Realtime Readmissions Feedback at PENN Medicine – Making the Data “Actionable” University of Pennsylvania Health System Presented by: Victoria L. Rich, PhD, RN, FAAN Chief Nurse Executive University of Pennsylvania Medical Center Who we are PJ Brennan, MD Chief Medical Officer & Senior Vice President University of Pennsylvania Health System Victoria Rich, PhD, FAAN, RN Chief Nursing Executive, University of Pennsylvania Medial Center Associate Professor, University of Pennsylvania School of Nursing Joan Doyle, MBA, MSN, RN Executive Director, Penn Home Care and Hospice Services University of Pennsylvania Health System Assistant Dean for Clinical Practice, University of Pennsylvania School of Nursing Linda May, PhD Principal CFAR 2 Penn Medicine — Philadelphia, PA School of Medicine University of Pennsylvania Health System Hospital of the University of Pennsylvania Pennsylvania Hospital Penn Presbyterian Medical Center Penn Home Car & Hospice Services #9 US News Magnet Adult admissions — 77,500 Admissions — 18,000 Employees — 12,700 Employees — 450 3 Penn Medicine is working to improve Transitions-inCare from hospital to home — and prevent readmissions The aim is to keep patients safe and stable and give them a safe “medical landing” Preadmission Hospital Stay Admission It’s the right thing to do for our patients — AND we’re trying to get ahead of the curve for the new world of healthcare Post-acute Care Discharge “Medical Landing” What we’re learning will give us a head start in a new healthcare environment of ACOs and bundled payments. 4 Realtime readmissions feedback is at the heart of our model for Transitions-in-Care UPHS Transitions Model — Seven “Levers” Screen for patients at greates t risk Real-time readmissions feedback to actively manage patients Interdisciplinary care planning Links to postacute follow-up services Primary care follow up Med mgmt across the continuum Education & red flag mgmt 5 It starts with the daily readmissions reports — but the report is the “least” of it Daily Readmissions Report Readmitted patients (across all three hospitals) — with chief complaint, facility, unit, service, attending Full report is distributed each morning to Discharge Planners, Homecare and others. Each hospital unit gets a tailored version, with just its own patients. Detailed history of previous admissions But … It’s the organizational “machinery” that makes the data actionable 6 Today’s talk about making the realtime readmissions data actionable has three parts 1 “Changing the way we work” The story of frontline leadership 2 “Speaking with a united clinical voice” The story of the CMO/CNO Alliance 3 “Mobilizing other people’s energies” The story of the Transitions Steering Group 7 The story of frontline leadership 1 Changing the way we work 8 In-the-moment and long term Long-term changes to clinical practice Daily Troubleshooting Readmissions data are available in time to take action on specific cases Screen for patients at risk Real-time readmissions feedback Interdisciplinary care planning Tools, standards, education, faster turnaround, tighter feedback loops — based on opportunities we see in the data Links to post-acute follow-up services Primary care follow up Med mgmt across the continuum Education & red flag mgmt UPHS Transitions Model — Seven “Levers” 9 “ Findings with feet … ” — Executive Administrator 10 Daily troubleshooting At the System Level Discharge Planners review every UPHS readmission, every day On the phone with each other daily to troubleshoot specific patients Homecare/ Hospice review every one of their readmissions, every day Hospice dispatches a team to investigate its patients, along with the inpatient medical team On the Individual Hospital Units For example, a general medicine/telemetry unit started interviewing each of its readmitted patients to learn why the patients themselves thought they came back into the hospital Discharge Planners interview readmitted UPHS patients. They’re learning that most patients don’t see the link between readmission and things like not taking their meds. This is a teaching opportunity This got picked up at the system level 11 Long-term changes to clinical practice For example, here’s how Hospice is changing the way It works … Hospice conducts regular case conferences to understand why their patients are readmitted. They’ve learned that many are coming back because of pain or dehydration. Hospice has developed a tool to indentify their patients at greatest risk for readmission. Hospice is building in new practices for those high-risk patients: • • • • Frontloading visits Proactive phone calls Educating staff Tighter feedback loops And they’ve developed a tool for patients to help them know when to call if their symptoms are getting out of control. 12 What’s next? Two things on our plate … Building out the daily review process on the hospital units ? ? ? Who’s responsible? If the daily readmissions report goes to “everyone,” it might as well go to “no one.” What actions are “automatically” taken for a readmitted patient? What interventions are triggered — Homecare referral? Patient education? Discharge safety check? Follow-up phone call? Making common cause with the Cardiac Oncology Service Lines ? ? ? How can we share their readmissions data so it’s “hearable” and “actionable”? How can we tap into what the service lines are already planning to do? How can we shape what they’re doing? 13 A funny thing is happening along the way — we’re breaking down our silos and collaborating in new ways From To Service Lines Unit Leadership Trios Discharge Planners Homecare/ Hospice 14 So, what does it take to make the readmissions data “actionable”? the way 1 Changing we work Daily troubleshooting to take action on specific cases Realtime readmissions data — the report is the “least” of it Tracking and trending the readmissions data to identify longer-term interventions Making changes to clinical practice — tools, standards, education, faster turnaround, tighter feedback loops Along the way, breaking down our silos and collaborating in new ways 15 It takes a village — and the village is here today Med/Surg UBCLs — and their unit-based partners: Medicine Residents Quality Track CRCs/SWs Pharmacists HCHS, GSPP and other postacute providers Educators/ Clin Specs IBC, AETNA AP Nurses Infection Control Other outpatient stakeholders People who have been developing tools & resources CMO/CNO Alliance Transitions Steering Group Other senior leaders from CRM/SW, IS, HR, Pharmacy, Quality, HCHS, Operations 16 “Changing the way we work” — lessons learned Collaboration at the local level didn’t happen overnight. One day at a time, we earned new reputations for what each other could bring. We focused on the work — which led to new ways of thinking about each other. It’s not just about “educating” each other. The best way to collaborate was to work together on common problems — and bring our clinical expertise to bear. It’s easier to “act your way to new thinking” than to think your way to new actions. 17 But frontline actions, by themselves, aren’t enough … 18 The story of the CMO/CNO Alliance with a united 2 Speaking clinical voice 19 The CMOs and CNOs have banded together across the continuum of care CMO/CNO Alliance The CMO/CNO Alliance spans the care continuum: • All three hospitals • Penn’s homecare and hospice services • Penn’s rehab facilities • Physician practices 20 The CMOs and CNOs set clinical direction for UPHS — with Transitions-in-Care as a major element UPHS Blueprint for Quality and Patient Safety Reduce mortality and reduce 30-day readmissions Four Imperatives Priority Actions 1. Transitions in care Transition planning Med management Reduce hospital-acquired infections Reduce medication errors 3. Coordination of care Interdisciplinary rounding 4. Accountability Unit clinical leadership 2. Reduce variations in practice 21 To bring clinical strategy to the frontline, we’ve established “local leadership” on each hospital unit Leadership Trio on Each Hospital Unit We needed a multi-purpose solution on the units to handle almost any Quality problem. “ We call these trios “UBCLs,” for “Unit Based Clinical Leadership” This isn’t a project, it’s a way of doing things. You can bolt different strategies onto it. ” —UPHS CFO 22 We started modestly on purpose so the leadership trios could learn to work with each other 13 pilot units in 2007 The job: Weekly operations meeting of the Physician Leader, Nurse Leader, Project Mgr. for Quality Interdisciplinary rounding Orienting house staff Two improvement projects 2007 2008 2009 2010 23 Today we’ve covered the house and the trios are ready to take on Transitions, a major system-wide initiative Today it’s 34 “official” units — and another dozen who are “operating as.” The job: Today the trios manage Quality on the unit, drawing in others as needed. UBCLs are ready this year to shoulder Transitions in Care, a major system-wide initiative. 2007 2008 2009 2010 24 “Choice within a framework” — each year we develop targets and work with the hospital units to pick theirs UPHS Blueprint for Quality and Patient Safety Reduce mortality and reduce 30-day readmissions. Four Imperatives Transitions in care Priority Actions Transitions in Care — FY’11 Targets Risk stratification — screening tool and daily review of realtime readmissions Discharge time out Discharge communication Med rec on discharge HCAHPS medication domain Reduce variations in practice Transition planning Med Management Reduce hospitalacquired infections Reduce med errors Coordination of care Interdisciplinary rounding Accountability Unit clinical leadership 25 “Focusing attention” — we negotiated a Transitions metric in every senior leader’s incentive plan METRIC: Increase referrals to post-acute services (homecare, hospice, rehab, SNF, infusion, LTAC) We’re setting the stage for a more ambitious “readmissions” metric next year. We picked this metric because it supports a key element of our Transitions model — and because Penn could measure it. Hospital 1 Q1 Q2 Q3 HP HP HP Q4 Threshold (3%) Hospital 2 Hospital 3 Target (5%) HP HP High Performance (10%) 26 Quality outcomes are moving in the right direction — including the ones focused on Transitions-inCare MORTALITY INFECTIONS PEER RECOGNITION LENGTH OF STAY PATIENT & STAFF SATISFACTION READMISSIONS REFERRALS TO POSTACUTE CARE P4P IS ON TRACK 27 We’re getting out ahead of the budget cycle and negotiating with a united clinical voice The old way The new way First step — set margins for each hospital or other entity. Entities are locked in. Discussion of system-wide quality initiatives before margins are set. Entities (separately) submit budgets. CMOs and CNOs submit a joint budget for system-wide quality initiatives they all agree on. Negotiation — across entities and with Finance — occurs after budgets are submitted. Negotiation occurs before budgets are submitted. We’re making our job AND the CFO’s job easier. 28 We’re bringing payers to the table Paying for the Naylor Transitional Care Program A major insurance company pays Penn to provide the “Transitional Care” (Naylor model) follow-up program to its patients. In this program, the same advanced practice nurse follows patients before and after discharge. Sharing the gains Penn has also negotiated an agreement with the insurance company to share the savings when patients are able to stay out of the hospital. 29 So, how are we aligning infrastructures and supports to make readmissions data “actionable”? with a 2 Speaking united clinical voice CMO/CNO Alliance across the continuum of care Local leadership on each hospital unit — Physician Leader, Quality Project Manager Clinical strategy — with Transitions-in-Care as a major element Metrics as feedback — each hospital unit and each senior leader know where they stand Aligning quality metrics across the system, including senior leaders’ incentive targets Realtime readmissions data — the report is the “least” of it Quality redesign to dedicate a Quality Project Manager to each hospital unit Negotiating the budget with a united clinical voice Bringing the payers to the table 30 Speaking with a united clinical voice — lessons learned To paraphrase James Carville: “ It’s the work, stupid. ” A united clinical voice is based on actions, not just words. We started with the work — developing the Blueprint, establishing the unit teams, setting the metrics, negotiating the budget. Succeeding at the work is what turned the CMOs and CNOs into a real leadership team that could speak with a united voice. That’s very different from trying to do it the other way around. 31 But leadership at the top isn’t enough … 32 The story of the Transitions Steering Group other people’s energies 3 Mobilizing and keeping the moving parts aligned 33 The Transitions Steering Group is in the integration business This interdisciplinary group of senior leaders: Transitions Steering Group • • • • Sets direction for Transitions-in-Care Integrates the moving parts Opens doors at the system level Troubleshoots to keep things on track 34 We developed UPHS’ Transitions Model as a framework — with realtime readmissions feedback at the heart UPHS Transitions Model — Seven “Levers” Screen for patients at greates t risk Real-time readmissions feedback to actively manage patients Interdisciplinary care planning Links to postacute follow-up services Primary care follow up Med mgmt across the continuum Education & red flag mgmt 35 We’re mobilizing “other people’s energies.” Our biggest job is keeping them aligned. Knowledge-Based Charting (HER protocols & tools) under development Penn Medicine Leadership Forum INTERNAL “action learning” Transitions projects Transitions CMO/CNO Collaboratives Alliance across — active the continuum of operational care arms Unit-based Pharmacists Med Mgmt redesign EXTERNAL CMS penalties for readmissions will begin in 2012 Pay-forperformance contracts Public reporting influences patient choice TRANSITIONS IN CARE for better patient outcomes & reduced readmissions Bundled payments and ACOs are on the horizon Payers willing to fund follow-up programs and negotiate gain-sharing arrangements 36 For example — We took advantage of Penn’s flagship leadership development program Penn Medicine Leadership Forum is targeted this year to the unit-based leadership teams — along with homecare and other partners The purpose of Penn Medicine Leadership Forum is to develop leadership skills … • • • • Innovation Strategic orientation Execution Relationship mgmt “Action Learning” … and apply them to a strategic system-wide initiative This year the strategic initiative is Transitions-inCare. Each team took on a project to improve Transitions on a specific hospital unit. 37 “Test beds” — each team tested an aspect of the Transitions Model. All over the place, but look at the energy! Transitions Projects for Penn Medicine Leadership Forum Real-time readmission analysis and intervention End-of-life goals of care Screening tool for post-acute referrals Screen for patients at risk New approaches to interdisciplinary care planning Team-based Improve Discharge internal Planners Transitions “Opt-out” for House staff homecare awareness of referral homecare & hospice services Real-time readmissions feedback Interdisciplinary care planning Links to post-acute follow-up services UPHS Transitions Model — Seven “Levers” Post-discharge phone calls Discharge “time out” safety check Follow-up appointments with primary care Primary care follow up Medication management across continuum Patient & family education, with emphasis on self management Discharge summary follows patient to post-acute services Med mgmt across the continuum Education & red flag mgmt 38 To pull it all together, we turned the teams’ work into an integrated Transitions process for the health system Preadmission Hospital Stay Post-acute Follow-up Discharge Admission Work as far “upstream” as possible — prior to admission where that makes sense. Risk stratification 1 Screening on admission 2 Medical “Landing” Daily review of realtime readmissions report Interdisciplinary rounds 3 Plan of care looks ahead to post-discharge 4 Referral to post-acute care as early as feasible Patient and family education Education for post-discharge care and meds, with emphasis on self management 5 6 Med reconciliation on discharge Discharge communication 7 Discharge safety check (for high-risk patients) 8 Discharge summary to primary care & post-acute 9 Schedule appointment with primary care (for high-risk patients) Follow-up phone calls (for high-risk patients) 10 39 We can’t implement the new Transitions process all at once — so where to start? The readmissions data helped us decide where to focus first: Readmits and the top 10-20% at greatest risk for readmission The “big three” diagnoses that will affect CMS payments for readmissions in 2012 — Heart Failure, Heart Attack, Pneumonia Two Penn service lines with the biggest impact on those three diagnoses — Cardiac and Oncology 40 We’re learning a lot from the readmission data. Some things have surprised us … Readmits and the top 10-20% at greatest risk for readmission Readmits are younger than we expected. Twothirds are younger than 65. One-third are younger than 49. The “big three” diagnoses that will affect CMS payments for readmissions in 2012 — Heart Failure, Heart Attack, Pneumonia Two Penn service lines with the biggest impact on those three diagnoses — Cardiac and Oncology Link between Oncology and Pneumonia. Analysis of our Pneumonia readmits shows that almost a third are on the Oncology service. And overall analysis of readmits shows that 30% are Oncology 41 So, how are we using other people’s energies to make the readmission data “actionable”? 3 Mobilizing other people’s energies Transitions model as a framework — seven “levers” that make the biggest difference Realtime readmissions data — the report is the “least” of it Tapping into other people’s projects and efforts — and keeping the moving parts aligned Leadership development in “action-learning” mode Tracking and trending the readmissions data to figure out where to focus first 42 Mobilizing energies — lessons learned By tapping into other people’s efforts and projects, you can create results and critical mass as you go. You get change that sticks, because people are creating it themselves. You don’t have to do all the work yourself. Your job is to align what might otherwise work at cross purposes. Tapping into other people’s energies and momentum creates “pull” for the changes you want to make. Other people pull the changes along. 43 It takes a village — and the village is here today Med/Surg UBCLs — and their unit-based partners: Medicine Residents Quality Track CRCs/SWs Pharmacists HCHS, GSPP and other postacute providers Educators/ Clin Specs IBC, AETNA AP Nurses Infection Control Other outpatient stakeholders People who have been developing tools & resources CMO/CNO Alliance Transitions Steering Group Other senior leaders from CRM/SW, IS, HR, Pharmacy, Quality, HCHS, Operations 44 45 This is our moon shot… Blueprint for Quality & Patient Safety (2.0) Penn Medicine will eliminate preventable deaths and preventable 30-day readmissions by July 1, 2014. 46 47 Patient Navigation There is no accepted definition Role established in 1990 by a Harlem physician to assist indigent cancer patients. However, “Navigators do things for patients by working with the patients and others in both the social network of the organization and in the community.” Health Services Research Trust 48 Emerging Roles for Nurses Across the Care Continuum A. Inpatient Care setting B. Across settings C. Outpatient 49 A. Inpatient I. Inpatient Care Coordinator Also Called: Primary Care Coordinator, Patient Care Coordinator, Unit Based Care Manager, Hospital-Based Case Manager Capsule Description: Serves as a primary contact for physicians and other care providers; responsible for managing patient care needs and progress, care plan development and discharge planning Key Functions/Attributes: - Interacts with patients and families throughout the length of stay - Collaborates with other medical staff face-to-face as needed Individuals Commonly Deployed: Social Worker, Case Manager, RN with BSN, RN with MSN and CNL licensed 50 B. Across Settings II. Inflection Point Navigator Also Called: Nurse Life Care Planner Capsule Description: Provides guidance to patients, families and physicians during acute inflection points in healthcare (such as cancer diagnosis) or catastrophic illness Key Functions/Attributes: - Works independently of hospital systems - Act as consultants for businesses, families or courts of law Individuals Commonly Deployed: RN 51 B. Across Settings (con’t) III. Disease-Specific Chronic Care Coordinator Also Called: Diabetes Coach, Chronic Disease Manager, Asthma Coach Capsule Description: Counsels patients regularly regarding disease-related symptom management and advises patients on lifestyle choices to improve prognosis Key Functions/Attributes: - Meet with patients on a monthly basis (at minimum) - Provide disease management over the phone and in person Individuals Commonly Deployed: Community Member, Pharmacist, RN, licensed NP 52 C. Outpatient IV. Co-morbidity Chronic Care Coordinator Also Called: RN Chronic Care Coordination (CCC) Coordinator, Health Coach, Team Member, Case Manager Capsule Description: Follows patients deemed heavy users of expensive inpatient care due to multiple chronic illnesses, high ED utilization or recent discharge from a SNF; promotes more active and informed patient role in self care Key Functions/Attributes: - Provides assistance via the telephone - Conducts in-home visits and office appointments as needed Individuals Commonly Deployed: Community Member, Medical assistant, RN, Social Worker, Case Manager 53 C. Outpatient (con’t) V. IT Based Care Coordinator Also Called: Telehealth Nurse Capsule Description: Utilize technological resources to prevent complications associated with chronic health conditions to avoid hospital admissions. Key Functions/Attributes: - Performs initial visit in person during first week of care 54 Role CNL (generalist) CNS (expert) Education RN prepared at the Master’s degree level as a generalist RN prepared as an advanced practice nurse (APN) in a clinical specialty at the Master’s, post Master’s or Doctoral level Direct Manager Unit Administrator or Nurse Manager Specialty Area Administrator or CNO Function Provides and manages treatment at the point of care for patients, families and communities as a generalist Implements the principles of “mass customization” to ensure consistency of clinical care within populations Expert clinician in a particular specialty or subspecialty ; functions as an expert Provides knowledge and expert skill in a specialized area to nurses and other member of the multidisciplinary care team for complex or critically ill patients Patient Focus Coordinates care for patient individuals and patient cohorts Designs, implements and evaluates patient-specific and population based plans of care Clinical Area of Practice Hospital units/wards, outpatient clinics or home health agencies Entire facility Key Activities Assess and modify to patients’ care plan as necessary Perform patient and family education Lead multidisciplinary groups in formulation and implementation of solutions to address system issues concerning patient care delivery Act as consultant to other nursing and medical staff in a specific area of specialization for complex diagnoses or critically ill patients Accountable for care delivered and outcomes of care for specified cohorts of patients Common CrossContinuum Roles Inpatient Care Coordinator, Unit Based Care Manager Disease-Specific Chronic Care Coordinator Reference: Hall, G et al., “Working Statement Comparing the Clinical Nurse Leader sm and Clinical Nurse Specialist Roles: Similarities, Difference and Complementarities”, December 2004, available at: http://www.aacn.nche.edu/cnl/pdf/CNLCNSComparisonTable.pdf, assessed July 20, 2011 55 Community Health Care Worker - The Future of Transitions In Care ???? 56 General Services Provided by a Patient Navigator Facilitating communication among patients, family members, survivors and healthcare providers Coordinating care among providers Arranging financial support and assisting with paperwork. Arranging transportation and childcare. Ensuring that appropriate medical records are available at medical appointments. Facilitating follow-up appointments. Community outreach and building partnership with local agencies and groups. Ensuring access to clinical trials. 57 Thank You….