Introduction to the Acute Care Hospitalization Improvement Matrix

1
Introduction to the Acute Care Hospitalization
Improvement Matrix

• Part I
• October 20, 2005

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Objectives

• Provide an overview of the CMS acute care
  hospitalization initiative
• Discuss the Acute Care Hospitalization Pilot
  Project
• Review the Acute Care Hospitalization Improvement
  Matrix its application to Plan of Action
  Development
• Discuss the Acute Care Hospitalization Planning
  Packet how to use it

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CMS Health Care Quality Improvement Program

• Vision The right care for every person every
  time
• Key strategies
• Performance measurement public reporting
• Process redesign
• Effective use of health information technology
• Organizational culture change
• Priority focus for home health
• Reducing acute care hospitalization

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OBQI Definition for Acute Care Hospitalization

• Percentage of home health episodes in a 12-mo
  period that end with hospitalization (emergent,
  urgent, elective)
• Numerator - all episodes with a hospital
  inpatient facility admission
• Denominator - all episodes excluding patient
  deaths
• Risk-adjusted

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National Hospitalization Episode Rate
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Outcome Performance Gap Opportunity for
Improvement
Nationally, over 950,000 hospitalizations
from April 2003-March 2004
25th percentile 23.16 50th percentile
29.03 75th percentile 36.46
Source QIES, OBQI Rollup Summary
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Potential Cost Savings to Medicare Trust Fund

• 81,318 fewer acute care hospitalization episodes
  from 9/2006-8/2007
• Medicare Trust Fund savings could equal 1.68
  billion
• (Based upon length of stay average cost at
  3506.00 per day)

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Home Health Length of StayPrior to
Hospitalization
Home Health LOS All Episodes w/ hospitalization 5-State episodes w/hospitalization
Within 1 week of SOC 25.44 30.81
Within 2 weeks of SOC 44.65 49.58
Within 3 weeks of SOC 57.83 62.44
Source CY2003 OASIS
Source CY2003
hospital claims for MD, MI, NY, RI, VA
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Hospital Home Care Primary Diagnosis
Category 5-state Hospital Claim Dx All Hospitalized OASIS HC Dx
Circulatory System Disease 27.11 24.47
Congestive Heart failure 9.65 8.15
Respiratory System 14.47 9.56
Pneumonia 5.74 2.76
Injuries and Poisonings 9.94 7.54
Source CY2003 hospital claims for MD, MI, NY, RI,
VA all OASIS
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Relationship of Emergent Care to Acute Care
Hospitalization

• Episodes with hospitalization
• 66.43 also had emergent care
• Episodes with emergent care
• 83.73 ended with hospitalization
• Source CY2003 OASIS

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Characteristics of Hospitalized Patients

• More functionally impaired prior to at start
• Fewer with moderate recovery prognosis
• Fewer with good rehab prognosis
• 68 - hospital discharge within 14 days
• Source CY2003 OASIS

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Literature Review

• Available studies to date provide limited
  information on best hospitalization rates for
  home health patients
• National and New York OBQI demonstration projects
  HHAs overall were able to attain
  hospitalization rates in the low-mid 20 range

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Acute Care Hospitalization

• Proxy measure for deterioration in health status
• Do not expect 0
• Nature of some illnesses limits of medical
  science
• Elective reasons for admission
• Goal is to reduce avoidable hospitalizations
• Prevent deterioration
• Identify warning signs to trigger early
  intervention

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Target Goals

• CMS has established a high performance goal of
  23 over the next three years
• 25 of HHAs have achieved this or lower
• May not be achievable for all agencies
• Imperfect risk models
• Greater volatility of rates for small agencies
• NYS LTHHCP patient population
• Caution - Should not be achieved at the cost of
  denying high risk patients access to home health
  care services or necessary hospitalization

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Acute Care Hospitalization Pilot ProjectMarch
29, 2005 July 11, 2005
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Pilot Participants

• Michigan
• New York
• Rhode Island
• Tennessee
• Utah
• Virginia
• Washington

• VNSNY Center for Home Care Policy and Research
• QIOs
• Arizona
• Idaho
• Louisiana
• Maryland/DC

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Big Thanks To Our Leaders Champions!

• v     At Home Care
• v     Community Health Center
• v  Hospitals Home Health Care
• v     Ideal Senior Living Center LTHHCP
• v     Lifetime Care Home Health Hospice
• v     Seton Home Health
• v     South Nassau Communities Hospital Home Care
• v     St. Joseph's Certified Home Care Agency
• v     St. Peter's Hospital Home Care
• v     Univera Home Health
•  v    VNA of Albany
• v     VNA of Staten Island
• v     VNA of Utica Oneida County
• v     Winthrop Hospital Home Health

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Background on Development

• Partner with VNSNYs Center for Home Care Policy
  and Research
• Data Analysis
• Literature Search
• Consultation with Experts
• VNSNY Home Health Expert Panel
• Pilot Test 113 HHAs in 12 states

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Primary Objectives of Pilot

• Review and test strategies aimed at preventing
  avoidable hospitalizations
• Learn directly from HHAs implementing strategies
• Learn from QIOs supporting HHAs
• Modify/refine materials based on lessons learned
  in pilot test for use in the 8th SOW

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Acute Care Hospitalization (ACH) Improvement
Matrix
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Change Binder
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ACH Improvement Matrix Definitions

• Change Framework entire set of change concepts
  organized into Areas for Improvement and Stages
  of Care
• Improvement Matrix big picture of the
  organization and high-level strategies
• Strategy high-level change concept represents
  a series of actions designed to achieve a
  specific objective
• Action specific change idea that can be tested
  and implemented at the agency level
• Tool a form, instrument, or manual that can be
  used as is or modified to support strategies and
  actions
• Resource a reference for more information
  related to implementing specific strategies and
  actions

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ACH Improvement Matrix Stages of Home Health
Care

• Before the Home Health Agency Accepts the Patient
  for Care
• The First 24-48 Hours at Home
• Throughout the Episode of Home Care
• If the Patient has Reached the Emergency
  Department

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ACH Improvement Matrix Rationale The Chronic
Care Model

• ¾ of hospital in-patient stays attributable to
  people with chronic conditions
• Chronic care poorly managed in U.S. healthcare
  system
• Need to overcome healthcare silos
• Model widely used in improvement efforts across
  country

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Key Findings / Issues Shaping Design of ACH
Improvement Matrix

• Chronic conditions
• Multiple diagnoses
• Transitions
• Hospitalizations early in home health episode
• Stages of care
• Multiple factors - complexity

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ACH Improvement MatrixAreas for Improvement

• Promoting Patient Self-Management
• Implementing Evidence-Based Practices
  Guidelines
• Using Systems and Technology to Promote
  Effectiveness and Efficiency
• Improving Care Delivery Systems Mobilizing
  Community Resources
• Creating a Culture of Quality

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Evidence Base for Change Strategies

• Face validity - No-Brainers
• Urgent Care Plan
• Patient Tracking System
• Front-End Strategies
• Discharge planning
• Transitions
• Long-Term Strategies
• Evidence-based disease management
• Self care management

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Area for Improvement Example Improving Care
Delivery Systems Mobilizing Community Resources
Stage of Care Strategy
Before the HHA Accepts the Patient for Care Strategy D.1 Collaborate with hospitals to establish key criteria for safe, appropriate discharge from hospital to homecare
The First 24-48 Hours at Home Strategy D.2 Establish transition protocol for transfers from hospital or other facilities to homecare
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Example Strategies, Actions and Tools

• Strategy D1 Work with hospitals to make
  discharge planning more effective for homecare
  (Tool 61, 62, 63)
• Discharge checklist
• Transition protocol for patients coming from
  hospital
• Pre and post hospital discharge assessment and
  education
• Advance practice nurses or transition coaches
• Multi- disciplinary management teams
• Strategy D.2 Establish transition protocol for
  transfers from hospital or other facilities
  (e.g., SNF) to homecare (Tool 6, 64, 65, 66)
• Full medication reconciliation
• MD verification and communication
• Reconnect patient to primary care physician

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ACH Pilot Most Frequently Used Strategies

• Use evidence-based risk assessment tools to
  identify high-risk patients and incorporate risk
  factors into individualized patient care plans
• Equip patients and caregivers with information
  and options to address immediate/urgent care
  needs
• Use evidence-based, condition-specific/problem-spe
  cific interventions
• Implement systems to identify and track patients
  at increased risk for hospitalization and related
  problems

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ACH Pilot Most Frequently Used Actions

• Identify/adapt/adopt an evidence-based assessment
  tool to identify patients who are at risk of
  hospitalization and train physicians in its use
• Establish individualized urgent/emergent care
  contact plan for each patient
• Establish patient/caregiver understanding of
  high-risk health conditions and signs/symptoms of
  worsening conditions
• Identify/adapt/adopt evidence-based guidelines,
  protocols, interventions, and monitoring for
  disease-and problem-specific conditions

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Application of the Improvement Matrix to OBQI
Process
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OBQI and the Improvement Matrix

• Where how to start key issue
• Comprehensive Change Framework
• Represents excellent system of care required to
  make transformational change
• Not intended to do everything
• Add strategies over time
• Issues not the same in every agency
• The OBQI process along with some additional
  diagnostic tools can help narrow the focus

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Acute Care Hospitalization Planning Packet

• Risk-adjusted Outcome Report
• Descriptive Outcome Report
• Case Mix Report
• Outcome Case Mix Tally Reports in Workbook
  format
• Case Mix Analysis Report hospitalized versus
  non-hospitalized patients

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Acute Care Hospitalization Planning Packet

• Plan of Action Template
• Sample Risk Assessment Tool
• Process of Care Investigation Audit Tool
• ACH Improvement Matrix
• ACH Tools Resources

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Case Mix Analysis Tool

• Provides comparison of risk factors for
  hospitalized and non-hospitalized patients within
  your Case Mix Report

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Case Mix Analysis Tool -Example
Patient Characteristic Hospital-Yes Hospital-No
Moderate recovery prognosis 82.37 92.43
Good rehab prognosis 61.48 79.61
Terminal condition 13.44 6.76
Intractable pain 16.13 12.51
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Case Mix Analysis Tool -Example
Patient Characteristic Hospital-Yes Hospital-No
IV/infusion therapy 4.56 2.67
Enteral nutrition 3.25 1.32
Lives alone 15.01 11.33
Medicaid payment 16.23 11.14
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OBQI Outcome Enhancement Process
Collect transmitOASIS data
Measurepatientoutcomes
Monitoractionplan
Interpretoutcomereports
Implementaction plan
Specifytargetrate
Developaction plan
Investigatecareprocesses
Identifyproblems/strengthsand best practices
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Next Steps for Plan of Action Development

• Interpret Outcome Reports Specify
• Target Rate for Agency
• Compare agency risk-adjusted rate to other
  agencies in state other benchmarks (e.g., 23)
• Average rate is not necessarily the goal
• Extend the review of the case mix report to
  examine case mix differences between patients who
  are and are not hospitalized
• Can help focus process of care investigation
• Excel-based tool or gather during process of care
  investigation

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Target Setting

• Major Component of Plan of Action development
• Expectations for reductions should be based on
  agencys baseline rate
• Reaching the ultimate desired target rate should
  be expected over time

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Next Steps for Plan of Action Development

• Investigate Care Processes
• Begin with an organizational assessment
• Use information from case mix analysis outcome
  reports
• Construct audit tool
• Use Tally Workbook to identify 30 cases to sample
  for record review

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Next Steps for Plan of Action Development

• Identify Problems/Strengths and Best Practices
• Identify the problem or strength
• Specific Actions from the Change Framework can be
  considered for clinical best practices,
  especially those from
• Promoting patient self-management
• Implementing evidence-based practices and
  guidelines

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Next Steps for Plan of Action Development

• Develop Action Plan
• Specific Actions can be considered for
  intervention activities to implement clinical
  Actions (best practices), especially system
  changes
• Using systems and technology
• Improving care delivery systems
• Creating a culture of quality
• Strategy Combinations Identified Identifying
  patients at risk and implementing Actions to
  address the risk
• Disease management
• Transition from hospital to home health care

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Next Steps for Plan of Action Development

• Implement Monitor
• Implement the Action Plan
• Emphasize small test of change before full-scale
  implementation
• Monitor the Action Plan
• Measure outcome and process
• Measurement strategy provides examples

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Questions Feedback Suggestions Recomme
ndations
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Website Resources

• MedQIC Website www.medqic.org
• IPRO www.ipro.org
• Joint Effort New York (JENY) Website -
  http//jeny.ipro.org
• Home Health Compare - www.medicare.gov/hhcompare/h
  ome.asp

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Contact Information

• Sara Butterfield , RN, BSN, CPHQ, CCM / Project
  Director
• Phone [phone] ext. 104
• Email sbutterfield_at_nyqio.sdps.org
• Christine Stegel RN, MS / Performance Improvement
  Coordinator
• Phone [phone] ext. 113
• Email cstegel_at_nyqio.sdps.org
• Susan Hollander MPH, CPHQ / Assistant Director
• Phone [phone] ext. 241
• Email shollander_at_nyqio.sdps.org