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Reducing Avoidable Readmissions: Care Transitions

This is the second in our series, recapping the lessons learned from the Institute for Healthcare Improvement’s Reducing Avoidable Readmissions course.

Care transitions are seen as key to improving readmission rates, and understanding that readmissions are not just the hospital’s responsibility but involve a care team that includes the patient, the patient’s caregiver, homecare, and skilled nursing depending on where the patient is discharged.

Both ensuring good care transitions to decrease readmissions, but also discharging to the right facility are crucial for lowering costs and improving care. Post-acute care shows the greatest discrepancy in costs per patient and is growing at 6% annually for Medicare patients. Today, 40% of Medicare patients discharge to a post-acute care facility, and 33% of patients in these facilities experience a care-related adverse event. By 2017, skilled nursing facilities could face penalties of up to 3% of Medicare payments for readmissions, thus there are real incentives to improve transitions, if patient safety isn’t enough to effect change.

The first step in improving care transitions is to ensure that the patient is going to the right setting, and this requires a decision by the care team that includes the patient and the patent’s caregivers. If money is not an object, many hospitals discharge to skilled nursing as a way of insuring that the patient doesn’t readmit. However, if care transitions are not handled properly, this adds costs without improving quality.

One of the biggest challenges in care transitions, is that there are no universally agreed upon assessment tools for determining the best next step for patients on hospital discharge, hence the over prescribing of skilled nursing. Beginning to track readmissions and outcomes should help organizations stratify risk and begin to be able to predict the best setting based on data. In addition to data, interview patients. Often missed care transitions are only identified by the patient him or herself as they are more aware of what was lost in transition.

Possibly because of the make-up of the attendees in the course, the transition from hospital to skilled nursing was a hot topic. Hospital attendees admitted to have little insight into how skilled nursing facilities worked. Skilled nursing attendees expressed frustration with the amount of patient information they received when admitting a patient. One attendee begged “just let me see the patient’s medical record.”

In order to facilitate better transitions, cross-functional teams need to be developed and these need to include members of the receiving facility. One skilled nursing facility reported significantly better transitions by simply placing one of their nurses in the hospital part-time to meet with patients before they were transferred.

These teams must have support at two levels: the executive level must provide resources and be open to changes recommended by the functional team that handles the care transitions. Functional teams must feel empowered to change and improve processes for care. Organizations that are pursing ACO models and bundled payments were seen as great opportunities for these types of cross-organizational and cross-discipline care teams.

The INTERACT tool is a way to ensure that the receiving organization gets the right patient care information during this transition. Unfortunately, given the lack of interoperability of medical systems, this approach requires additional paper work. There is no easy way to share patient records between EMRs or organizations, or sometimes within the same organization.

Other best practices in patient transfer include:

  • “warm handovers” that is, no patient is transferred with out a real-time conversation between physicians
  • Sending the patient with a 3-day supply of medication so there is no interruption and include pharmacy in the transfer team
  • Following up with the skilled nursing facility by phone within 24-48 hours post transfer
  • Sending information about patient preferences. One example was given of a patient who preferred to take her medication with Coke. She was greeted at the skilled nursing facility with a Coke and her medication.
  • Regular meetings between skilled nursing and hospital
  • Relationship building and storytelling for all parties to understand constraints that other side is facing
  • Creating a standard follow up and communication protocol based on patient risk of readmission

Post Acute Care Follow Up Communications

In keeping with the opening statement of the course, there is no silver bullet, just a lot of practical common sense advice, and clear and timely communication.

Next we’ll look at some best practices for discharging to home and the role of the primary care physician.

Posted in: Health Regulations, Healthcare motivation, Healthcare Policy, Healthcare Technology, Healthcare transformation

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Healthcare Reform and the Affordable Care Act: One Year Later

APTA CSM 2015 Recap: Healthcare Reform and the Affordable Care Act: One Year Later

Speaker(s):

Edward Dobrzykowski, PT, DPT, ATC, MHS

Janice Kuperstein, PhD

Karen Ogle, PT, DPT

Charles Workman, PT, MPT, MBA

CSM StepsThe consensus from the speakers in this session was that the changes are real, they require work on the part of healthcare providers, and that physical therapists have a great opportunity to participate. There was definitely a greater sense of urgency on this topic than in previous years at CSM, and speakers made sure the audience knew that:

“While we’re all worried about G-codes, new players like Walmart, Walgreen’s, and Google are creating entirely new models of care.”

“Patient satisfaction is not enough, we need to look at outcomes”

“Reducing length of stay is not going to be the only way to reduce costs.”

Some of the major themes of the Affordable Care Act that speakers believed impact physical therapy include:

  • Realignment of care models from management of chronic disease to preventative medicine
  • Conservative interventions preferred over surgery due to costs and outcomes
  • New payment models and reduction in visits
  • Direct access to physical therapy
  • Standardization of service
  • Accountability for services delivered
  • Outcomes measurement

All of these were seen to provide both challenges and opportunities to the profession. Similar to other sessions, opportunities in improving outcomes and decreasing costs of post acute care, and in improving discharge, and care transitions to reduce readmissions were seen as key areas where physical therapy could have a big impact, however, physical therapists needed to participate more in the process.

Presenters pointed out that homecare workers and occupational therapists are already working in health coaching positions for population health management, but physical therapists were not really serving in these roles. Given that many studies show that discharge to home is best for the patient, and also lowers costs, this is seen as a missed opportunity for physical therapists.

Full moon over Indianapolis

Full moon over Indianapolis

In order to effect change, moving to more accountability and measurement is important, for example predictor tools to score patient on risk of readmit and standardized outcome tools. By moving to these measures and recording outcomes, physical therapists will be better able to participate as part of new payment models, like bundled payments.

Considering that for the patient, function is usually the most important outcome, and physical therapists are experts in delivering a return to function, the core value equation could be applied directly to physical therapy to deliver better outcomes at lower costs.

Value = Quality x Patient satisfaction

Attendees were encouraged to ask questions during the session and feedback ranged from a hospital-based physical therapist participating in a bundled total joint replacement scenario, where the hospital was receiving 3% back from CMS due to delivering positive outcomes at a lower cost than stipulated to those in smaller or private practice wondering whether there was room for them to participate in these types of payments with hospitals, or whether they would be shut-out. This was a common theme at the conference as private practice owners questioned whether controlling costs and outcomes would mean that hospitals would bring outpatient physical therapy in-house.

Similar to other sessions, suggested that the two keys to delivering on new value-based payment models required better care collaboration among multi-disciplinary teams and standardized outcome reporting.

“Merely aligning financial incentives between providers of acute and post-acute care will not improve quality and reduce costs for episodes of care. True coordination of care is required to ensure the best possible outcomes.” Ackerly DC and Grabowski DC. Post-Acute Reform- Beyond The ACA. NEJM 2014;370(8):689-691

For outcome reporting, the question was asked if patient-reported outcomes were the new gold standard. If patient satisfaction and functional outcomes are key in the value equation, then they are.

To conclude presenters reminded participants what they can do to participate in this new world, which reflects the larger clinical, demographic, and social trends.

  • Develop strategies and tactics around population health management
  • Optimize efficiency in each practice segment
  • Build collaboration “upstream” and “downstream”
  • Position for more integration

The session did a great job of showing that the change is real, the opportunities are there, but also making attendees understand that the time is now. Our overall impression of the conference this year is that physical therapists have a great opportunity to be on the front-lines of some of this change but that they may need to move faster than in the past. Exciting times to be in patient-centered care!

Posted in: Behavior Change, Health Regulations, Healthcare transformation, Outcomes, Physical Therapy, Rehabilitation Business

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Stroke Rehabilitation is the Poster Child for the Need for Collaborative Care

APTA CSM 2015 Recap: Anne Shumway-Cook Lecture: Transforming Physical Therapy Practice for Healthcare Reform

Speaker: Pamela Duncan, PhD

Interdisciplinary teams and patient-centered care are key to the future of healthcare, and physical therapists attending this keynote of the Neurology track at APTA CSM 2015 in Indianapolis were encouraged to embrace this change. Bemoaning the lag time from research to clinical practice, Pam Duncan suggested that researchers find ways to work with interdisciplinary teams of biomechantical engineers and even private companies to bring innovation to patients faster. She started with the inspiring example of Carol Richards who received the Order of Canada for her work with the interdisciplinary team on the Stroke Network Canada, aimed at decreasing the impact of stroke across Canada.

Source @mdaware on Twitter

Source @mdaware on Twitter

Duncan then told a story to explain her passion for changing post-acute stroke care, involving a personal experience that changed the course of her career. Duncan’s mother suffered a stroke and while Duncan was trying to provide comfort in her mother’s last days, a traveling physical therapist arrived in the hospital room with a goal of getting her mother to get her mother to stand, which was apparently the clinical protocol she was assigned to do. Duncan protested and later spoke to the owner of the physical therapy company that had contracted to the hospital. He shrugged and asked her why she cared since Medicare would pay for the visit. Incensed at the waste of time and money but more furious at the way this care completely disregarded the patient’s best interests, Duncan put aside her plans for opening a private practice and focused research to improve post-acute care for stroke patients.

Translating Research to Evidence and the Humble Researcher

With the same vehemence, Duncan described how she believed that over 180 publications she’d made on the topic had done little to advance stroke care, largely due to the difficulty of translating clinical research into practice, and asked the researchers in the audience to change this by developing interdisciplinary teams, questioning all their assumptions, and thinking about the patient holistically, not just from their own discipline.

She asked researchers to be “humble researchers” referencing a column by the New York Times columnist David Brooks and not just set out to prove what they want to be true. Duncan used an example in her own research which disputed a popular belief on stroke recovery and showed that home-based exercise was more effective than treadmill-based. Duncan described herself as still having arrows in her back from that publication.

Best Practices for Stroke Recovery

After lighting a fire for the audience to think about things differently  by saying

“Take off your neuro-plasticity hat and think about patients holistically.”

Duncan continued with specific examples on how to change care. First was to understand the overall situation. 10-30% of stroke patients face permanent disability, something that is not always clear when they are released from hospital within 3-5 days of the incident. She gave an example of a patient who was discharged with care instructions and prescriptions yet when she got home she couldn’t follow them: she discovered the stroke had affected her ability to do basic calculations.

“If you asked if I had discharge instructions I would have said yes, I heard what the nurse said and I showed her I could inject my drugs, and my math deficit wasn’t diagnosed until I got home. I did the things I needed do to get discharged but wasn’t really able to cope.”

This is a clear example of how our current system fails us. It does not support the patient outside the clinic, and yet it’s so much less expensive and more comfortable for the patient to be released to home. Looking at the costs it’s clear that we need to improve home health options.

Post stroke care costs:

  • Acute inpatient care: $8,000
  • Skilled Nursing Facility: $41,000
  • Inpatient Rehab: $14,000
  • Home health: $6,000
  • Long-term care: $62,000

As Duncan put it, “Home health is a dirty word in Washington” yet this where the patient should be. She called stroke the poster child for the discontinuity of care in healthcare as 73% of post stroke readmissions are for other issues not related specifically to the heart. Duncan sees hope though, and called bundled payments the best thing to happen to stroke recovery as providers will have to collaborate across the care continuum.

She sees the benefits as:

  • Coordinated high quality care with seamless transitions
  • One primary metric for integrated care
  • Excellence based on outcomes

The message to physical therapists is that they are uniquely suited to these multi-disciplinary teams focused on patient outcomes. For patients, outcomes are measured by function. For CMS, value is measured by those functional outcomes divided by the cost and physical therapists can deliver on both.

This session was a great kick-off to the conference, which had an overall tone of embracing the changes coming in healthcare and the role of physical therapists in it. As a company providing continuity of care through digital treatment plans and connections with healthcare providers outside the clinic we were inspired to see so many people embracing this change.

Posted in: Aging, Health Regulations, Healthcare Disruption, Healthcare transformation, Physical Therapy

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Good, Fast, and Cheap: Demonstrating Value in Health Innovation

The goal of Triple Aim is to say that, despite what any project manager will tell you, you can have all three.

Good, Fast, Cheap

Source: http://ollmann.cc/

This provocative statement, set the tone for this third installment in Seattle’s  Health Innovator’s Collaborative, a talk called “Demonstrating Value in Health Innovation: Lessons from Comparative Effectiveness Research” by Larry Kessler, Professor and Chair, Department of Health Services, UW School of Public Health and formerly of the FDA, NIH, and NIMH. Dr. Kessler believes that the new accountable care organizations are mandated to deliver on all three and used the example of the Institute for Healthcare Improvement which was founded in 1991 on this principle and brings together leading hospitals, policy people, and researchers who are finding the best ways to deliver triple aim across many specialties.

Changes in how healthcare systems deliver care will drive innovation; however, innovation for its own sake will not win. Innovation must show evidence, cost savings, and revenue drivers. At the same time, it must satisfy a much wider group of stakeholders than previously including patients, physicians and clinicians, payers and providers. Innovative approaches and technology will take the leap past simply showing evidence of clinical outcomes to delivering value. This is a dramatically different approach from how typical NIH or FDA studies are done today. Those studies are done with a small slice of the population that is homogeneous, for example, they only have one issue and no co-morbidities. This type of study may prove outcomes with this particular population, but it doesn’t show cost or revenue based value and is no indicator of how something would work in the population at large, where the sickest patients are usually struggling with more than one issue.

Quality needs to be redefined as the best service AND the best health outcomes AND the best cost outcomes. Dr. Kessler went on to show some clear examples where solutions needed to go to the next level to be adopted and show results.

The first example provided a model that showed over a 5 year period, gastric bypass surgery proved cost effective. However, insurance plans do not include this surgery and require copious paperwork to justify it. This may make sense though, as the determinates of whether surgery is actually cost effective include a number of additional factors like the population and especially whether they will be part of your problem in 5 years. This is where the new accountable care organizations that are charged with population health will have an easier time with the cost benefit analysis as they be responsible for these patients in 5 years.

Another similar example is the new drug Solvaldi for the treatment of Hepititis C. It’s recently been in the news for its staggering price tag: $84,000 for a 12-week course. However, the drug has proved to be extremely effective, and University of Washington health economist Sean Sullivan points out “the drug is far cheaper than the alternative, which is a liver transplant and a lifetime of immunosuppressant drugs.” Again, though, whether this is a bargain or not depends on how long the payer thinks they will be responsible for the patient.

Successful business outcomes based on cost savings were shown in the example of two diagnostic tests for whether breast cancer would reoccur. The FDA-approved test MammaPrint could predict the recurrence of breast cancer. The non-FDA approved test Oncotype DX could predict the recurrence of breast cancer AND whether chemotherapy would work for the patient. This test, while not FDA-approved became far more popular as it showed very clear cost savings and quality of life for patients who did not undertake unnecessary chemotherapy.

Another study, Back Pain Outcomes Using Longitudinal Data-Extension of Research (BOLDER) was able to consider the patient experience as part of treatment. This study looked at 5,239 patients over 65 with new primary care visits for back pain across 3 integrated systems: Kaiser Permanente of Northern California, Henry Ford Health System, Harvard Vanguard/Harvard Pilgrim. The study goal was to determine the impact of early imaging as an intervention. The results are not yet published, but a couple of observations were already apparent. First, patients sent for MRIs, delay getting physical therapy and if the MRI shows they need physical therapy rather than surgery they have delayed their recovery by the time they waited for the MRI. In this case, the intervention of imaging if it was not needed produced less positive results for patients.

This study used the Roland-Morris Disability Questionnaire and it was also noted that many of the standardized testing tools do not account for what the patient actually considers a good outcome, like whether they can sleep soundly or have sex. Again, this shows that studies need to go a step further into the real world application of the patient’s situation.

These examples showed that it’s not enough to show that an intervention or new technology worked in a study, they also need to work in the real world. For payers that means lowering costs, for providers that means lowering costs or generating revenue while improving outcomes, and for patients that means delivering outcomes that are important to them, not just clinically validated.

The final lecture in this series will be June 3rd with Peter Neupert of Health Innovation Partners. See you there!
“IT can make a big difference in health:  Why hasn’t it?”

Health Innovators Collaborative
4:30 PM, W.H. Foege Building, UW Campus
Seminar: Foege Auditorium (S060)
Reception: Foege North 1st Floor Lobby

 

Posted in: Healthcare Disruption, Healthcare Technology, Healthcare transformation, Seattle

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UW Medicine’s Journey To Become An Accountable Care Organization

As part of the newly forming Health IT community in Seattle, the Unveristity of Washington and the Washington Biotechnology and Biomedical Association have partnered on the “Health Innovator’s Collaborative” which launched with a series of seminars on how the coming changes in US healthcare affect organizations and innovation.

Accountable Care OrganizationsThis past Tuesday, I attended a talk by Paul Ramsey, MD, and CEO of University of Washington Medicine entitled “The Transformation of Healthcare: Forces, Directions and Implications.” Despite this lofty title, Dr. Ramsey focused on the nuts and bolts of the new Affordable Care Act (ACA) with specific examples of how UW Medicine is becoming an Accountable Care Organization (ACO).

First off, Dr. Ramsey started with some definitions of the goals of the Affordable Care Act and Accountable Care Organizations. When asked if the ACA is having a profound effect, he stated that regardless of any other measures, the number of individuals who are now insured is significant. Harborview Medical Center, a member of the UW Medicine System that covers a diverse and often low-income population, has already seen a 2% decrease in patients without coverage.

What was striking about the session was Dr. Ramsey’s clear conviction that while the ACA is morally just (we need to stop pricing people out of healthcare) organizations becoming ACOs were currently doing it because it makes human sense, while not currently financial sense. The reason it doesn’t currently make financial sense is that the first ACO contracts between payers and providers are still in negotiation and in the switch between reimbursements for procedures to reimbursement for outcomes providers initially see lower revenues as they decrease the number of unnecessary procedures. In the long run, this is mitigated by getting the right care to patients and by managing population health in addition to individual health

The triple aim of the ACA is to improve experiences for individuals, improve overall population health, and reduce the cost of care: lofty but extremely important goals. While managed care and HMOs were supposed to do this in the 90s, their main failure was having the primary care physician as the gatekeeper to all other services. This did not guarantee that the patient received the best and most cost effective care. Dr. Ramsey contrasted this to the goals of an ACO, where a patient might call a nurse hotline and be referred to emergency, their primary care physician, or receives an e-care visit, depending on which was best for the patient and most cost effective in the long run.

When asked if this model was a capitated model, Dr. Ramsey said yes, but at a population level, and that is why the current negotiations between payers and providers are so important. Providers are choosing which measures they will be held accountable for in their first year as an ACO. UW Medicine is choosing seven disease management measures, three health status and screening measures, and number of caesarian sections, which is apparently a hot button measure for CMS. Because all measures will not be implemented immediately UW Medicine will spend some time transitioning between models, however, this does not mean they won’t continue to improve care in all areas. He cited his own recent experience as a cataract patient at UW Medicine as of an example where high quality outcomes, patient care, and cost-effectiveness were combined.

As a guide for these types of measures, and as an example of the medical profession taking on best practices regardless of financial incentives, Dr. Ramsey cited http://www.choosingwisely.org where each medical specialty association provides their own guidelines for reducing unnecessary procedures and promoting best practices. This is a great resource for patients as well to review whether costly procedures are actually recommended and effective.

Accountable Care OrganizationsThere was some discussion that the US medical system as a whole could decrease costs by 25% without reducing the quality of care. UW Medicine has been able to reduce costs by $90M annually which is only a 2-3% of their operating budget and remain a top hospital. UW Medicine will continue to improve on both costs and their overall ratings.

Interestingly, the most important factor in patient satisfaction, a key health system rating, is the communication with their healthcare provider, rather than the outcomes. Improving patient/provider communication is an extremely cost effective way to ensure great care.

This was a great talk, realistic yet optimistic about the challenges and opportunities inherent in this transition to the new models of care we so desperately need.

The two remaining talks are:

May 13, 2014: “Demonstrating Value in Health Innovation: Lessons from Comparative Effectiveness Research”

Larry Kessler, ScD, Chair of UW Department of Health Services and former Director, Center for Devices and Radiological Health, FDA, will consider the coming necessity for innovations to demonstrably provide value and how the experience with comparative effectiveness can help innovators gather the needed evidence.

June 3, 2014: “IT can make a big difference in health: Why hasn’t it?”

Peter Neupert, Operating Partner of Health Evolution Partners and former VP of the Health Solutions Group at Microsoft will draw on his extensive experience with both institutional and consumer aspects of health IT to consider the enormous potential and serious pitfalls that make this area of innovation so challenging.

Editor’s Note: The primary care physician as gatekeeper is a failure in the single payer system as well. It denies patients access to the care they need and also adds waste into the system. In Canada for example, a referral to a specialist must be done by a primary care physician and expires every 6 months. So, if a patient has a chronic disease that they need to see a specialist for, the patient cannot keep seeing that specialist without getting another referral, even if all parties agree the patient should keep seeing that specialist.

Posted in: Health Regulations, Healthcare Disruption, Lean Healthcare

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