Designing Delivering WholePerson Transitional Care The Hospital Guide

Designing & Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing Medicaid Readmissions National Launch Webinar September 9, 2016

Our Speakers H. Joanna Jiang, Ph. D. Senior Social Scientist Agency for Healthcare Research and Quality Amy Boutwell, M. D. , M. P. P. President Collaborative Healthcare Strategies

Our Agenda • Introduction to the AHRQ Reducing Medicaid Readmissions Project • Testing and Evaluation of Version 1 of the Guide • Overview of The Hospital Guide to Reducing Medicaid Readmissions and the ASPIRE framework • Q&A welcome via chat

Objectives • Understand the purpose of the AHRQ Hospital Guide to Reducing Readmissions • Understand the focus on Medicaid as the catalyst for promoting “whole-person”care for all high-risk patients • Understand the Guide’s ASPIRE framework as intended to support a data-informed, strategic redesign of readmission reduction efforts

Why Medicaid? Source: Trends in Hospital Readmissions for Four High-Volume Conditions, 2009 -2013, HCUP Statistical Brief #196.

Nonmaternal Adult Medicaid Patients At High Risk of Readmission Source: All-Cause Readmissions by Payer and Age, 2009 -2013, HCUP Statistical Brief #199, AHRQ

Top 5 conditions with the largest number of readmissions Medicare • Congestive heart failure • Septicemia • Pneumonia • Chronic obstructive pulmonary diseases • Cardiac dysrhythmias Private insurance • Cancer chemotherapy, radiotherapy • Mood disorders • Complications of surgical procedures or medical care • Complication of device, implant or graft • Septicemia (except in labor) Medicaid • Mood disorders • Schizophrenia & other psychotic disorders • Diabetes w/ complications • Complications of pregnancy • Alcohol-related disorders Uninsured • Mood disorders • Alcohol-related disorders • Diabetes w/ complications • Pancreatic disorders (not diabetes) • Skin and subcutaneous tissue infections Source: HCUP Statistical Brief #172: Conditions With the Largest Number of Adult Hospital Readmissions by Payer, 2011

AHRQ Reducing Medicaid Readmissions Project • 2011 -2012: Identify factors at the patient, provider, and system levels that contribute to Medicaid readmissions • 2012 -2013: Explore whether the best practices to reduce readmissions apply to the Medicaid population as well • 2013 -2014: Create a guide for hospitals to increase awareness and address unique issues in reducing Medicaid readmissions (Version 1. 0, released in August 2014) • 2014 -2016: Test and evaluate the guide through dissemination, use in collaboratives, and direct implementation with safety net hospitals • 2016: Update and disseminate Version 2. 0 of the guide

Reducing Medicaid Readmissions Project Team Amy Boutwell, MD, MPP Collaborative Healthcare Strategies James Maxwell, Ph. D Angel Bourgoin, Ph. D Katie De. Angelis, MPH Sarah Genetti Michelle Savuto John Snow, Inc. H. Joanna Jiang, Ph. D Program Officer and Senior Social Scientist Agency for Healthcare Research and Quality

Acknowledgements Field Testing Hospitals • Northwest Hospital, Baltimore MD • St Agnes Hospital, Baltimore MD • Univ. of Maryland-Midtown Hospital, • • • Baltimore MD Presence St Mary-St Elizabeth, Chicago IL Norwegian American Hospital, Chicago IL St Bernard Hospital, Chicago IL Temple University Hospital, Philadelphia PA Baystate Medical Center, Springfield MA Olive View Medical Center, Sylmar CA University Health System, San Antonio TX Frederick Memorial Hospital, Frederick MD Huntsville Hospital, Huntsville AL Medical University of South Carolina, Charleston SC Partnering Organizations • Maryland Hospital Association and Virginia Health Quality Partners (Maryland QIO) • South Carolina Hospital Association and Carolinas Center for Medical Excellence (SC QIO) • Illinois Hospital Association and Telligen (IL QIO)

Acknowledgements Advisory Panels (2012 -2016) • Stephanie Calcasola, RN-BC, M. S. N. , • • • David Kelley, M. D. , M. P. A. , Pennsylvania Office of Medical Assistance Programs Baystate Health • Deborah Kilstein, J. D. , M. B. A. , Association of Judith Chamberlin, M. D. , Aetna Medicaid Community Affiliated Plans Larry Gage, J. D. , National Association of • Sarah Levin, M. D. , Contra Costa Health System Public Hospitals • Enrique Martinez-Vidal, M. P. P. , Academy. Health Sheryl Garland, M. H. A. , Virginia • Maureen Milligan, Ph. D. , Texas Health and Human Commonwealth University Services Commission Anne Gauthier, M. S. , National Academy for • Erica Murray, M. P. A. , California Association of Public State Health Policy Hospitals and Health Systems • Joseph Ouslander, M. D. , principal investigator, Liza Greenberg, RN, M. P. H. , Medicaid INTERACT Health Plans of America • Karen Rago, RN, M. P. A. , University of California, San Michael Hochman, MD. , Alta. Med Health Francisco Services • Jeff Richardson, M. B. A. , LCSW-C, Community of Wendy Jameson, M. P. H. , M. P. P. , California Behavioral Health Association of Maryland Health Care Safety Net Institute • Nancy Vecchioni, RN, M. S. N. , Michigan Peer Review Karen Joynt, M. D. , MPH. , Office of the Organization (retired) Assistant Secretary for Planning and • Bryan Weiner, Ph. D. , UNC Gillings School of Global Evaluation, Department of Health and Public Health Human Services

INSIGHTS FROM FIELD TESTING VERSION 1

Testing and Evaluation of Version 1 of the Guide • Analyzed stages of implementation based on implementation science & organizational change theory – – Knowledge Readiness Adoption Institutionalization • Eight domains of readmissions work 1. 2. 3. 4. 5. 6. 7. 8. Have a specific readmissions reduction goal Have a portfolio of readmission reduction strategies Collect and analyze quantitative data Collect and analyze qualitative data Implement standard hospital-based transitional care Implement enhanced services for high-risk patients Implement ED-based strategies Collaborate with cross-continuum partners

Adoption of Strategies - Results Knowledge= recognize value readiness = prepare to test adoption = at least 1 test institutionalization = hardwire Ø Baseline is first dark blue bar; mid-point (7 months) is medium blue Ø Most change occurred during mentored implementation coaching period Ø Most “Institutionalization” occurred after midpoint (7 -13 months)

Findings • High-volume Medicaid / safety net hospitals are willing and able to test multiple strategies to reduce readmissions • Change can occur quickly – Teams were able to recognize the need, prepare, test, and institutionalize a number of readmissionsrelated activities within the span of 13 months – 5 of 6 teams changed their baseline to endpoint activity dramatically • Change can occur in multiple domains in parallel – 3 or more of the 6 teams tested use of quantitative data, qualitative data, developing Medicaidrelevant cross-setting partnerships; improve inpatient care; deliver enhanced services – 4 of 6 teams consistently work with Medicaid-relevant cross setting partnerships, use qualitative data, implement strategies in the ED to reduce readmissions

Implementation Challenges Major challenges included: • Leadership turnover • Ability to run straightforward data analysis • Ability to produce monthly readmission data • Ability to interpret data to inform efforts • Preference for delivering targeted enhanced services rather than improving standard care processes • Lack of tracking intervention implementation

Feedback on the Guide • Very positive reactions to the relevance and utility of the Guide and Tools – The Guide – “For someone like me who walked in with very little idea of what to do, it was very helpful, because it is methodical and organizes an approach. We have worked the booklet here in a systematic way, and I think that is part of the reason we are having good results. ” – Hospital C – Portfolio Development Tool – “This tool assists me in putting our readmission reduction efforts on paper… We probably don’t take credit for the things we do every day, so this tool allows me to put things in perspective and present a total readmission package. ” – Hospital B • Recommendations for improvement – More actionable formats (e. g. slide templates that can be presented to senior management, work plans) – More guidance on coordinating who uses the tools and what should be done with the results

Table of Contents • Introduction • Why focus on Medicaid Readmissions? • How to Use This Guide • Analyze Your Data • Survey Your Current Readmission Reduction Efforts • Plan a Multi-Faceted Data-Informed Portfolio of Strategies • Implement Whole-Person Transitional Care for All • Reach Out to Collaborate With Cross. Continuum Providers • Enhance Services for High-Risk Patients

List of Tools The guide comes with 13 customizable tools to be used in hospital teams’ day-to-day operations. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Data Analysis Readmission Review Hospital Inventory Community Inventory Portfolio Design Operational Dashboard Portfolio Presentation Conditions of Participation Handout Whole-Person Transitional Care Planning Discharge Process Checklist Community Resource Guide Cross Continuum Collaboration ED Care Plan Examples

The ASPIRE Framework Analysis Reduce Medicaid Readmissions Action A • Analyze Your Data S • Survey Your Current Readmission Reduction Efforts P • Plan a Multi-faceted, Data-Informed Portfolio of Strategies I • Implement Whole-Person Transitional Care for All R • Reach Out and Collaborate with Cross-Continuum Providers E • Enhance Services for High-Risk Patients

WHY MEDICAID READMISSIONS?

6 Foundational Message from CMS • Reducing readmissions pays – or at least inaction hurts • Hospitals must improve standard “discharge planning” processes • Reducing readmissions is a cross-continuum effort • Attend to non-clinical needs for post-hospital supports & services • Shared learning is an valuable improvement tool • Reducing readmissions requires better data Ø All of this is true and helpful! Has it helped Medicaid patients?

Why Medicaid? • Medicaid patients have high readmission rates – Medicaid all-cause readmission rates for patients aged 21 -44 (19. 2%) and 4564 (21. 6%) are higher than Medicare all-cause readmission rates (17. 3%) – Medicaid heart failure readmission rates are higher than Medicare rates: 29. 1% versus 23. 7% • Strategies developed for Medicare patients may need to be adapted to better address Medicaid patients’ needs – In Massachusetts 40% of all hospitalized adults had a behavioral health condition; among Medicaid patients, the prevalence was 61% – In South Carolina, the diagnosis leading to the highest number of readmissions among Medicaid adults was sickle cell; this was not a top cause for Medicare

Medicare Penalty Focus Has Created Blinders • Medicare Focus – Medicare patients are not the only patients at risk of readmission – Older adults are not the only adults at high risk of readmission Ø Patients with readmission risks are not limited to Medicare • Limited, Diagnosis-Specific Focus – – – Ø Ø Heart failure, heart attack, pneumonia, COPD, hip/knee replacement These are not the most frequent diagnoses leading to readmissions These are not the diagnoses with the highest rates of readmissions Patients with readmission risks are not limited to the “penalty condition” list A “case-finding” approach has limited improving standard care processes

Whole-Person Approach Analyses highlight the multi-factorial causes of readmissions: – Patient interviews – Root cause analysis Experience in the field has found success with transitional care models that address clinical, behavioral, and social needs – Interdisciplinary, social work, social service models appear effective – Several “clinical” approaches have been adapted to include social work, navigation, advocacy, resources to address basic needs

Whole-Person Approach • Successful readmission reduction teams state: – “We look at the whole person, the big picture” – “We always address goals and ask what the patient wants” – “We meet the patient where they are” – “First and foremost it’s about a trusting relationship” – “You can’t talk to someone about their medications if there is no food in the fridge” – “We do whatever it takes”

Why Take A Data-Informed Approach? • Many readmission reduction efforts have been launched in direct response to Medicare readmission penalties • The discharge diagnoses in the penalty program are not the top reasons for readmissions in the Medicare population • There are many high risk patients that go without improved transitional care when the focus is just on penalty conditions • Focusing on those diagnoses only will not reduce hospital-wide readmission rates

Data-Informed Approach • Articulate your hospital’s readmission reduction goal • Analyze your own hospital’s data to identify patients at high risk and unique readmission patterns • Understand root causes of readmissions among your patients • Implement an approach that is designed to effectively meet the transitional care needs of your patients • Track implementation and outcome data to continuously improve processes to reach your goal

Table of Contents • Introduction • Why Focus on Medicaid Readmissions? • How to Use This Guide • Analyze Your Data • Survey Your Current Readmission Reduction Efforts • Plan a Multi-Faceted Data-Informed Portfolio of Strategies • Implement Whole-Person Transitional Care for All • Reach Out to Collaborate With Cross. Continuum Providers • Enhance Services for High-Risk Patients

List of Tools The guide comes with 13 customizable tools to be used in hospital teams’ day-to-day operations. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Data Analysis Readmission Review Hospital Inventory Community Inventory Portfolio Design Operational Dashboard Portfolio Presentation Conditions of Participation Handout Whole-Person Transitional Care Planning Discharge Process Checklist Community Resource Guide Cross Continuum Collaboration ED Care Plan Examples

ALL PAYER AND PAYER-SPECIFIC READMISSION ANALYSIS

Why Analyze Your Own Data? Your hospital-specific readmission patterns may differ in important ways from national patterns: especially true for safety net hospitals. Look at: • Readmission rates by payer • Top 10 diagnoses leading to the most readmissions • Proportion of all readmissions with a behavioral health comorbidity • Readmissions by discharge disposition • Readmissions for frequently hospitalized patients • Timing of readmissions

Discharge Disposition Top 10 Medicare Dx: 1. CHF 2. Sepsis 3. Pneumonia 4. COPD 5. Arrythmia 6. UTI 7. Acute renal failure 8. AMI 9. Complication of device 10. Stroke Top 10 Medicaid Dx: 1. Mood disorder 2. Schizophrenia 3. Diabetes complications 4. Comp. of pregnancy 5. Alcohol-related 6. Early labor 7. CHF 8. Sepsis 9. COPD 10. Substance-use related Medicare (% discharges) Medicaid (% discharges) Discharge to Home 55% 84% Discharge to SNF/IRF/LTAC 24% 5% Discharge to Home with Home Health 14% 8%

15 -Point Analytic Plan: All Payer and Payer-Specific 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Total discharges (exclude deaths and transfers to inpatient care settings) Total readmissions Readmission rate Proportion of discharges and readmissions, by payer Days between discharge and readmission, <4 days, <10 days, 11 -30 days Top 10 diagnoses resulting in highest number of readmissions Percent of all readmissions accounted for by the top 10 diagnoses Proportion of all discharges with any behavioral health (including substance use) condition Proportion of all readmissions with any behavioral health condition Discharge disposition (home, home with home health care, skilled nursing facility) Readmission rate by discharge disposition Number of patients with a personal history of high utilization (4 or more admissions / year) Number of discharges among this group (“high utilizers”) Number (and percent of total) of readmissions among this group (‘high utilizers”) Readmission rate among high utilizers

Data Analysis Tool

ASK YOUR PATIENTS “WHY” Elicit the story behind the chief complaint; identify root causes

Review readmissions from “whole person” view • 41 woman with longstanding HIV never hospitalized in past; hospitalized for pneumonia, started on HIV medications and antibiotics and told to follow up with HIV and PCP providers. Readmitted 8 days later. • 61 man with 8 hospitalizations this year for shortness of breath returns to the hospital 10 days after discharge with shortness of breath. “Billing data aren’t going to tell you whether a patient needed a pharmacy intervention, needed a place to live, or couldn’t afford their medications. ”

Readmission Review Tool Purpose: • To understand patient perspective • To understand root causes • To understand there are multiple factors • To identify opportunities for improvement • To develop a better plan for the patient • To develop better services to offer Recommendation: • Conduct at least 5 during planning • Review all readmissions

Using Data to Identify Your High Risk Populations

Table of Contents • Introduction • Why Focus on Medicaid Readmissions? • How to Use This Guide • Analyze Your Data • Survey Your Current Readmission Reduction Efforts • Plan a Multi-Faceted Data-Informed Portfolio of Strategies • Implement Whole-Person Transitional Care for All • Reach Out to Collaborate With Cross. Continuum Providers • Enhance Services for High-Risk Patients

List of Tools The guide comes with 13 customizable tools to be used in hospital teams’ day-to-day operations. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Data Analysis Readmission Review Hospital Inventory Community Inventory Portfolio Design Operational Dashboard Portfolio Presentation Conditions of Participation Handout Whole-Person Transitional Care Planning Discharge Process Checklist Community Resource Guide Cross Continuum Collaboration ED Care Plan Examples

“WE RUN THE CARE COORDINATOR PILOT; I THINK NURSING IS WORKING WITH IT ON GETTING A HIGH-RISK FLAG IN THE RECORD. I DON’T KNOW HOW THAT IS COMING. …”

Inventory Hospital-Based Efforts & Resources • Readmission reduction activities have proliferated over time • Some efforts may have developed in isolation from one another • Resources or assets may exist that could be leveraged – Readmission flags, high risk flags in EMR – Post-discharge follow up calls – Centralized appointment scheduling – Pharmacists or pharmacy technicians – ACO, bundled payment teams

Hospital Inventory Tool Use this tool to: • Identify readmission reduction efforts across departments • Identify whether efforts are coordinated • Identify whethere is duplication • Identify gaps

“YOU DON’T UNDERSTAND, THERE ARE JUST NO RESOURCES IN THE COMMUNITY”

Inventory Community Efforts & Resources • Post-acute and community providers may offer services and supports hospital staff are unaware of • Health plans may offer high risk patients transitional care and/or care management • Resources or assets may exist that could be leveraged – Practices that are patient centered medical homes: care manager – Home health agencies that specialize in behavioral health – Health homes offering outreach, engagement, case management – Housing agencies with case management services

Community Inventory Tool Use this tool to identify: • Peer supports? • Navigators? • Medical-legal advocates? • Behavioral health providers • Medicaid MCO care managers? • Formal partnerships? • Informal arrangements? • Optimizing available resources? • Is linkage as easy as it needs to be? • Gaps in services and supports?

Bon Secours Baltimore Health System Internal Inventory • • Peer recovery coaches in the ED Outcomes Management Social Work Behavioral Health Program Clinics provide post-discharge follow up <7 -10 days for anyone IT: ACO patients flagged IT: Use CRISP for notifications Community Inventory • • Health Enterprise Zone The Coordinating Center Homeless Outreach Program Transitional Housing Providers Home Health Agencies Skilled Nursing Facilities Baltimore Area Agency on Aging Collaboration w UM Midtown What’s needed next: • Care coordination model for high risk patients • Create care plans for high utilizers • Integrate medical and behavioral health care clinical information • Continue to innovate to meet need of patients Source: presentation to HSCRC Care Coordination workgroup, Dec 2014

Reflect on Findings to Date • Which high-risk populations are and are not being currently served? • Do the strategies offered for the current target population effectively address the transitional care needs and root causes of readmissions? How do you know? • Have the strategies offered for the current target population reduced readmissions for the target population? How do you know? • Are there opportunities to better serve the current target population and reduce readmissions even more? • Are there opportunities to serve new target populations? Which populations? With what services, process improvements, and/or partners?

Table of Contents • Introduction • Why Focus on Medicaid Readmissions? • How to Use This Guide • Analyze Your Data • Survey Your Current Readmission Reduction Efforts • Plan a Multi-Faceted Data-Informed Portfolio of Strategies • Implement Whole-Person Transitional Care for All • Reach Out to Collaborate With Cross. Continuum Providers • Enhance Services for High-Risk Patients

List of Tools The guide comes with 13 customizable tools to be used in hospital teams’ day-to-day operations. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Data Analysis Readmission Review Hospital Inventory Community Inventory Portfolio Design Operational Dashboard Portfolio Presentation Conditions of Participation Handout Whole-Person Transitional Care Planning Discharge Process Checklist Community Resource Guide Cross Continuum Collaboration ED Care Plan Examples

Take a Data-Informed Approach 1. What is our aim? 2. What does our data show? 3. Who should we focus on? 4. What should we do? Many teams start in the reverse order!

Create a Data-Informed Strategy 1. Specify the goal and target population – The goal should be data-informed and specify what will be achieved for whom, by how much, and by when 2. Identify 3 -4 primary ways by which the aim will be achieved, such as: – Improving hospital-based transitional care processes – Collaborations with cross-setting partners – Delivering enhanced services

Example 1: Baltimore Hospital Intervene in ED prior to (re)admit Reliably deliver inpatient transition of care practices Reduce hospital-wide readmissions by 20% Real-time identification ED staff available to coordinate Use individualized care plans Needs assessment Engage caregiver/”learner” Customized instructions & teach back Arrange for follow up & services Provide or link to transitional care services Follow up phone calls Bedside delivery of medications Time-limited transitional care Link to community support Develop cross-setting partnerships, norms & protocols Monthly cross-continuum meetings Cross-setting readmission reviews Warm handoffs, “receiver” oriented Share use of common tools, eg INTERACT

Example 2: Chicago Hospital Reduce readmissions hospital-wide by 20% Create structures and capacity to drive continuous improvement Regular review of readmission data Regular review of patient/provider identified root causes Engage physician leadership Team meetings 2 x/week to support rapid-cycle improvement Improve & enhance hospital-based services Deploy Social Worker in ED 40 h/wk to link to services Deploy CM in ED 40 h/wk to support (re)admit avoidance Interview all readmitted patients to inform To. C planning Provide bedside medication delivery Ensure linkage to follow up and services Follow up calls to patients and to home health agencies Schedule follow up <7 days in [hospital owned] clinics Coordinate with on-site behavioral health providers Provide transportation assistance

Driver Diagram Tool

Analyze Your Strategy: Is it Complete? q Are all readmission reduction related activities captured? q Will this strategy address the root causes of readmissions for your target population? q What target populations have & have not been prioritized? Why? q What strategies have & have not been prioritized? Why? q Are the following data-informed or high-leverage elements included? If not, why not? q q q q Medicaid adults Behavioral health Social support needs High utilizers High risk diagnoses based on your data (sepsis, renal failure, sickle cell, etc) Discharges to post-acute care settings Collaborations with: MCOs, BH providers, clinics, social services, housing services q Does this strategy align with value based /alternative payments and other incentives? q Medicare readmission penalties? Medicare value-based purchasing (total cost)? q Medicaid readmission penalties? Medicaid MCO at-risk contracts? DSRIP goals? q Board-level goals relating to quality, patient experience, disparities, or stewardship?

Operational Dashboard Tool

Portfolio Presentation Tool

Table of Contents • Introduction • Why focus on Medicaid Readmissions? • How to Use This Guide • Analyze Your Data • Survey Your Current Readmission Reduction Efforts • Plan a Multi-Faceted Data-Informed Portfolio of Strategies • Implement Whole-Person Transitional Care for All • Reach Out to Collaborate With Cross. Continuum Providers • Enhance Services for High-Risk Patients

List of Tools The guide comes with 13 customizable tools to be used in hospital teams’ day-to-day operations. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Data Analysis Readmission Review Hospital Inventory Community Inventory Portfolio Design Operational Dashboard Portfolio Presentation Conditions of Participation Handout Whole-Person Transitional Care Planning Discharge Process Checklist Community Resource Guide Cross Continuum Collaboration ED Care Plan Examples

UNDERSTAND EVOLVING GUIDANCE AND REQUIREMENTS USE THESE AS YOUR BLUEPRINT TO IMPROVE STANDARD CARE

Excerpts from Recent CMS Guidance and Proposal • Have a written discharge process approved by governing body • Analyze and track readmissions • Review readmissions and look for patterns • Regularly review and improve the discharge processes • Every patient in inpatient or observation needs a discharge plan • Actively solicit the preferences of the patient and family/friends/support person • The plan must be able to be realistically implemented • Address behavioral health follow up as part of the discharge plan • Provide customized education • Provider verbalized instructions, using the teach-back technique • Know capabilities community based providers – including Medicaid home and community based services • Know options for Medicaid long term services and supports or have a contact at Medicaid who can help • Provide patients with data to inform their choice of post-acute providers • Transmit discharge summaries within 48 hours of discharge • Follow up with patients at high risk of readmission Source: CMS May 2013 and November 2015

Improving Standard Processes for All Patients • • • Identify all patients at high-risk of readmission Assess all patients for clinical, behavioral and social needs Communicate with patients simply and effectively Link patients to follow-up and post-hospital services Provide real-time information to receiving providers Ensure timely post-discharge contact AND • Have a process • Track, trend and review readmissions • Continuously improve the process to better meet needs

IMPROVING TRANSITIONAL CARE FOR ALL TOOL

Whole-Person Transitional Care Planning Tool

Discharge Checklist Tool

Table of Contents • Introduction • Why focus on Medicaid Readmissions? • How to Use This Guide • Analyze Your Data • Survey Your Current Readmission Reduction Efforts • Plan a Multi-Faceted Data-Informed Portfolio of Strategies • Implement Whole-Person Transitional Care for All • Reach Out to Collaborate With Cross. Continuum Providers • Enhance Services for High-Risk Patients

List of Tools The guide comes with 13 customizable tools to be used in hospital teams’ day-to-day operations. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Data Analysis Readmission Review Hospital Inventory Community Inventory Portfolio Design Operational Dashboard Portfolio Presentation Conditions of Participation Handout Whole-Person Transitional Care Planning Discharge Process Checklist Community Resource Guide Cross Continuum Collaboration ED Care Plan Examples

“WE WOULD BE THRILLED IF SOMEONE FROM THE HOSPITAL CALLED US”

Cross-Continuum Collaboration: Who’s Job is It? • It’s the hospital’s job! • CMS policies signal that hospitals are expected to lead delivery system transformation to more effectively deliver care across settings • Hospitals that do reach out to post-acute and community based providers and agencies find those partners are very receptive

“THERE ARE MANY RESOURCES IN THE CITY, BUT IT CAN BE HARD TO FIND THEM. WE NEED TO INVENTORY THEM AND COLLECT THIS INFORMATION IN ONE PLACE. ”

Identify Medicaid-Relevant Partners Medicaid-Relevant Clinical Providers • • Behavioral Health Centers Community Health Centers Behavioral Health Homes Resident Physician Clinics Patient Centered Medical Homes Substance Use Treatment Centers Adult Day Care Centers Medicaid Managed Care Plans Medicaid-Relevant Service Agencies • • Health Homes Group Homes Housing Authority Transportation Providers County Health Departments Food Assistance Legal Advocacy Assistance Peer Support

Look for Care Management Resources • • • • • Accountable care organizations Patient-centered medical homes Bundled payment initiators Health homes Behavioral health homes Medicaid managed care organizations CMS demonstration initiatives State Innovation Model initiatives Duals-demonstration programs Medicaid Delivery System Reform Incentive Payment (DSRIP) programs Medicaid Delivery System Transformation Initiatives (DSTI) programs Local or national foundation grant-funded initiatives State agency funded initiatives State behavioral health agency Housing authority or housing agencies Peer support programs Faith-based organizations Volunteer organizations

Community Resource Guide Tool

DEVELOP “REFERRAL PATHWAYS” MAKE DOING THE RIGHT THING THE EASY THING FOR STAFF

Cross Continuum Coordination – Getting Started If you are just getting started: • Hold regularly scheduled monthly meetings • Start with a “coalition of the willing” – doesn’t need to be perfect • Invite new partners/ agencies as you learn about them • Allow 3 -4 months for the group to gel • Start with common agenda items: – – – Readmission data Readmitted patient stories Readmission stories from “receiver” perspective Handoff communication What information do “receivers” need that they frequently don’t have?

Cross-Continuum Collaboration Tool

Table of Contents • Introduction • Why focus on Medicaid Readmissions? • How to Use This Guide • Analyze Your Data • Survey Your Current Readmission Reduction Efforts • Plan a Multi-Faceted Data-Informed Portfolio of Strategies • Implement Whole-Person Transitional Care for All • Reach Out to Collaborate With Cross. Continuum Providers • Enhance Services for High-Risk Patients

List of Tools The guide comes with 13 customizable tools to be used in hospital teams’ day-to-day operations. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Data Analysis Readmission Review Hospital Inventory Community Inventory Portfolio Design Operational Dashboard Portfolio Presentation Conditions of Participation Handout Whole-Person Transitional Care Planning Discharge Process Checklist Community Resource Guide Cross Continuum Collaboration ED Care Plan Examples

Enhanced Services • Additional services and supports in the time following hospitalization • Services not provided to all patients as part of routine care • Offered to subgroups identified as “high risk” of readmission • Delivered prior to and after discharge, often for 30 days • Deployed at provider expense so as to reduce readmissions • Delivered by hospital staff or by contracted staff from other entities Ø Specific section on strategies to improve care for patients with a history of recurrent hospitalizations (“high utilizers”) Ø Specific section on Emergency Department-based strategies

“Our [navigators] are flexible, proactive, and persistent; they address all needs. Each of them has incredible interpersonal skills. ”

“Whole-Person” Adaptations to Transitional Care • Navigating • Hand-holding • Arranging for…. • Providing with…. • Harm reduction • Meet “where they are” • Patient priorities first • Relationship-based

Adapt Transitional Care Models to Better Address Whole-Person Needs In Practice: Social Workers In Practice: Community Health Workers The social worker calls the high-risk patient within two days of discharge, and first focuses on developing rapport with the patient or their caregiver. The social worker identifies problems to be addressed, with about three-fourths of these problems not becoming apparent until after discharge. The three most common problems are difficulty coping with change, caregiver stress, and problems managing medical care, including medications. Other common issues include trouble obtaining community services, communication breakdowns between providers, trouble managing a new treatment or diagnosis, and difficulty understanding the discharge plan. The hospital assigns a CHW to all patients with three or more readmissions in the past year. The CHWs meet with patients as early as possible during the hospitalization and try to meet with the patient multiple times before discharge. This connection while in the hospital makes it much easier to continue the relationship in the posthospital setting. By design, CHWs meet with patients independently of doctors and nurses. CHWs have noted that patients feel more comfortable telling them about psychosocial and economic problems that may prevent them from adhering to their care plan, such as being unable to afford heat in their home or not understanding what the doctor said. The Bridge Model of social worker-led transitional care reduced all-cause any-hospital 30 -day readmissions by 20%, as published in the Journal of the American Geriatrics Society (May 2016).

Adapt Transitional Care Models to Better Address Whole-Person Needs

Principles to Guide High Utilizer Programs • Identify the patient in real-time • Engage the patient while they are on-site • View utilization as a symptom of unmet needs • Prioritize engagement • Deploy an interdisciplinary team • Be proactive in post-hospital follow up • Be patient and persistent • Have resources to deploy to meet short term needs • Use care plans to improve care across settings and over time

Care Plans Improve Care Across Settings and Over time • Longitudinal Care Plan – A comprehensive plan to achieve health-promoting goals and objectives. Specific goals regarding clinical, behavioral, and/or functional status are often included, and are measured via serial assessments over time. Longer term; care management over time. • Transitional Care Plan – Identifies post-hospital needs, patient priorities, and readmission risks and the plan to address those needs, priorities and mitigate risks in the 30 days post discharge. Focus on ensure linkage to providers and services within the 30 day transitional period. • ED Care Plan (examples) – Summary information for the ED provider to inform safe, effective, and consistent care in the ED and facilitate discharge with team-based follow up, as appropriate.

ED Care Plan Tool

“In previous times, the path would’ve been to simply admit the patient, and we’ll sort it out 5 days later. We’re becoming more accustomed to having resources in the ER to help us discharge patients from the ED. That’s a culture change. ”

Reducing Readmissions from the ED 1. Create a 30 -day return flag on the ED Tracker Board 2. Use the 30 -day return flag to notify the high risk care team 3. Use care plans and care teams’ involvement in the ED 4. Consider developing “treat and return” pathways 5. Engage hospitalists in decision to admit

Summary • The AHRQ Hospital Guide to Reducing Medicaid Readmissions encourages hospitals to: – Expand readmission reduction efforts to all patients – Adapt strategies to better serve Medicaid patients – Employ a data-informed approach to designing efforts – Implement a whole-person approach to identifying and addressing patients’ transitional care needs • The ASPIRE Framework: – Supports an updated strategic planning process – Recommends improving care in 3 domains: improve hospital-based care, collaborate across settings, deliver enhanced services

Thank you for your commitment to reducing readmissions Amy E. Boutwell, MD, MPP Collaborative Healthcare Strategies amy@collaborativehealthcarestrategies. com Angel Bourgoin, Ph. D & Jim Maxwell, Ph. D John Snow, Inc. Angel_Burgoin@jsi. com; Jim_Maxwell@jsi. com