Table Of ContentReinvigorating Inpatient Care Coordination
Infrastructure
Presented by: Sruti Nataraja, MPH, The Advisory Board Company
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©
2011
The
Advisory
Board
Company
–
22421B
Reinvigora*ng
Inpa*ent
Care
Coordina*on
Infrastructure
Sru;
Nataraja,
MPH
Prac;ce
Manager
The
Advisory
Board
Company
[email protected]
©
2011
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Board
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3
Road
Map
for
Discussion
Na;onal
Call
to
Ac;on
on
Care
I
Coordina;on
II
Best
Prac;ces
for
Hardwiring
Inpa;ent
Care
Communica;on
Best
Prac;ces
for
Migra;ng
Toward
a
III
Transi;on
Mentality
©
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4
Na;onal
Call
to
Ac;on
on
Care
Coordina;on
©
2011
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5
Care
Coordina;on
Rising
to
Top
of
Execu;ve
Agenda
Leaders
Cite
as
Key
Priority
for
2011
Top
Priori*es
Iden*fied
by
Hospital
Leaders1
Priority
2010
Rank
Priority
2011
Rank
Quality/pa;ent
safety
1
Cost
reduc;on
1
Physician
recruitment/reten;on
2
Quality/pa;ent
safety
2
Cost
reduc;on
3
Reimbursement
3
Pa;ent
experience/pa;ent
sa;sfac;on
4
Pa;ent
experience/pa;ent
sa;sfac;on
4
Reimbursement
5
Developing
an
accountable
care
organiza;on
5
Construc;on/capital
improvements
6
Care
coordina*on
6
Physician
staff
ventures/realignment
7
Physician
recruitment
and
reten;on
7
Technology
system/equipment
8
Technology
system/equipment
8
Employee
sa;sfac;on
9
Construc;on/capital
improvements
9
Care
coordina*on
10
Physician
staff
ventures/realignment
10
Leadership
development
11
Dealing
with
uncompensated
care
11
Revenue
cycle
12
Revenue
cycle
12
1
Based
on
response
to
survey
ques;on:
“Rank
your
Source:
“HealthLeaders
Media
Industry
Survey
2011,”
HealthLeaders
Media,
organiza;on’s
top
3
priori;es
for
the
next
3
years.”
hSp://www.healthleadersmedia.com/pdf/survey_project/2011/
©
2011
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Leadership_press.pdf;
Clinical
Advisory
Board
interviews
and
analysis.
6
Seemingly
An
Area
of
High
Performance
Hospital
Leaders
Give
High
Marks
to
Care
Coordina=on
How
Would
You
Rate
the
Current
Status
of
Care
Coordina*on
At
Your
Organiza*on?
n=487
Weak/Very
Weak
14%
64%
Very
Strong/Strong
Neutral
22%
Source:
“HealthLeaders
Media
Industry
Survey
2011,”
HealthLeaders
Media,
hSp://www.healthleadersmedia.com/pdf/survey_project/2011/
©
2011
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Board
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Leadership_press.pdf;
Clinical
Advisory
Board
interviews
and
analysis.
7
Consumer
View
Less
Rosy
Mismatch
Between
Hospital
Percep=on
and
Pa=ent
Reality
Consumer
Views
of
Care
Coordina*on1
n=1,238
Major
Problem
Roughly
4
of
10
consumers
report
17%
problems
with
care
coordina;on
Not
a
Problem
at
all
52%
27%
Minor
Problem
3%
Don’t
Know/Refused
1
Based
on
response
to
survey
ques;on:
“In
general,
do
you
think
that
Source:
“The
Public
and
the
Health
Care
Delivery
System,”
NPR/
coordina;on
among
all
of
the
different
health
professionals
that
you
Kaiser
Family
Founda=on/Harvard
School
of
Public
Health,
April
see
is
a
major
problem,
a
minor
problem,
or
not
a
problem
at
all?”
2009,
hSp://www.kff.org/kaiserpolls/upload/7887.pdf;
Clinical
©
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Advisory
Board
interviews
and
analysis.
8
Academic
Research
Also
Illumina;ng
Problems
Over
700
Ar=cles
on
Coordina=on
Published
in
Last
Two
Years
Rehospitalizations Eo
ffne Hctos sopfi Ctaalirzea Ctioonor, dQinuaatliitoyn
Among Patients in the
of Care, and Health Care
Medicare Fee-‐‑For-‐‑Service
Expenditures Among
Ar;cles
Published
on
Program
Medicare Beneficiaries
711
Care
Coordina;on
2009
-‐
2011
Thirty-‐‑Day Readmission Hospital Readmission as
Rates for Medicare
an Accountability
Beneficiaries by Race and
Measure
Site of Care
Research
Methodology
in
Brief
• Searched
PubMed
for
ar;cles
published
between
January
1,
2009
and
March
7,
2011
in
English
with
the
words
“care
coordina;on”
or
“readmissions”
appearing
in
the
;tle
or
abstract
• A
total
of
711
ar;cles
were
published
within
;me
frame
Source:
Ar;cles
listed
above;
Clinical
Advisory
©
2011
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Board
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Board
interviews
and
analysis.
9
Fragmenta;on
Garnering
the
ASen;on
of
Regulators
Medpac
Explains
Perils
of
Coordina=on
in
US
System
A
Fragmented
System
“Providers
need
to
increase
care
coordina*on
and
be
jointly
accountable
for
quality
and
resource
use…There
is
no
incen;ve
for
providers
to
coordinate
care.
Each
provider
may
treat
one
aspect
of
a
pa;ent’s
care
without
regard
to
what
other
providers
are
doing.
There
is
a
focus
on
procedures
and
services
rather
than
on
the
beneficiary’s
total
needs.
This
becomes
a
par;cular
problem
for
beneficiaries
with
several
chronic
condi;ons
and
for
those
transi;oning
between
care
providers,
such
as
at
hospital
discharge.
Poorly
coordinated
care
may
result
in
pa;ent
confusion,
over-‐treatment,
duplica;ve
service
use,
higher
spending,
and
lower
quality
of
care.”
-‐
Medpac
Report
to
the
Congress:
Reforming
the
Delivery
System
Source:
Report
to
the
Congress:
Reforming
the
Delivery
System,
September
16,
2008,
Statement
of
Mark
Miller,
Execu;ve
Director,
Medicare
Payment
Advisory
Commission,
to
U.S.
Senate
Finance
CommiSee,
hSp://www.medpac.gov/documents/20080916_Sen%20Fin_tes;mony%20final.pdf;
Clinical
©
2011
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Advisory
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interviews
and
analysis.
10
P4P
Already
a
Reality
Accountability
Measures
Transcend
Hospital
Walls
Targe=ng
Hospitals
for
System
Performance
Emerging
Scope
of
Hospital
Accountability
Pre-‐Admit
Care
Hospital-‐Based
Care
Post-‐Acute
Care
CMS
Measures
Requiring
Coordina*on
R 30-‐day
AMI1
R 30-‐day
AMI
readmission
rate
mortality
rate
R 30-‐day
heart
failure
R 30-‐day
heart
failure
readmission
rate
mortality
rate
R 30-‐day
pneumonia
R 30-‐day
pneumonia
readmission
rate
mortality
rate
Accountable
En*ty
Hospitals
increasingly
penalized
for
subpar
care
outcomes
despite
diffuse
responsibility
Source:
U.S.
Department
of
Health
and
Human
Services,
“Hospital
Compare,”
available
at:
1
Acute
Myocardial
Infarc;on.
hSp://www.hospitalcompare.hhs.gov,
accessed
March
10,
2011;
Clinical
Advisory
Board
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interviews
and
analysis.
11
New
Payment
Models
Extend
Realm
of
Responsibility
Reimbursement
Increasingly
Spanning
Con=nuum
of
Care
Con*nuum
of
Care
Pre-‐Acute
Inpa*ent
Acute
Post-‐Acute
Readmissions
Penal;es
Inpa;ent
Bundling
(ACE
Demonstra;on)
Episodic
Bundles
(Na;onal
Pilot
Program
on
Payment
Bundling)
Shared
Savings
(Medicare
Shared
Savings
Program)
©
2011
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Company
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Source:
Clinical
Advisory
Board
interviews
and
analysis.
12
Rethinking
Our
Rela;onships
Across
the
Con;nuum
Hospitals
Must
Partner
with
Previously
Siloed
Stakeholders
Con*nuum
of
Care
Pre-‐Acute
Inpa*ent
Acute
Post-‐Acute
Stakeholders
involved:
PCP
Pa*ent
Specialists
Hospitalists
Nurses
Home
Health
SNF
Medical
Home
Case
Manager
Pa*ent
Allied
Health
PCP
Pa*ent
Specialists
Care
q Adequate
q Length
of
stay
management
q Partner
with
post-‐acute
coordina*on
preventa;ve
care
q Inpa;ent
u;liza;on
providers
impera*ves:
q Disease
preven;on
management
q Standardize
care
site
q Reduce
readmissions
transi;ons
q Reduce
readmissions
©
2011
The
Advisory
Board
Company
–
22421B
Source:
Clinical
Advisory
Board
interviews
and
analysis.
13
One
Thing
We
Can
All
Agree
On
Readmissions
the
Star;ng
Point
Carrots
and
S=cks
to
Improve
Transi=ons
HR
3590
Sec*on
3025
Sec*on
399KK
Sec*on
3026
Readmissions
Quality
Improvement
Community-‐Based
Care
Reduc*on
Program
Program
Transi*ons
Program
• Star;ng
in
October
2012,
• Establishment
of
a
quality
• Beginning
in
2011,
program
will
hospitals
will
face
penal;es
for
improvement
program
for
receive
mandatory
30-‐day
all-‐cause
readmissions
hospitals
with
high
readmission
appropria;ons
of
$500
million
for
three
condi;ons
(AMI,
HF,
rates
within
two
years
of
bill
over
5
years
pneumonia)
passage
• Funding
for
en;;es
that
provide
• Possible
expansion
to
COPD1,
• Hospitals
will
work
with
pa;ent
care
transi;on
services
for
high
CABG2,
PTCA3,
other
vascular
safety
organiza;ons
to
reduce
risk
Medicare
beneficiaries
condi;ons
readmissions
1 Chronic
Obstruc;ve
Pulmonary
Disease.
2 Coronary
Artery
Bypass
Gras.
3 Percutanueous
Transluminal
Coronary
Angioplasty.
Source:
HR
3590
Pa;ent
Protec;on
and
Affordability
Act;
©
2011
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Advisory
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Clinical
Advisory
Board
interviews
and
analysis.
14
Penal;es
Adding
Urgency
Excess
Payment
Calcula*on
Adjustment
Based
on
Maximum
Penalty2
Number
%
Higher
Average
Excessive
Total
Opera*ng
Payments:
Condi*on
of
Than
Pa*ents
Reimbursement
Expected1
Payment
$50
million
HF
450
$5,000
15%
$337,500
Excess
payment
of
Maximum
AMI
300
$4,500
5%
$67,500
$625,000
as
percentage
percentage
allowed
of
total
opera=ng
in
FY
2013=1.0%
payments=1.25%
Pneumonia
250
$4,000
22%
$220,000
Total
Excess
Payment
$625,000
Actual
Penalty=$500,000
Customized
Readmissions
Assessment
• As
a
special
service
to
our
members,
the
Clinical
Advisory
Board
is
offering
a
customized
assessment
of
es;mated
readmissions
penal;es
• If
interested
in
obtaining
an
assessment
for
your
hospital,
e-‐mail
[email protected]
1 Published
rate
on
Hospital
Compare
divided
by
Na;onal
Average.
2 Adjustment
factor
calculated
as
percentage
of
revenue
paid
for
excessive
readmissions
divided
by
total
revenue,
with
a
maximum
of
1%
of
total
DRG
payments
in
2013,
2%
in
2014,
and
3%
in
2015.
©
2011
The
Advisory
Board
Company
–
22421B
Source:
Clinical
Advisory
Board
interviews
and
analysis.
15
Readmissions
Not
the
Only
Metric
Worth
Considering
Experts
Ques=on
Value
as
an
Accountability
Measure
Recommended
Process
Measures
Related
to
Care
Coordina*on
High-‐quality
medica;on
reconcilia;on
Telephone
follow-‐up
“Acco
untability
measures
should
have
a
strong
evidence
base
f
or
their
validity,
should
accurately
measure
whether
Use
of
nurse-‐directed
high-‐quality
care
has
been
provided,
and
should
have
a
low
case
management
risk
for
unintended
consequences…although
hospital
readmissions
have
become
the
gold
standard
for
assess
ing
the
effec*veness
of
hospital
discharge
proce
sses,
this
outcome
measure
remains
a
surrogate
for
Health
and
quality
of
the
re
al
outcomes
of
interest—health,
quality
of
life,
and
life
aser
discharge
value.
”
Source:
Axon,
R.
and
M.
Williams,
"Hospital
Readmission
as
an
Accountability
Measure,"
JAMA,
February
2,
2011,
305(5);
©
2011
The
Advisory
Board
Company
–
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Clinical
Advisory
Board
interviews
and
analysis.
Promp;ng
the
Need
for
a
Broader
Framework
for
16
Care
Transi;ons
Domain
Measure
Source
Pa;ents
discharged
from
an
inpa;ent
facility
to
home
or
any
other
site
of
care,
or
their
ABIM;
ACP;
PCPI;
caregiver(s),
who
received
a
transi;on
record
(and
with
whom
a
review
of
informa;on
SHM
was
documented)
at
the
;me
of
discharge
Pa*ent
and
Family
Pa;ents
discharged
from
ED
to
ambulatory
care
or
home
health
care
who
received
a
ABIM;
ACP;
PCPI;
Informa*on
transi;on
record
at
the
;me
of
ED
discharge*
SHM
at
Discharge
Pa;ents
discharged
from
an
inpa;ent
facility
to
home
or
any
other
site
of
care,
or
their
ABIM;
ACP;
PCPI;
caregiver(s),
who
received
a
reconciled
medica;on
list
at
the
;me
of
discharge*
SHM
3-‐Item
Care
Transi;on
Measure
(CTM-‐3)*
NQF
Pa;ents
discharged
from
an
inpa;ent
facility
to
home
or
any
other
site
of
care
for
whom
a
ABIM;
ACP;
PCPI;
Informa*on
transi;on
record
was
transmiSed
to
the
facility
or
PCP
or
other
health
care
professional
SHM
Transfer
to
designated
for
follow-‐up
care
within
24
hours
of
discharge*
other
Sites
of
Care
No;fica;on
to
PCP
that
pa;ent
was
admiSed
to
an
acute
inpa;ent
facility
within
24
hours
Observed
prac;ce
of
admission
Pa;ents
discharged
with
a
follow-‐up
appointment
scheduled
within
5
days
of
discharge
Observed
prac;ce
Follow-‐Up
Care
Pa;ent
compliance
rate
with
showing
up
at
first
follow-‐up
appointment
Observed
prac;ce
Follow-‐up
phone
calls
conducted
for
high-‐risk
pa;ents
within
48
hours
of
discharge
Observed
prac;ce
Discharge
Percentage
of
admissions
where
pa;ents
and
family
caregiver
are
included
in
assessing
IHI
Planning
post-‐discharge
needs
Source:
Na;onal
Quality
Forum
(NQF),
Preferred
Prac;ces
and
Performance
Measures
for
Measuring
and
Repor;ng
Care
Coordina;on:
A
Consensus
Report,
2010;
AHRQ,
Care
Coordina;on
*Endorsed
by
the
Na;onal
Quality
Forum.
Measures
Atlas,
January
2011,
available
at:
hSp://www.ahrq.gov/qual/careatlas/,
accessed
March
©
2011
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6,
2011;
Clinical
Advisory
Board
interviews
and
analysis.
17
Defining
Care
Coordina;on
Resul;ng
in
All-‐Encompassing
Defini;ons…
“Care
coordina*on
is
the
deliberate
organiza;on
of
pa;ent
“Coordina*ng
Care
to
Improve
Health
Outcomes
for
care
ac;vi;es
between
two
or
more
par;cipants
(including
Pa;ents:
Developing
new
models
that
make
it
easier
for
the
pa;ent)
involved
in
a
pa;ent’s
care
to
facilitate
the
doctors
and
clinicians
in
different
care
sewngs
to
work
appropriate
delivery
of
health
care
services.
Organizing
care
together
to
care
for
a
pa;ent.
Examples
include
iden;fying
involves
the
marshalling
of
personnel
and
other
resources
and
widely
deploying
the
best
advanced
primary
care
and
needed
to
carry
out
all
required
pa;ent
care
ac;vi;es,
and
is
health
home
models,
and
suppor;ng
innova;ons
in
osen
managed
by
the
exchange
of
informa;on
among
accountable
care
organiza;ons.”
par;cipants
responsible
for
different
aspects
of
care.”
AHRQ
in
conjunc*on
with
Stanford-‐UCSF
Center
for
Medicare
and
Medicaid
Innova*on
Evidence-‐based
Prac*ce
Center
(Innova*on
Center)
“N3C
defines
care
coordina*on
as
a
client-‐centered,
“Care
coordina*on
is
a
func;on
that
supports
informa;on-‐
assessment-‐based
interdisciplinary
approach
to
integra;ng
sharing
across
providers,
pa;ents,
types
and
levels
of
service,
health
care
and
social
support
services
in
which
a
care
sites
and
;me
frames.
The
goal
of
coordina;on
is
to
ensure
coordinator
manages
and
monitors
an
individual’s
needs
and
that
pa;ents’
needs
and
preferences
are
achieved
and
that
preferences
based
on
a
comprehensive
care
plan.”
care
is
efficient
and
of
high
quality.”
The
Na*onal
Coali*on
on
Care
Na*onal
Commihee
for
Quality
Coordina*on
(N3C)
Assurance
(NCQA)
Source:
AHRQ
at
www.ahrq.gov;
Center
for
Medicare
and
Medicaid
Innova;on
at
hSp://innova;ons.cms.gov/;
Na;onal
Coali;on
on
Care
Coordina;on
at:
hSp://otrans.3cdn.net/9f87d9634b2a786e51_f6m6iyik5.pdf;
NCQA
©
2011
The
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Board
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at
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Clinical
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analysis.
18
…And
Infinite
Areas
of
Explora;on
A
Thousand-‐Foot
View
of
Care
Coordina=on
BCaosemdm
Seurnviticye-‐s Care
Transi;ons
Programs Chronic
Disease
Access
to
Care Disease
Management DRuepdliuccai;nogn
Care
Plans Medical
Home TeInchfonromloag;yo
(nIT
)
Preven;ng
Readmissions Care
Coordina*on Pa;ent-‐Centered
Care
Case
Management
Inpa;ent
Handoffs
Health
Coaches
Geriatrics
Discharge
Planning
©
2011
The
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Source:
Clinical
Advisory
Board
interviews
and
analysis.
19
Our
Perspec;ve
Placing
Acute
Care
at
the
Center
Mul=ple
Entry
Points
to
Health
Care
System
SNF
Specialist
Home
ED
Medical
Home
Hospital
Pharmacy
Community
Agency
Home
Health
LTAC
Primary
Care
©
2011
The
Advisory
Board
Company
–
22421B
Source:
Clinical
Advisory
Board
interviews
and
analysis.
20
Arriving
at
a
Workable
Scope
for
Care
Coordina;on
Defining
the
Focus
for
Today’s
Presenta=on
Three
Screens
for
Other
Advisory
Board
Research
Study
Inclusion
on
Care
Coordina*on
Preven*ng
Unnecessary
Criteria
Descrip*on
Readmissions:
Transcending
the
Hospital’s
Four
Walls
for
Topic
is
largely
within
the
control
of
Collabora0ve
Care
Coordina0on
Controllability
the
hospital
and
could
be
inflected
by
CAB
(2010)
hospital
staff
Next
Genera*on
Capacity
Implementa;on
of
best
prac;ces
Impact
on
Management
Vol
2:
Best
within
category
would
posi;vely
Quality
Prac0ce
for
Collabora0ng
to
impact
clinical
quality
outcomes
CAB
Drive
Toward
Discharge
Strategy
and
terrain
not
covered
at
(2009)
length
by
past
research
within
the
Originality
Clinical
Advisory
Board
program
or
Medical
Home
Project:
external
research
www.advisory.com/hcab/
medicalhome
HCAB
Fron*er
Strategies
for
Care
Management
Whitepaper
(Coming
Soon
in
2011)
CAB
©
2011
The
Advisory
Board
Company
–
22421B
Source:
Clinical
Advisory
Board
interviews
and
analysis.
Description:Source: Report to the Congress: Reforming the Delivery System, September 16,
. high-‐quality care has been provided, and should have a low ABIM; ACP;
PCPI;. SHM. Pa;ents discharged from ED to ambulatory care or Source: AHRQ
at www.ahrq.gov; Center for Medicare and Medicaid Innova .. policies
