VHHA's Home is the Hub Readmissions Reduction Playbook

Readmissions HOME IS THE HUB
Reduction
Playbook REDUHCIN G SSIONS
O SPITAL READMI
High-Leverage Strategies
for Virginia Hospitals and
Health Systems

HOME IS THE HUB

REDUHCIN G SSIONS
O SPITAL READMI

Support for the Home is the Hub initiative
is provided by the Virginia Hospital and
Healthcare Association.

How to cite this document: Boutwell AE.
Home is the Hub Readmission Reduction
Playbook. Lexington, MA: Collaborative
Healthcare Strategies; September 2017.

Copyright © 2017 Collaborative Healthcare
Strategies, Inc. All rights reserved.

Dear Colleague:

During development of the Virginia Hospital & Healthcare Association’s 2015-2020
Strategic Plan, the VHHA’s Board of Directors identified reducing statewide hospital-
wide readmissions rates as one its top improvement objectives. An analysis of data
and best practices led the Board to identify three readmission reduction priority
areas within that goal:

• Hospital-wide readmissions.

• Post-acute care readmissions.

• Total hip/ total knee replacement readmissions.

In response, VHHA’s Center for Healthcare Excellence in 2016 launched the “Home is the
Hub” statewide readmissions learning series. “Home is the Hub” is more than a project
name, it also is an affirmation that the goal of hospital-based health care services is to
help patients return to, remain in, and thrive in their own homes.

For the past 18 months, this initiative has provided VHHA members as well as post-acute
and community-based partners with practical advice, best practices, and innovative
approaches for working together to reduce hospital readmissions. In tandem with VHHA’s
Center for Healthcare Excellence, this work has been guided by Dr. Amy Boutwell, a
nationally-recognized expert with experience advising large-scale collaborative efforts
focused on system redesign to reduce readmissions and improve care across settings.

This Readmission Reduction Playbook is intended to provide to VHHA members and
post-acute and community-based partners a compendium of the content shared
during a series of in-depth educational sessions (both web-based and in-person)
organized and presented by the Center and Dr. Boutwell during the course of the
18-month readmission reduction initiative. To support and assist the people who staff
already busy readmission reduction teams, this Playbook features a series of one-page
summaries of key points, effective practices, and recommendations. These summaries
are valuable resources that readmission reduction teams can use to help stimulate
review and discussion as they work to develop and implement an effective portfolio of
strategies to achieve readmission reduction goals.

This ambitious, statewide initiative would not be possible without the active
engagement of our post-acute and community based organization partners.
Important contributions have also been made by Health Quality Innovators (HQI), and
the Centers for Medicare & Medicaid Services’ Quality Improvement Organization for
Virginia. The engagement of the various health care payer organizations in Virginia,
including the Department of Medical Assistance, is also valued and appreciated.

On behalf of all who have contributed to this important work, we offer our sincere
thanks to providers and clinicians for your commitment to delivering high-quality and
high-value patient care to the patients that you serve.

Sean T. Connaughton Toni R. Ardabell

President & CEO, VHHA Chair, VHHA Center for Healthcare Excellence

About the Authors

AMY BOUTWELL, MD, MPP
President, Collaborative Healthcare Strategies

Dr. Boutwell is a nationally recognized thought leader in the field of
reducing readmissions and improving care for high utilizers. Dr. Boutwell
co-developed the Institute for Healthcare Improvement’s STAAR Initiative
as well as the AHRQ Hospital Guide to Designing and Delivering Whole-
Person Transitional Care (the ASPIRE Guide). Dr. Boutwell is the strategic
and technical advisor to state and national efforts to improve care and
reduce avoidable hospital use, including the VHHA Home is the Hub
Initiative. Dr. Boutwell is a graduate of Stanford University, Brown University
School of Medicine and the Harvard Kennedy School of Government
where she received the Robert F. Kennedy Award for Excellence in Public
Service. She trained in primary care internal medicine at Massachusetts
General Hospital and practices hospital medicine.

ABRAHAM SEGRES, MHA
Vice President, Quality and Patient Safety, Virginia Hospital & Healthcare Association

As VHHA’s Vice President for Quality and Patient Safety, Abraham provides
leadership for the statewide quality and performance improvement
efforts among Virginia hospitals. Since joining VHHA in 2012 he has led
Virginia hospitals’ participation in the Centers for Medicare and Medicaid
funded Hospital Improvement Innovation Network. Prior to joining VHHA,
Abraham served as Director of Patient Safety and Risk Management
at the University of Virginia Health System. He has a Master’s Degree
in Health Administration from Virginia Commonwealth University and a
Bachelor’s of Science Degree in Public Health from the University of North
Carolina at Chapel Hill. He is also a trained Improvement Advisor through
the Institute for Healthcare Improvement (IHI).

CARLA THOMAS, MS, CTRS, CPHQ
Director, Care Transitions, Health Quality Innovators

Carla Thomas is a well-known partner and leader among Virginia’s
care transitions initiatives. As Health Quality Innovators’ (HQI’s) Director
of Care Transitions for the Medicare Quality Innovation Network-Quality
Improvement Organization (QIN-QIO) contract, Carla oversees a team
that supports community coalitions working to reduce hospitalizations
in Maryland and Virginia. She is a graduate of Slippery Rock University
in Pennsylvania where her master’s degree led to extensive Alzheimer’s
program development for a large nursing home corporation. Her 15
years of quality improvement leadership at HQI includes improvement
initiatives for nursing homes, hospitals and care transitions. Carla is a
certified professional in healthcare quality and a trainer in TeamSTEPPS
and coalition-building.

Table of Contents

Call to Action: Current State & High Leverage Strategies 2

High-Leverage Strategy: Hospital-Wide Readmissions 3
High-Leverage Strategy: Post-Acute Care Readmissions 4
High-Leverage Strategy: Hip/Knee Replacement Readmissions 5

Special Topic: Multi-Visit Patients (MVPs) 6
Special Topic: Emergency-Department Based Strategies 7
Special Topic: Working with Payers 8
Special Topic: Community Health Workers 9

Recommended Action: Know Your Data and Root Causes 10

Recommended Action: Articulate Your Portfolio of Strategies 11

Recommended Action: Collaborate Across the Continuum 12

Recommended Action: Measure What You Implement 13

Resource: Readmissions Interview Tool 14

Resource: Hospital to Skilled Nursing Facility Planning Worksheet 15

Other Resources 16

1

Call to Action: Current State & High Leverage Strategies

The opportunity to accelerate efforts to reduce readmissions in Virginia is clear. In 2016:

• Virginia ranked #46 in US for average amount of readmission penalties
per hospital

• 68 of 89 hospitals received a readmission penalty
• Virginia hospitals forfeited $21M in readmission penalties
In large part, the magnitude of the impact of readmission penalties in
2016 appears to be due to the expansion of the conditions included in the
penalty program, specifically in that year the addition of COPD and hip/
knee replacements. Each year that a new condition is added to the penalty
program, the impact of the penalties would be expected to increase.
To date, many readmission reduction teams have been focused on targeting
readmission reduction efforts only on patients with conditions directly penalized
by the Medicare Hospital Readmission Reduction Program. This was a logical
place to start, but as the market continues to evolve, it may be wise to identify
“high-leverage” strategies that will reduce a broader set of readmissions -
mitigating the impact of future changes to the readmission penalty program while
building capability for success in future value-based payment arrangements.
What are “high-leverage” strategies? They are data-informed and
operationally and clinically meaningful, resulting in a plan that can be
expected to achieve the VHHA Board Priorities of reducing all-payer, all cause
readmissions by 20% by 2020. Consider the following:
• The average Medicare readmission rate in Virginia is ~18%
• Heart failure readmissions account for only ~5% of all Medicare readmissions
• The 10 diagnoses leading to the most readmissions account for only

~25% of all readmissions
• The readmission rate for all Medicare patients discharged to post-acute

care is ~20%
• The readmission rate for multi-visit patients is ~46%

In the VHHA Home is the Hub Initiative, we identified the following as high-
leverage strategies:

• Hospital-wide readmissions, with a focus on multi-visit patients;
• Readmissions among patients discharged to post-acute care;
• Readmissions following hip or knee replacement surgery

For more information
Home is the Hub webinar 1, June 2016

2 Readmissions Reduction Playbook / High-Leverage Strategies for Virginia Hospitals and Health Systems

High-Leverage Strategy: Hospital-Wide Readmissions

Key statistics

• The top 10 diagnoses leading to the most readmissions account for ~25%
of all readmissions

• Heart failure readmissions account for ~5% of all readmissions

• Adult non-OB Medicaid readmission rates are often as high or higher
than Medicare rates

• Readmission rates among patients with any behavioral health comorbidity
are 77% higher than patients without a behavioral health comorbidity

Key concepts

• The VHHA Board established a goal of reducing all cause readmissions
by 20% by 2020

• Targeted and generalized efforts are needed to reduce hospital-wide
readmission rates

• CMS has issued updated surveyor guidance and proposed changes to
the Discharge Planning Conditions of Participation: these form a blueprint
of improved transitional care

• Elements of improved transitional care for all patients include: screen all
patients for readmission risks and post-hospital support needs, directly link
(not just refer) patients to needed post-hospital care, include behavioral
health as part of discharge plan

• Develop transitional care plans that can be realistically implemented by
working with patients and their care partners or community resources to
develop plans

Recommendations For more information
Home is the Hub webinar 1,
Have a process to track and trend all cause and June 2016
target population specific readmission rates ASPIRE Guide, Chapter 4 and
Tools 8 and 9
Regularly review readmissions to identify root AHA/HRET HIIN Readmission
causes and continuously Reduction Whiteboard
improve strategies videos 4, 5, and 6

Identify a caregiver for all hospitalized patients;
write the name/number on the whiteboard

Screen all patients for readmission risks; address
all readmission risks in the discharge plan

Make appointments; link to clinical, behavioral,
social and supportive services

Readmissions Reduction Playbook / High-Leverage Strategies for Virginia Hospitals and Health Systems 3

High-Leverage Strategy: Post-Acute Care Readmissions

Key statistics

• In VA, there are ~ 275,000 Medicare discharges; ~110,000 are discharged to
post-acute care

• 40% of all Medicare discharges are to post-acute care (PAC)

• The average Medicare readmission rate is ~18%

• The readmission rate among Medicare patients discharged to PAC is ~20%

Key concepts

• Skilled Nursing Facilities (SNFs) are exposed to a readmission penalty program

• The SNF readmission penalty program is a 2% withhold in payments, with the
opportunity to “earn back” payments based on their “achievement” and
“improvement” in rates

• The first year of penalties will be based on all cause readmission rates in 2017,
and whether there has been improvement in those rates between 2015 and 2017

• The first year that the withhold will be implemented is October 2018

• Reducing readmissions for patients discharged to PAC is a co-produced outcome

• Meaningfully collaborate to implement improvements or new care models

• Ask the “receiver” to identify opportunities to improve the transition of care

• Communication is best done iteratively; it may take time to build a
collaborative relationship

Recommendations For more information
Home is the Hub webinar 3,
Conduct a warm hand-off, with a “circle back” call September 2016
to ensure successful transition Home is the Hub webinar 10,
May 2017
Follow the patient across settings, continuing HQI’s “Circle Back” video:
care management through the 30-day period https://youtu.be/0wCZc3hkPdY

Identify changes in clinical status early; respond
in-place using established
care pathways

Treat-and-return a patient from the ED to post-
acute care, when safe and appropriate

Hold regular meetings; engage in joint
problem-solving

4 Readmissions Reduction Playbook / High-Leverage Strategies for Virginia Hospitals and Health Systems

High-Leverage Strategy: Hip/Knee Replacement Readmissions

Key statistics

• According to CMS data, from 2011-2014 the hip/knee readmission rate
in VA was 5.2%

• In 2016, Virginia ranked 49 of 51 in the nation for hip/knee readmission
penalties

• In 2016, 41 Virginia hospitals received penalties for hip/knee readmissions

• In 2016, the penalties for hip/knee readmissions totaled ~$12 million,
~50% of total penalty

• The top readmission diagnoses following hip/knee surgery are hypertension
and diabetes

• ~30% hip/knee readmissions occur within 5 days of discharge

• The top diagnoses for early knee readmissions (<5 days) are: infection,
anemia, GI bleed and pulmonary embolism

Key concepts

• Patients and caregivers should be educated about post-surgical recovery
prior to admission

• Provide anticipatory guidance regarding pain, bowels, mobility, recovery,
and who to call

• A dedicated navigator can be deployed to monitor for and respond to
issues post-discharge

• A dedicated hip/knee task force is valuable to understand penalties,
review data, identify root causes and support implementation of
standardized process changes

• The root causes of hip/knee readmissions include surgical, medical, social
and logistical issues

Recommendations For more information
VHHA webinar, Analyzing
Know the details of the readmission penalty and Reducing Total Hip and
program: keep stakeholders updated on details Total Knee Replacement
Readmissions in Virginia,
Use internal data to track impact of process January 2016
changes: valuable even if limited

Analyze timing of readmissions; readmissions at
different times have different root causes

Use a zone teaching tool to guide patients and
caregivers about symptoms and responses

Deploy navigators to detect and respond to
issues post-discharge, before an ED visit
is needed

Readmissions Reduction Playbook / High-Leverage Strategies for Virginia Hospitals and Health Systems 5

Special Topic: Multi-Visit Patients (MVPs)

Key statistics

• 4 hospitalizations in a 12-month period is 2 standard deviations above the
mean for utilization

• In MA, the readmission rate for “multi-visit patients” is 38%; rate among non-
MVPs is 8%

• In MA, 7% of patients were MVPs; they used 25% of all admissions and 59% of
all readmissions

• In Virginia, there were ~49,000 discharges and ~22,000 readmissions among
Medicare MVPs

Key concepts

• Define a “high utilizer” (or “multi-visit patient”) by a specific utilization threshold

• Utilization thresholds for inpatient MVPs and ED MVPs are different: Inpatient MVP:
4+ admissions in the past 12 months; ED MVP: 10+ ED visits in the past 12 months

• High utilization is a symptom of an unmet, unrecognized or inadequately
addressed need

• Identify the “driver of utilization.” This is distinct from the chief complaint, the
primary diagnoses, or a needs assessment. Don’t over-medicalize the “driver
of utilization”

• “ED care plans” promote longitudinal and cross-setting memory, coordination
and alignment among providers, and transparent and consistent care for MVPs

Recommendations For more information
Identify the MVP in real-time Home is the Hub webinar 4,
October 2016
Identify and address the “driver of utilization” ASPIRE Guide Chapter 6 and
Tool 13
Prioritize effective engagement, problem solving, AHA/HRET HIIN Readmission
navigating, mobilizing resources Reduction Whiteboard video 9

Be patient, persistent, and proactive; manage over
time and across all care settings

Use “care plans” to convey need-to-know
information for the next ED provider

Case conference with clinical, behavioral, social
services to coordinate and strengthen plans

6 Readmissions Reduction Playbook / High-Leverage Strategies for Virginia Hospitals and Health Systems

Special Topic: Emergency-Department Based Strategies

Key statistics

• In MA, 26% of discharged inpatients returned to the ED within 30 days

Key concepts

• Historically, research on readmissions focused on the ways in which the discharge
process was inadequate and/or variable in quality. As a result, improvement efforts
focused on the discharge process and post-discharge transitional care period

• However, some innovative teams have identified opportunities to reduce
readmissions when a patient presents to the ED, prior to the decision to (re)admit

• “Treat and return:” would it be safe and appropriate to return the patient to
the sender?

• Do we admit a high percentage of patients sent in from SNF? If so ask “why” 5 times

• Re-engineer ED processes to make it more feasible to “return” patient after evaluation

• “Reach in and transition out:” the patient’s care team is notified upon ED registration

• The care team “reaches in” to the ED to engage patient, communicate baseline
to ED provider, arrange for timely follow up contact, and avoid readmission

• “ED Care Plan:” used to improve the care of a patient the next time they
present to the ED

• Clinician-to-Clinician executive summary of prior utilization, the “driver
of utilization,” recommendations for consideration, and care manager or
provider contact information

Recommendations For more information
Home is the Hub webinar 7,
Create a 30-day return flag on the ED January 2017
tracker board ASPIRE Guide Chapter 6
AHA/HRET HIIN Readmission
Use the 30-day flag to notify the high-risk care Reduction Whiteboard video 7
team to “reach in and transition out”

Use ED care plans to convey baseline &
recommendations when care team is
unavailable

Develop “treat and return” pathways to reduce
avoidable admissions & readmissions

Readmissions Reduction Playbook / High-Leverage Strategies for Virginia Hospitals and Health Systems 7

Special Topic: Working with Payers

Key statistics

• Hospitalizations account for one-third of the $2 trillion spent on health care in the US

• Anthem data shows that ~40% of readmissions occurred within 7 days of discharge

• Anthem data shows that <2% of their members have 5+ admissions in a
12-month period

Key concepts

• Payers seek to achieve the triple aim: improve care, patient experience and
reduce costs

• Payers seek to reduce avoidable hospital use; meet needs in most appropriate
care setting

• Payers review daily census tracker which includes: DRG, total admits, total ED
visits, readmits, most recent office visit: this is information a payer has that can
be helpful to hospital team

• Review of daily census may trigger interdisciplinary rounds presentation, Medical
Director consultation, case management referral, review eligibility for special services

• Payers seek to know about socio-economic needs, behavioral health
comorbidities and inadequate or lack of caregiver support, recognizing these
are readmission risks

• Effective strategies from duals and Medicaid programs include: interdisciplinary
care, house calls, treat-in-SNF; advanced illness support, navigation, support,
24/7 availability

• Establishing contact prior to discharge increases effectiveness of post-hospital services

Recommendations For more information
Home is the Hub webinar 8,
Know what payers are doing to reduce February 2017
readmissions: meet with them ASPIRE Guide, Chapter 5,
Tool 12, and webinar 5
Identify a single point of contact at the plan AHA/HRET HIIN Readmission
and at the hospital to facilitate collaboration Reduction Whiteboard
video 10
Develop and test strategies for collaborating on
risk assessment, the transitional care plan, and
post-discharge support: test, gather feedback,
meet, iterate and improve

Allow care managers to meet with patients
prior to discharge

8 Readmissions Reduction Playbook / High-Leverage Strategies for Virginia Hospitals and Health Systems

Special Topic: Community Health Workers

Key statistics

• In a Sentara readmission reduction program, RN case managers estimated
50% of time was spend on non-RN specific activities; in response, they paired
CHWs with RN case managers

• VCU deploys CHW in a wide range of programs, including: complex care,
geriatrics, transitional care, heart failure, and sickle cell programs

• There is a Virginia CHW Advisory Group that meets monthly, raises awareness of
CHW efforts statewide and addresses scope, credentialing, reimbursement, etc.

• In Virginia, CHWs are employed in Area Agencies on Aging, Hospitals,
Department of Health, Managed Care organizations, Behavioral Health
Authorities, Community Service Agencies

Key concepts

• Healthcare delivery transformation requires us to develop more effective
systems and strategies to manage care over time and across settings and
address “whole-person” needs

• Social and behavioral variables are powerful drivers of health and
healthcare utilization

• CHWs effectively engage patients by establishing a trusting, helpful relationship

• CHWs help with education, navigation, logistics, informal counseling and
social support, advocating for individual and community needs, and assuring
people get services they need

• CHWs also called: outreach worker, health advocate, promotora de salud,
navigator, guide

• Examples of successful programs in Virginia show that CHWs are effective and
relevant for Medicare, Medicaid, dual, disease-specific, complex care and
transitional care programs

Recommendations For more information
Consider adding CHWs to your internally- Home is the Hub webinar 9,
resourced readmission reduction teams April 2017
ASPIRE Chapter 6
Identify services in your region that utilize CHWs; AHA/HRET HIIN Readmission
gather eligibility and referral information Reduction Whiteboard video 8

Partner with agencies that provide transitional
care services delivered by CHWs

Readmissions Reduction Playbook / High-Leverage Strategies for Virginia Hospitals and Health Systems 9

Recommended Action: Know Your Data and Root Causes

Many readmission reduction teams focus their readmission reduction efforts on the
“Medicare penalty” conditions – and with good reason. However, hospitals that aim
to reduce hospital-wide readmissions will find value in conducting an all cause all
payer readmission analysis.

• Which patients are high risk of readmission at your hospital?

• Do you know your hospital-wide all cause (adult, non-OB) readmission rate?

• Do you know your all cause readmission rate by payer (Medicare, Medicaid,
commercial)?

• What are the top 10 discharge diagnoses leading to the most readmissions?
Any surprises?

• Do you know your readmission rate for discharges to post-acute care?

• Do you know how many multi-visit patients you have?

• What’s the readmission rate for your high-risk target population(s)?

The best data analysis will only ever provide part of the information needed to reduce
readmissions. Seek to understand root causes through a patient, caregiver and
provider lens:

• Do you know why your patients return to the hospital soon after discharge? Have
you asked your readmitted patients and/or their caregivers to describe the events
and issues that arose between the day of discharge and the day of readmission?

• Do you seek to identify all of the factors - the clinical, non-clinical, social,
behavioral, and logistical - that contribute readmission among your patients?

Recommendations For more information
Analyze your own all payer, all cause data; use Home is the Hub learning
Tool 1 of the ASPIRE Guide session, November 2016
ASPIRE Guide Chapter 1,
Interview 5 readmitted patients; use Tool 2 of Tools 1 and 2, and webinar 2
the ASPIRE Guide AHA/HRET HIIN Readmission
Reduction Whiteboard
Quantify how many and what percent of your video 2, 3
discharges are high-risk of readmission

Calculate the readmission rate for patients who
meet your high-risk criteria

10 Readmissions Reduction Playbook / High-Leverage Strategies for Virginia Hospitals and Health Systems

Recommended Action: Articulate Your Portfolio of Strategies

Many hospitals have several readmission reduction related efforts underway.
Readmission reduction efforts have proliferated over time, across departments,
service lines, disease-specific programs, accountable care organizations, bundled
payment programs, etc. All of these efforts will contribute to your goal of reducing
hospital-wide readmissions – and can do so even more effectively if you coordinate
and align these related efforts as a “portfolio of strategies.”

• Are you aware of all readmission reduction-related efforts at your hospital?

• Are you aware of the readmission reduction resources or efforts across the continuum?

• Do you know which efforts are intended to help which target populations?

• Do you have resources in place to track readmission data and identify root causes?

• Do you have efforts in place to improve transitional care for all patients?

• Do you have efforts in place to identify “whole-person” transitional care needs?

• Do you have disease-specific programs in place? For which conditions?

• Do you have programs in place to address patients with social or behavioral
health needs?

• Do you have efforts in place to better collaborate with post-acute care providers?

• Are there gaps that should be addressed to strengthen your portfolio of strategies?

Recommendations For more information
Home is the Hub webinar 6,
Survey the readmission reduction related efforts December 2016
within your hospital; use ASPIRE Tool 3 ASPIRE Guide Chapters 2 and
3 and webinar 3
Survey the readmission reduction related efforts ASPIRE Tools 3, 4, 5, and 7
across the continuum; use ASPIRE Tool 4

Analyze what resources and efforts are in
place; articulate your current portfolio of
strategies

Use the survey results and current driver diagram
to consider whether there are gaps to fill or
opportunities to improve the implementation of
existing efforts

Design a data-informed strategy that is
designed to get the results you want to achieve

Readmissions Reduction Playbook / High-Leverage Strategies for Virginia Hospitals and Health Systems 11

Recommended Action: Collaborate Across the Continuum

Many readmission reduction teams are already working on one important cross-
continuum collaboration: with skilled nursing facilities. As you develop and improve
collaborative efforts with SNFs, consider which other providers and agencies share
in the care of your high-risk patient populations:

• Do you have collaborative relationships with behavioral health providers?

• Do you have collaborative relationships with community service agencies?

• Do you have collaborative relationships with payers?

Your data and root cause analysis will likely suggest that your patients with
behavioral health comorbidities and patients with social service needs have
high rates of readmission. You may find that your staff believe that there are few
resources available to patients to meet their needs. While it may be true that there
are not enough resources, there are some resources in every community. Inventory
what resources do exist, and collaborate with them to the benefit of your patients.

• Is it as easy as it needs to be to directly link patients to behavioral or social services?

• Are you applying the same principles of “warm handoffs” and “timely follow up” for
patients who need to be connected to behavioral health and /or social services?

• Have you asked the “receiving” providers for their ideas on how to improve the
process of linking patients from your hospital into their services?

Recommendations For more information
Use ASPIRE Tools 4, 11 to inventory and identify HQI’s “Circle Back” video:
relevant resources in your community https://youtu.be/0wCZc3hkPdY
ASPIRE Guide Chapter 5 and
Take the perspective of working with the webinar 5 and Tool 4, 11, 12
resources that do exist, even if there is scarcity AHA/HRET Readmission
Reduction Whiteboard video 10
Re-engineer the process of linking hospitalized
patients to community resources

Use ASPIRE Tool 12

Develop “new pathways” with 1 clinical, 1
behavioral, and 1 social service provider

12 Readmissions Reduction Playbook / High-Leverage Strategies for Virginia Hospitals and Health Systems

Recommended Action: Measure What You Implement

You are busy every day trying to implement improved care for your patients. You
may be wondering: What are we doing? For which patients? How consistently
are we doing it? What are the results? For the target population? For patients who
received the service?

An operational dashboard can help you know what services are being delivered,
to which patients, with what results? An operational dashboard might contain the
following elements:

• All discharges in the target population(s)

• Number of discharges who received the service/process

• % of target population discharges that received the service/process

• Readmission rates of the target population

Before you conclude that a given service/process is not effective to reduce
readmissions:

• Quantify the total number of discharges in the target population: How many
patients have we defined as being at risk of readmission? Are we effectively
identifying all target population patients? Are we effectively engaging them in
care? Are we delivering intended services once identified and engaged?

• Drive to a high level of implementation of services for the target population.
The services can’t reduce readmissions if they are not being delivered to high
risk patients!

Recommendations For more information
Create an “operational dashboard” to track the ASPIRE Guide Chapter 3 and
implementation of your various strategies webinar 3
ASPIRE Tool 6
Track the % of target population patients who AHA/HRET Readmission
receive the intended service(s) Reduction Whiteboard video 11

Improve and innovate to drive up the % of target
population patients “served”

Track the readmission rate for all patients, target
population(s), and patients “served”

Track, trend, display, share monthly
performance and outcome data visibly;
use as a tool

Start with the information you have, and build a
comprehensive dashboard over time

Readmissions Reduction Playbook / High-Leverage Strategies for Virginia Hospitals and Health Systems 13

Resource
Readmissions Interview Tool

Section 1: Brief Chart Review (10-15 minutes)
Elicit the following basic information:

• Date of first admission:
• Date of first discharge:
• Chief complaint and medical issues during first hospitalization:
• Discharge disposition:
• Was a follow-up appointment made prior to discharge:
• Date of readmission:
• Days between discharge and readmission:
• Site of care readmitted from (home, SNF, home health, etc.):
• Readmission chief complaint and medical issues during the second hospitalization:
• Discharge disposition (if they are no longer in the hospital):

Section 2: Patient/family caregiver interview (10-15 minutes)
Suggested script: “We are working to improve the discharge process and noticed that
you have been in the hospital twice recently. I’d like to ask you for about 10 minutes
of your time to provide us with some feedback about what happened between the
time you were discharged and the time you returned to the hospital. This will help us
understand what we might be able to do better for you, and what we might be able
to do better for our patients in general. Would that be OK with you?”

• Why were you in the hospital (dates of the first admission)?
• What did the hospital team do to help you get ready to leave the hospital?
• Did the hospital team talk to you about what to do and expect once you left the hospital?
• Did you know who to call if you had questions or problems?
• Tell me about anything that was unclear or confusing or difficulty for you when you

left the hospital.
• I see you went to discharged disposition. How did it go once you got there?
• Did any new symptoms or issues come up after you were discharged?
• Did you see a doctor, nurse or other provider after you were discharged? Who?
• Why do you think you needed to come back to the hospital?
• Was there anything we could have done differently to help keep you from needing

to come back?
• Do you have any other suggestions for us?
• Thank you!

Section 3: Provider interview (3-5 minutes)
Suggested script: “We are working to improve care transitions and reduce avoidable
readmissions. One of your patients was recently readmitted to our hospital and we’d
like to ask for your perspective about opportunities for improvement in our overall
processes. It will take no more than five minutes of your time.”

• Did you know the patient was admitted on (first hospital date)?
• Did you know the patient was being discharged to (setting) on (date)?
• Did the patient contact you after discharge?
• Did our hospital contact you at all about the admission or discharge plan?

If so, describe interaction.
• Did you have contact with the patient after discharge? If so, describe the interaction.
• Why do you think the patient ended up being readmitted?
• Do you think there was anything that could have been done (socially or clinically)

to prevent this?

14 Readmissions Reduction Playbook / High-Leverage Strategies for Virginia Hospitals and Health Systems

Resource 15
Hospital to Skilled Nursing Facility Planning Worksheet

This worksheet is a suggested discussion guide to help you identify opportunities for improvement.
1. Know your data and review readmission events
Hospitals: Do you track readmissions from SNFs (and/or other facilities)? By facility?

Hospitals: What is your hospital’s readmission rate from SNF?

SNF/facility: Do you track (re)admissions to the hospital?

SNF/facility: Describe how your facility measures acute (re)hospitalization.

Both: Do you review readmissions from SNF? Together?

Both: Do you use a structured format? Involve both hospital and SNF? Patient/families?

2. Identify opportunities for improvement
Hospitals: What improvement efforts do you have in place? How are they working?

SNF/facility: What improvement efforts do you have in place? How are they working?

Both: Do new/other partners or facilities or professionals need to be involved?

Both: Have you considered warm (verbal) handoffs?

Hospitals: Have you considered providing contact information for clarification?

Hospitals: Do all SNF patients leave with documented goals of care?

Both: Do you jointly review medications to identify any that may be difficult to obtain?

SNF/facility: Do you use the INTERACT tools? Which ones?

Hospital: If yes (above) have you trained your ED staff to use INTERACT tool?

Specific ACTION STEPS we will take to improve our hospital to SNF transitions:
1.
2.
3.
4.
5.
Readmissions Reduction Playbook / High-Leverage Strategies for Virginia Hospitals and Health Systems

Other Resources

Virginia Hospital & Healthcare Association (VHHA):

Please see the VHHA Home is the Hub webpage to access the full curriculum of
recorded webinars and presentation materials:
http://www.vhha.com/quality-patient-safety/home-is-the-hub-initiative/

1. Accelerating Efforts to Reduce Readmissions in Virginia………… June 2016
2. Data and Analytics to Support Readmission Reduction Efforts… August 2016
3. Post-Acute Care Readmissions………………………………………… September 2016
4. Improving Care for High Utilizers (Multi-Visit Patients)……………… October 2016
5. In-Person Learning Session……………………………………………… November 2016
6. Articulating Your Strategy ……………………………………………… December 2016
7. ED-Based Strategies……………………………………………………… January 2017
8. Payer-Led Strategies……………………………………………………… February 2017
9. Community Health Workers …………………………………………… April 2017
10. Deep Dive: Post-Acute Care Strategies……………………………… May 2017

VHHA Data and Analytics Services

VHHA supports its members to address readmissions via several avenues. Each quarter,
all hospitals receive electronic reports noting their state ranking, observed and predicted
readmissions, and a modeling of the diagnoses driving the readmissions. These reports
are cut by all payer and Medicare only datasets. The numbers are computed using
CMS’s programing to assure outcomes consistent with CMS findings. Hospitals also
receive a quarterly hard copy report about their readmission experience. It trends
their data, showing readmission hot spots, sources (home, post acute facilities and
home health) and payer mix. These resources are free to all members. The reports are
available 90 days after the close of the quarter. If you are not receiving the reports
please contact, [email protected] to add your name to the mailing list. If you are
interested in a deeper readmissions dive with the ability to manipulate criteria on the fly,
VHHA Analytics may be the answer. This is an online tool that is available by subscription.
VHHA Analytics is designed to help VHHA members gain data-driven insights to achieve
top-tier performance in safety, quality, value, service, and population health.
http://www.vhha.com/research/

Health Quality Innovators (HQI)

Please see the Health Quality Innovators (HQI) webpage and resource center to
access resources, strategies and tools to assist health care providers, in a variety of
settings, expand their capacity for quality improvement.
http://www.hqi.solutions/about/
http://qin.hqi.solutions/resource-center/

16 Readmissions Reduction Playbook / High-Leverage Strategies for Virginia Hospitals and Health Systems

Agency for Healthcare Research & Quality (AHRQ) 17

Please see the AHRQ webpage to access the full curriculum of the ASPIRE Guide
(Designing and Delivering Whole-Person Transitional Care: The Hospital Guide to
Reducing Medicaid Readmissions)
https://www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/

• ASPIRE Guide
• ASPIRE Toolkit
• ASPIRE Webinars

1. Introduction & Overview
2. Analyze Data and Caregiver Perspectives
3. Review & Update Readmission Reduction Efforts
4. Implement Whole-Person Transitional Care for All
5. Reach Out to Collaborate with Partners Across Settings
6. Enhance Services for High-Risk Patients

American Hospital Association’s Health Research &
Education Trust (AHA HRET)

Please see the American Hospital Association/Health Research & Education Trust Hospital
Improvement Innovation Network (HIIN) webpage to access the “Readmission Reduction
Whiteboard Video Series”
http://www.hret-hiin.org/Resources/readmissions/17/readmissions_whiteboard_series.shtml

1. Introduction
2. Know Your Data
3. Understand the Root Causes
4. Improve Transitions for All Patients
5. Develop a Customized Transitional Care Plan for All Patients
6. Effectively Communicating with Patients and their Caregivers
7. Engaging the ED in Readmission Reduction Efforts
8. Deliver Enhanced Services Based on Need
9. Improving Care for High Utilizers
10. Collaborating with Clinical and Non-Clinical Community Providers and Services
11. Measure What You Implement

Readmissions Reduction Playbook / High-Leverage Strategies for Virginia Hospitals and Health Systems

HOME IS THE HUB

REDUHCIN G SSIONS
O SPITAL READMI