoids duplication of services.

Equitable The availability and quality of transitions and referrals should not vary by the personal characteristics of patients.

IOM Report, 2001

Accreditation / Certification status

CARF

Joint Commission

• Accreditation

• Disease Specific Care (DSC) certification

Medicare Payment Advisory Commission

Quality Indicators

The Commission tracks three broad categories of IRF quality indicators:

• risk-adjusted facility-level change in motor and cognitive function during the IRF stay

• rates of discharge to the community and skilled nursing facilities

• rates of readmission

Between 2013 and 2014, there were small improvements in two measures of functional change and in the rate of discharge to the community

The rates of readmission remained unchanged

MedPAC report, 2016

Volume of IRF Stroke Cases

Quality of Care

We found that IRFs with the highest margins had a higher share of neurological cases and a lower share of stroke cases.

The consistent finding that high-margin IRFs have patients who are, on average, less severely ill in the acute care hospital but appear more functionally disabled upon admission to the IRF suggests the possibility that assessment and coding practices may contribute to greater revenues in some IRFs.

MedPAC report, 2016

Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014

The Deficit Reduction Act of 2005 directed CMS to develop a Medicare Payment Reform Demonstration that used standardized patient information to examine the consistency of payment incentives for Medicare populations treated in various settings.

The CARE Tool was designed to standardize assessment of patients’ medical, functional, cognitive, and social support status across acute and post-acute settings, including LTCHs, IRFs, SNFs, HHAs.

Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014

o The Secretary “shall require the submission of standardized clinical assessment data using assessments submitted to CMS by Long-Term Care Hospitals (LTCH), Skilled Nursing Facilities (SNF), Home Health Agencies (HHA) and Inpatient Rehabilitation Facilities (IRF)”

o The Act is interpreted as requiring this standardized data serve for multiple purposes including care coordination during transitions in care, discharge decision making, quality analysis, cross-setting quality comparison

o The Act conveys the inclusion of patient-centeredness in its requirements related to capturing patient preferences and goals

Standardized Patient Assessment Data

Data categories

• Functional status

• Cognitive function and mental status

• Special services, treatments, and interventions

• Medical conditions and co-morbidities

• Impairments

• Other categories required by the Secretary

Requirements for Reporting Quality Measures

• Functional status, cognitive function, and changes in function and cognitive function

• Skin integrity and changes in skin integrity

• Medication reconciliation

• Incidence of major falls

• Accurately communicate the existence of, and providing for, the transfer of health information and care preferences

Resource Use and Other Measures

• Total estimated Medicare spending per beneficiary

• Discharge to community

• Measures to reflect all-condition risk-adjusted potentially preventable hospital readmission rates

Stroke Quality Measures Work Group

American Academy of Neurology

• Diverse interdisciplinary group selected

• In Person Meeting in January 2016

• Conference calls in December 2015 / March 2016

• Measurement development, consensus and field review

• Quality measure for stroke population encompass from Emergency Department (ED) to Home Health

• Public Comment Period – coming soon!

National Quality Forum Work Group

• Diverse interdisciplinary group selected

• Measurement development, endorsement through approval process

• ARN represented

Potentially Preventable Readmissions (PPR)

Technical Expert Panel convened by CMS

2 ARN members selected to serve on TEP

Clinical conditions determined as potentially preventable

Post Acute Care venues include: IRFs, SNFs, home health and LTCHs

For more information: www.cms.gov

Factors Impacting Stroke Outcomes

Barriers• Poor Transitions

• Lack of Communication

• Lack of Discharge Processes

• Lack of Follow Through

• Misguided Education

• High Readmission Rates

Facilitators• Patient / Family Engagement

• Communication

• Seamless Transitions

Barriers to stroke care transitions

Barriers to effective care transitions are often categorized into 3 domains:

• The Clinician

• The Patient

• The Healthcare Delivery System

(Coleman, 2003; Greenwald &

Jack, 2009; Greenwald, Denham

& Jack, 2007).

Transitions for Stroke Patients Are Not Always Linear

Acute Rehab Home

Transitions for Stroke Patients

Outpatient

ED IRF Home

Health

SNF

LTCH

Acute

Definitions

Centers for Medicare & Medicaid Services (CMS) defines a transition of care as:

The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.

These transitions place patients at heightened risk of adverse events. Important information can be lost or miscommunicated as responsibility is given to new parties.

Definitions

American Geriatrics Society defines a transition of care as:

“a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location” (Coleman & Boult, 2003, p. 556)

Naylor describes it as:

wide-ranging activities which are time-limited to promote continuity of care across settings.(Naylor et al., 2011)

Transitions of Care: Barrier

May be fragmented, disorganized, guided by factors unrelated to quality of care or patient outcomes

Do not always promote utilization of clinicians skilled in advocating on behalf of the best interests of patients and their families

Can be confusing for patients and families

Failure to determine the appropriate site of care leads to higher hospital readmissions

Transitions of Care: Barrier

Patients and families are frustrated by fragmented “silos” in health care

Poor hand-offs lead to delays and miscommunications in care that may be dangerous or cause errors

There is enormous waste associated with unnecessary referrals, duplicate testing, unwanted and unnecessary specialist to specialist referral

Rehabilitation nursing care / practice will be more rewarding if we ensure a good transition

Readmissions: Barrier

The cost of readmissions is estimated to account for approximately $12 billion of healthcare costs annually

Approximately 75% of readmissions determined to be avoidable (Hansen, Young, Hinami, Leung &

Williams, 2011)

Evidence suggests that by using a coordinated and systematic approach to care transitions, readmissions to acute care can be reduced (Coleman & Berenson, 2004; Huffman, 2005;

Greenwald, Denham & Jack, 2007; Greenwald & Jack, 2009; Jencks, Williams & Coleman, 2009; Miller et al., 2010; Lavizzo-Mourey, 2013; Camicia et al., 2014)

Readmissions: Barrier

Rates of readmission are related to quality of care, particularly in the transition from the hospital to the next care setting.

Elevated risk-adjusted readmission rates are indicators that there are opportunities for improvements in patient care and transitions of care.

CMS hopes to reduce IRF readmission rates, improve patient safety and quality of care.

Reference -- http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/Downloads/DRAFT-

Specifications-for-the-Proposed-All-Cause-Unplanned-30-day-Post-IRF-Discharge-Readmission-Measure.pdf

Key Components

Four themes of interventions in the literature to reduce readmissions include:

Discharge planning protocols

Comprehensive assessments

Discharge support arrangements

Educational interventions

Parker et al.

(2002)

Predictors of Stroke Readmission

Prospective study, n = 674 over 11 rehab sites

Readmitted within 3 months of discharge

Functional status, depressive symptoms, and social support were important predictors of hospital readmission

Ottenbacher et al., 2012

Readmissions for Stroke

Thirty-day readmission rates for the 6 largest impairment categories receiving inpatient rehabilitation

30-day readmission rates ranged from 5.8% to 18.8% depending on impairment group

Stroke n=155 476; readmission rate of 12.7%

Approximately 50% of patients rehospitalized within the 30-day period were readmitted within 11 days of discharge

Ottenbacher et al., 2014

Top Reasons for Readmissions for Stroke

RIC 01 – Stroke

• Falls

• Urinary tract infections (UTIs)

• Another Stroke

• Pneumonia

• Dehydration

30 Day Readmit (Stroke)

• 2012: 5.9%

• 2013: 6.9%

• 2014: 7.0%

• 2015: 6.0%

Source: MedTel

Outcomes, LLC

Acute Care Transfers (ACTs)

Can impact outcomes

National data benchmarks vary

Variables predictive of ACTs include:

• Functional status

• Enteral feedings

• Depression

• Later admission times

Chung et al., (2012); Faulk et al., (2013); Hoyer et

al., (2013); Roberts et al., (2014)

Key Components: Facilitator

Evidence suggests a coordinated transition intervention focusing on the patient and family, including specific discharge instructions and active patient engagement through coaching can be cost effective while reducing the number of readmissions. Post discharge, follow up contact along with provider continuity is equally important.

(Coleman & Berenson, 2004; Lutz, 2004; Huffman, 2005; Greenwald,

Denham & Jack, 2007;Balaban, Weissman, Samuel & Woolhandler,

2008; Jack et al., 2009; Greenwald & Jack, 2009; Jencks, Williams &

Coleman, 2009; Miller et al., 2010)

Key Components: Facilitator

Key elements identified in the literature as being essential to successful and efficient transitions include active patient engagement, coordination of care and services and education on medication, equipment and follow-up care

(Coleman & Berenson, 2004; Lutz, 2004; Huffman, 2005; Greenwald,

Denham & Jack, 2007;Balaban, Weissman, Samuel & Woolhandler,

2008; Jack et al., 2009; Greenwald & Jack, 2009; Jencks, Williams &

Coleman, 2009; Miller et al., 2010)

Provider-patient communication: Facilitator

Essential elements - Engaged Communication

Having open discussion

Gathering information

Understanding the patient’s perspective

Sharing information

Reaching agreement on problems and plans

Providing closure (Dean, et al., 2014)

Patient Engagement: Facilitator

The Joint Commission, 2016

Guiding Principles

Post-hospitalization placements must first and foremost be based on patients’ clinical needs

Discharge planning tools must be designed to incorporate the medical judgment of treating physicians and other clinicians

Discharge planning tools must be administratively feasible and not add to current administrative burden

American Hospital Association in

collaboration with

Dobson DaVanzo & Associates, LLC,

January 2015

Guiding Principles (cont)

Discharge planning tools should provide information that helps clinicians optimize patient health

Standard information about the patient can be collected by tools with different design structures, reduce variation in post-acute placement, and assist in reducing readmissions

American Hospital Association in

collaboration with

Dobson DaVanzo & Associates,

LLC, January 2015

EVIDENCE-BASED CARE INTERVENTION PROJECT

Purpose of project

The purpose of the project was to implement and evaluate an evidence-based checklist targeted to improve the transition of care in stroke patients discharged home from inpatient rehabilitation.

Quality improvement

The initiative was targeted to reduce readmissions for stroke patients discharged home from inpatient rehabilitation

The intervention used a guided checklist to ensure a safe, coordinated discharge

The checklist encompasses elements identified in the literature as being critical to successful transitions including active patient engagement, coordination of care and services and education on medication, equipment and follow-up care

IRF unit within a large, academic medical center

Theoretical Model

Lewin’s Theory of Change was selected for the theoretical model for this project. The theory is built on the premise of 3 stages: Unfreezing, Moving, Refreezing. Both restraining and driving forces impact change (Lewin, 1951).

Evidence based checklist

Discharge Transition Checklist for Stroke Patients CMG_________ Please complete for ALL stroke rehabilitation patients discharged home Checklist for Discharge Transition to Rehab/Home Date / Initials ___________Review discharge instructions with patient ___________Have patient complete “teach back” of discharge instructions __________ Reconcile medications __________ Obtain medication prescriptions for patient from provider __________ Order all discharge equipment __________ Arrange for follow-up services such as home care, Outpatient Therapy, etc. ___________Schedule follow-up appointment with Primary Care Physician/Others as indicated ___________ Schedule follow-up lab work, if any __________ Provide individualized Home Exercise/Activity program to patient, if applicable ___________Provide listing of community resources such as Support Group, etc. ___________Provide copy of Home Evaluation results with recommendations, if applicable

Reason Item(s) Not Done: MUST CODE EACH ABOVE ITEM NOT COMPLETED 1 ---- Not applicable or not needed 2 ---- Patient Refused 3 ---- Patient Preference (to complete task or appointment) 4 ---- Other (please explain)

DONE BY MEDTEL OUTCOMES ONLY: __________ Conduct follow-up phone call: Follow-Up Phone Call Done by MedTel Outcomes

Evidence Used for Creation of Checklist: Coleman, E., Parry, C., Chalmers, S., & Min, S. (2006),

Hansen, L., Young, R., Hinami, K., Leung, A., & Williams, M. (2011), Miller et al., (2010).

Results

The checklist was utilized on a sample of twenty (n = 20) patients (11 men & 9 women) with stroke who completed rehabilitation and were discharged home.

The largest Case Mix Group (CMG) represented was 0110 (n = 7).

Thirteen patients (65%) had no tiered comorbidities.

All checklists were completed with no missing data.

At the time of follow-up by MedTel Outcomes, LLC only one patient had experienced a 30 day readmission to acute care.

Conclusion / Practice Implications

Preliminary findings of the project suggest the checklist was effective in reducing readmissions for the stroke rehabilitation population discharged home.

The evidence-based checklist can easily be implemented in other rehabilitation settings; however, it will need to be tested and validated for other diagnoses in the rehabilitation population in order to fully determine its effectiveness.

Environmental Scan & Assessment

What are YOUR best practices for ensuring quality stroke outcomes?

Patient / Family Engagement

• What is your process for ensuring this?

• How do you identify stroke patients at risk?

• What is the process for assessing the patient’s living situation post discharge?

What is the process for communicating patient information to the next setting/level of care?

How do you share information with patient’s primary care physician?

Environmental Scan / Assessment

What is the process for providing education and discharge instructions to the patient?• Day of discharge?

• Discharge rounds?

• Audiotaped and made available for future reference?

• Information legible and in patient friendly format / language?

Medication Management / Reconciliation / Obtaining Medication• How do you ensure this?

Post Discharge Support• Do you provide this? How?

• Follow up telephone calls? When? By whom?

• Home visits?

ARN White Paper

ARN White Paper Recommendations

• Practice

• Policy

• Research

• Education

It is critical to ensure that THE PATIENT

RECEIVES THE RIGHT CARE AT THE

RIGHT TIME BY THE RIGHT PROVIDERS IN

THE RIGHT SETTING

PCORI: PATIENT CENTERED OUTCOMES RESEARCH INSTITUTE

PCORI Overview

PCORI: Patient Centered Outcomes Research Institute

Independent, non profit, non governmental organization authorized in 2010 by Congress as part of the Affordable Care Act (ACA)

Mission: help people make informed healthcare decisions and improve healthcare delivery and outcomes by producing and promoting high integrity, evidence-based information that comes from research guided by patients, caregivers and the broader healthcare community

Key objective: to determine which of the many healthcare options available to patients and those who care for them work best in particular circumstances

Reauthorization: needed for continued funding with “sunset date” of September 2019

PCORI

Overarching Strategic Goals

• Increase quantity, quality, and timeliness of research information

• Speed implementation and use of evidence

• Influence research funded by others

PCORI Ideals

• Usefulness

• Transparency

• Patient-centeredness

• Inclusiveness

• Evidence

National Priority Funding Areas

Assessment of Prevention, Diagnosis, and Treatment Options:Comparing the effectiveness and safety of alternative prevention, diagnosis, and treatment options to see which ones work best for different people with a particular health problem.

Improving Healthcare Systems: Comparing health system–level approaches to

improving access, supporting patient self-care, innovative use of health information technology, coordinating care for complex conditions, and deploying workforce effectively.

Communication and Dissemination Research: Comparing approaches to

providing comparative effectiveness research information, empowering people to ask for and use the information, and supporting shared decision making between patients and their providers.

Addressing Disparities: Identifying potential differences in prevention, diagnosis,

or treatment effectiveness, or preferred clinical outcomes across patient populations and the healthcare required to achieve best outcomes in each population.

Accelerating Patient-Centered Outcomes Research and Methodological Research: Improving the nation’s capacity to conduct patient-centered outcomes

research, by building data infrastructure, improving analytic methods, and training researchers, patients, and other stakeholders to participate in this research.

Patient-Centeredness vs. Patient Engagement

Patient-Centeredness

Does the project aim to answer questions or examine outcomes that matter to patients within the context of patient preferences?

Patient Engagement

Does the project include a well thought of plan of active engagement among scientists, patients, and stakeholders?

PCORI Scoring Grid

Lower score is better!

Two Examples: Addressing Disparities

Community Engagement for Early Recognition and Immediate Action in Stroke (CEERIAS)

Awarded in 2014

Budget: $1,415,270

http://www.pcori.org/research-results/2014/community-engagement-early-recognition-and-immediate-action-stroke-ceerias

ESRD and PPS

Primary outcomes were regarding cost analysis and the prospective payment system

Secondary data analysis

Claims data

No evidence of patient engagement or patient centeredness

No letters of support from any patients

Successful Applications

Clearly defined target population

Clearly defined comparators

Strong rationale for comparators

Past experience with recruitment of targeted population

Real world setting

At least 2 alternative approaches

Outcomes meaningful to patient

Financial incentives to participants / stakeholders

Provision of preliminary evidence of the potential for successful recruitment

Barriers to recruitment (identifying potential barriers and plan to overcome)

Successful strategies used in the past

Likely to improve current clinical practice

Engages patients and stakeholders throughout research process

Engaging with PCORI

Visit website: www.pcori.org

Subscribe to the PCORI newsletter

Suggest a PCORI question

Become a Merit Reviewer / Review applications

Participate in PCORI events and activities

• PCORI Conference: September 28 – 30, 2016 in Washington, DC

Attend a teleconference / webinar

Attend free, in person meeting offered by PCORI

Join an advisory panel

Become a PCORI Ambassador

PCORI Ambassador Program

Unites individuals and organizations around the patient centered research philosophy and approach

Help patients, organizations and other stakeholders to share with the community PCORI’s mission and values, participate as full partners in the research process and help ensure the sharing and use of information generated from PCORI funded projects.

Questions?

Email contact Info: Tblack@nursing.umass.edu