Marsha Regenstein, PhD - PowerPoint Presentation

Slide1

Marsha Regenstein, PhDGeorge Washington University

Reducing Medicaid Readmissions:

Case Studies of Safety Net HospitalsSlide2

Background

1 in 5 individuals admitted to the hospital is readmitted within 6 months

Many readmissions considered avoidable and

marker for poor quality within the hospital setting, in ambulatory practices and across transitions in careSpending for Medicare readmissions alone accounted for $17 billion in 2004 (Jencks 2009)Reducing hospital readmissions is key approach to curbing health care costs and improving quality and patient experience

2Slide3

Background

Efforts to reduce readmissions have focused primarily on Medicare patients and the general population

Medicaid patients also experience readmissions, sometimes at rates comparable to Medicare patients

As states face continued budget shortfalls, many looking to follow Medicare’s lead to reduce unnecessary readmissions3Slide4

background

Few resources exist to inform initiatives to reduce readmissions among Medicaid beneficiaries

Medicaid patients

face unique challenges: Limited access to primary and specialty careDifficulties obtaining medicationD

iscontinuous

insurance

coverage

L

ess

family and social support Language barriersLow health literacyHousing instability Inadequate transportationPoorer health statusHigher rates of chronic disease and mental illness

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Project goals

Identify the critical factors uniquely contributing to hospital readmissions among Medicaid beneficiaries

Create and/or

adapt existing tools and strategies to reduce readmissions that specifically address the unique challenges of Medicaid patients5Slide6

Project components

Convene Advisory Panel

Recruit States and Hospitals

Research Factors Contributing to Medicaid readmissions through:Literature ReviewSite Visits InterviewsAnalysis of Medicaid dataModify existing strategies and/or develop new onesTest feasibility of implementing proposed strategies

Refine strategies and tools based on hospital feedback

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Project advisory panel

Medicaid Medical Directors

Judy

Zerzan, Colorado MedicaidDavid Kelley, Pennsylvania MedicaidMedicaid Managed Care Plan Medical DirectorPaul Mendis, Neighborhood Health Plan (MA)Safety Net Hospital Representatives

Bruce Siegel

and

Jill

Steinbruegge

,

National Association of Public HospitalsRochelle Ayala, Memorial Regional Hospital (FL)Readmissions ResearchersTodd Gilmer, UC-San DiegoEric Coleman, The Care Transitions Program, Univ of CO-DenverDarren DeWalt, UNC-Chapel Hill

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Literature review

Conducted search in March

2012

Aim: To identify factors related to readmissions that are unique to Medicaid populations to inform efforts to reduce Medicaid readmissionsSearched using SCOPUS database from 1990-2012Keywords: “Medicaid AND readmission” and “Medicaid AND rehospitalization”Identified additional reports

and research briefs

for inclusion in the review through

Google

search and

expert

advice8Slide9

Literature review

Conceptual Model of the Determinants of Preventable Readmissions

Source:

Vest JR,

Gamm

LD, Oxford BA, Gonzalez MI,

Slawson

KM. Determinants of preventable readmissions in the

United

States: a systematic review. Implementation Science 2010; 5:88.9Slide10

Flow Diagram for Literature Review Process

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Literature review

Characteristics and Rates of Medicaid Readmissions:

30-day readmission rates ranging from 11 to 19%

Higher risk of readmission than privately-insured patients, lower risk than Medicare patientsRisk increases with number of chronic conditionsRepresent significant expense for state Medicaid programs:Patients with readmissions accounted for nearly half of total inpatient costs for Washington Medicaid in 2008-09Cost $1 billion/year in New York Medicaid

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Literature review

Literature focuses on

patients with mental health or substance abuse issues, who are often high utilizers of health care within the Medicaid

populationKey factors that increase risk of readmission among Medicaid patients:Medication noncomplianceUnstable post-discharge care environmentsSubstance abuse

comorbidities

Psychosis comorbidities

Medicaid payer status is itself a risk factor for readmission

Participation in a managed care program thought to affect hospital readmissions, but evidence is mixed

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case studies

State selection process:

Geographically diverse

Mix of managed care policiesHospital selection process:Safety net hospital with at least 22% of patients covered by Medicaid (top quartile of Medicaid use)Diversity of ownershipMix of experience with readmissions efforts

Affiliation with community providers

Process more difficult than anticipated

Medicaid readmissions not strong area of focus

Quality improvement interests often trumped by resource concerns

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Case studies

Site Visit Process

One-day meeting in summer 2012

Open-ended agenda including:Showcase of readmissions initiativesRoundtable discussionRepresentatives from quality improvement, emergency department, admitting department, case managers/care coordinators,

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Case studies: St. luke’s

, Sioux City, Iowa

Part of St. Luke’s Health System

Faith-based, not-for-profit health system 11 hospitals and related health services in the Kansas City area and surrounding regionFlagship hospital in Kansas City opened in 1882

Provided

more

than $20.9 million in

charity care, community benefit, other

uncompensated

care and taxes in 201115Slide16

Case studies: St. luke’s

, Sioux City, Iowa

Hospital information:

Staffs 160 beds11,202 admissions and 65,765 outpatient visits in 201130-day readmission rate: 11.9Payer mix for readmissions:24% Medicaid

41% Medicare

29%

Private

Top reasons for readmission:

CHF

COPDDiabetes50% of readmissions come from home health and nursing homes16Slide17

Case studies: St. luke’s

, Sioux City, Iowa

Initiatives to Reduce Readmissions:

Physician champion who reviews all readmissions each day and consults with departments to address issuesCollaboration with nursing homes and FQHCs to improve communicationDeveloped consistent teaching tools used at all facilitiesInform providers when their patients are readmitted

Schedule follow-up appointments within 48-72 hours

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Case studies: St. luke’s

, Sioux City, Iowa

Initiatives to Reduce Readmissions:

“360” review with all readmitted patients to understand what went wrongStaff use of care map which shows what should happen each day as a patient progresses through treatment

CHF

tele

-management program

12 Care coordinators

Screen for “home situation” upon admission

Call to check on patients within 48-72 hours18Slide19

Case studies: St. luke’s

, Sioux City, Iowa

Key Challenges:

Medication reconciliation (no pharmacy on-site)Unwarranted admissions from nursing homesRepeat patients with mental health issues who don’t have acute needsCommunication between hospital and outside providers (PCPs, nursing homes, etc.)

Looking ahead: Plan for a virtual pharmacist who will review discharge records and provide medication

reconciliation

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Case studies: Harborview Medical center, Seattle, Washington

Academic

medical center o

wned by King County and managed by the University of WashingtonServes as the only Level 1 Adult and Pediatric Trauma and Burn Center for the states of Washington, Alaska, Montana and IdahoHas received numerous accolades for its commitment to serving the community and providing high-quality care

Provided $189

million in charity

care in 2011

Targets particularly

vulnerable populations,

such as: prisoners, mentally ill, persons with STDs, substance abusers, indigenous, LEP, and victims of domestic violence and sexual assault20Slide21

Case studies: Harborview Medical center, Seattle, Washington

Hospital Information

Staffs

413 beds, including 89 critical care and 66 psychiatric beds19,424 admissions and 65,515 ED visits in 201130-day readmission rate: 9.1%Medicaid: 13.5%Medicare 9.3%

Medicare and Medicaid patients account for 61 percent of readmissions:

Medicaid patients represent

23% of admissions and 30% of readmissions

Medicare patients represent 27% of admissions and 31% of readmissions

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Case studies: Harborview Medical center, Seattle, Washington

Hospital Initiatives to Reduce Readmissions:

Unit-based

discharge facilitator (UDF) program: 13 UDFs follow all admitted patients, providing coordination related to patients' different therapies, social work, financial counseling, nursing, discharge pharmacy, post hospital services, etcMonitor patients using electronic real-time “at-a-glance” white board with indicates a series of steps that must be completed prior to discharge

Enhanced care management for high-utilizers: Very proactive program for extremely vulnerable, disengaged patients

Patients must have mental health or substance issue

Use harm reduction approach

Key component is finding stable housing

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Case studies: Harborview Medical center, Seattle, Washington

Hospital Initiatives to Reduce Readmissions:

Respite and Health Care for the Homeless: Extensive shelters and health care services for the homeless in downtown Seattle

PCMH strategies: Data system to monitor inpatients and ED patients to ensure they have a PCP or connect them with one if they don't and to let PCPs know when their patients are in the hospitalPost-discharge clinical pharmacist visit: primary care patients in the adult medicine clinic with medium to high risk of readmission receive clinical pharmacist during inpatient stay for medication reconciliation, etc

.

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Case studies: Harborview Medical center, Seattle, Washington

Hospital Initiatives to Reduce Readmissions

:

Aftercare clinic: Provides follow-up PCP visits for patients who cannot get into other clinics within 2 weeks because they are fullConnects patients with PCP following aftercare visitSTAAR CHF project: Participated in State Action on Avoidable Rehospitalizations

(STAAR

) initiative focusing on heart failure readmissions

70% of CHF patients <65

Patients assessed for both social and clinical risk at intake and receive an action plan with prompts for assessing their health status

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Case studies: Harborview Medical center, Seattle, Washington

Key Challenges:

Being over capacity in many of their programs (enhanced case management, respite care, etc.)

Readmissions from skilled nursing facilitiesEffectively utilizing the wealth of data collected to improve care25Slide26

Case studies: Medical University of South Carolina (MUSC), Charleston

Academic medical center founded in 1824

700 beds

6 colleges that train approximately 2600 health care professionals per year32,672 admissions in 200826% Medicaid27% MedicareSite visit scheduled for later this month

Project will focus on pediatric asthma readmissions

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Early FINDINGS—impressions

Medicaid as a group is not often looked at separately

Efforts usually targeted to conditions rather than populations

When Medicaid population is targeted, tends to include uninsured as wellNot generally using standardized tools with Medicaid populationsHomegrown strategies particularly for Medicaid/uninsuredVery different approaches between 2 hospitals visited so far

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Next steps

Final Site Visit

Create and/or adapt strategies and tools tailored for Medicaid patients

Feasibility testing of strategies and tools with hospitalsRefine strategies and tools for widespread dissemination28Slide29

Suggested references

Boutwell

, A.E., Johnson, M.B., Rutherford, P., Watson, S.R.,

Vecchioni, N., Auerbach, B.S., Griswold, P., Noga, P., & Wagner, C. (2011). An early look at a four-state initiative to reduce avoidable hospital readmissions. Health Affairs, 30, 1272-1280.Bruen, B., Jensen, R., Riley, P., Lara, A. & Lu, X. (April 2011). Medicaid Cost Containment Options for Washington State.

George Washington University report for the Washington State Legislature and the Washington State Institute for Public Policy

.

Gilmer

, T. & Hamblin, A. (December 2010). Hospital Readmissions among Medicaid Beneficiaries with Disabilities: Identifying Targets of Opportunity.

New Jersey: Center for Health Care Strategies

.Jencks, S., Williams, M., & Coleman, E. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360, 1418-1428.Jiang, H.J. & Wier, L.M. (2010). All-cause hospital readmissions among non-elderly Medicaid patients, 2007 (HCUP Statistical Brief #89). Agency for Healthcare Research and Quality.

Raven, M. C., Doran, K. M.,

Kostrowski

, S., Gillespie, C. C., &

Elbel

, B. D. (2011). An Intervention to Improve Care and Reduce Costs for High-Risk Patients with Frequent Hospital Admissions: A Pilot Study.

BMC Health Services Research, 11

, 270

.

Raven, M. C., Carrier, E. R., Lee, J., Billings, J. C., Marr, M., &

Gourevitch

, M. N. (2012). Substance Use Treatment Barriers for Patients with Frequent Hospital Admissions

. Journal of Substance Abuse Treatment, 38

, 22-30

.

Vest

JR,

Gamm

LD, Oxford BA, Gonzalez MI,

Slawson

KM. Determinants of preventable readmissions in the

United

States: a systematic review. Implementation Science 2010; 5:88

.

Wier

, L.M., Barrett, M.L., Steiner, C., & Jiang, H.J. (June 2011). All-Cause Readmissions by Payer and Age, 2008 (HCUP Statistical Brief #115).

Agency for Healthcare Research and Quality

, Retrieved from:

http://www.hcup-us.ahrq.gov/reports/statbriefs/sb115.pdf

.

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