Today's Webinar Focuses on ARR Hospital Intervention Plans

Today's Webinar Focuses on ARR Hospital Intervention Plans

ARR: Intervention Plans and Budgets HSCRC Staff November 17, 2011 Todays Webinar Focuses on ARR Hospital Intervention Plans Introduction to ARR Implementation efforts Intervention plans and budgets Interventions Metrics Next steps and timeline Update on HSCRC case mix to CRISP data merge tests ARR: Intervention Plans and Budgets 11/17/2011 2

Introduction to ARR ARR: Intervention Plans and Budgets 11/17/2011 3 ARR is a Voluntary Revenue Constraint Agreement HSCRC initiated the Admissions Readmission Revenue constraint program for FY 2012 ARR builds upon the inpatient CPC HSCRC staff spent much of September and October meeting one-on-one with hospital staff to discuss ARR ARR: Intervention Plans and Budgets 11/17/2011

4 31 Hospitals Engaged in ARR for FY 2012 Mercy LifeBridge - Sinai LifeBridge - Northwest UMMS - Baltimore Washington Medical

Center UMMS - Civista Medical Center UMMS - Harford Memorial Hospital UMMS - Kernan Hospital UMMS - Maryland General Hospital UMMS - Upper Chesapeake Medical Center UMMS - University of Maryland Medical Center JHHS - Johns Hopkins Hospital JHHS - Johns Hopkins Bayview Medical Center JHHS - Howard County General Hospital JHHS - Suburban Hospital

Anne Arundel Medical Center Bon Secours St. Joseph Medical Center MedStar - Franklin Square MedStar - Good Samaritan MedStar - Harbor Hospital MedStar - St. Mary's Hospital MedStar - Montgomery General Hospital MedStar - Union Memorial Hospital Holy Cross Hospital Washington Adventist Hospital Shady Grove Adventist Hospital Peninsula Regional Doctors GBMC

Frederick Regional Health System Saint Agnes ARR: Intervention Plans and Budgets 11/17/2011 5 ARR Establishes a 30 Day Episode of Care Window Admission Date: 7/1/11 Discharge Date: 7/3/11 Initial Admission Admission Date: 7/15/11 Discharge

Date: 7/20/11 Readmission1 Admission Date: 8/2/11 Discharge Date: 8/9/11 Readmission2 ARR: Intervention Plans and Budgets 11/17/2011 Admission Date: 8/3/11 Discharge Date: 8/15/11 New Initial

Admission 6 ARR Builds Upon the Inpatient CPC for Case Exclusions and Weight Development Excluded Cases: Weights: C = CHRONIC CASE HSCRC staff will B = BURN CASE consolidate CPC weights Z = ILIZAROV into episodes of care O = ORGAN TRANSPLANT $ = CHARGE < $1 or > $2,000,000 D = DENIED ADMISSION L = LENGTH OF STAY*except for Delivery and Newborns ARR: Intervention Plans and Budgets

11/17/2011 7 Transfers to On-Site Distinct Rehab, Psych, Chronic Unit or Hospice will Start a New Episode of Care Discharged to home or transferred back to acute care Admission1 to Hospital-A Admission Date: 5/11/2010 Discharge Date: 5/13/2010 Admission2 to Hospital-A Admission Date: 5/13/2010 Discharge Date: 5/16/2010 Discharged to onsite Rehab, Chronic or Psych Unit Initial

Admission/Only Admission Admission3 to Hospital-A Admission Date: 6/15/2010 Discharge Date: 6/16/2010 Discharged to Home Initial Admission ARR: Intervention Plans and Budgets Readmission 11/17/2011 8 Transfers to Linked System Hospitals Discharged Home

Admission1 to System Hospital1 Admission Date: 4/24/2011 Discharge Date: 4/26/2011 Admission2 to System Hospital2 Admission Date: 4/26/2010 Discharge Date: 5/13/2010 Admission3 to System Hospital1: Admission Date: 5/25/2010 Discharge Date: 5/27/2010 Discharged Transfer to System Hospital 2 Initial Admission/ Only Admission Discharged to Home

Initial Admission ARR: Intervention Plans and Budgets Readmission 11/17/2011 9 Implementation Efforts ARR: Intervention Plans and Budgets 11/17/2011 10 HSCRC Staff is Continuing ARR Implementation Efforts Communication Continued development of Operational Policy

Guidelines documentation Weight development Intervention plans and budgets Reporting and monitoring ARR: Intervention Plans and Budgets 11/17/2011 11 Implementation Efforts: Communication Developed website http://www.hscrc.state.md.us/init_ARR.cfm Consolidated email box [email protected] Series of memos discussing ARR implementation Seed funding

ARR: Intervention Plans and Budgets 11/17/2011 12 Implementation Efforts: HSCRC Staff is Working to Issue ARR Weights and Documentation Weight development update: Earlier this week, HSCRC staff received the linked system data from hospitals Continuing to program and test CPC consolidation to develop ARR weights Continued development of Operational Policy Guidelines documentation ARR: Intervention Plans and Budgets 11/17/2011 13 Implementation Efforts: Final Year 1

Intervention Plans and Budgets Due to the HSCRC by November 30, 2011 HSCRC staff has collected draft intervention plans and budgets since early this calendar year Requiring hospitals to review intervention plans and budgets Hospitals to submit final implementation plans and budgets by November 30, 2011 ARR: Intervention Plans and Budgets 11/17/2011 14 Implementation Efforts: HSCRC Staff is Beginning to Develop Reporting and Monitoring Tools HSCRC staff understands the importance of program monitoring Ability to share best practices across Maryland hospitals Readmission is a national hot topic

ARR: Intervention Plans and Budgets 11/17/2011 15 Intervention Plans ARR: Intervention Plans and Budgets 11/17/2011 16 Intervention Plans (with Metrics) and Budgets Provide the HSCRC with an Understanding of ARR Programs The HSCRC has a responsibility to monitor hospitals ARR programs Staff must report to the Commission after Year 1 Intervention plans and budgets provide HSCRC staff with an

understanding of each hospitals ARR program Metrics demonstrate that the intervention is occurring and monitor the impact of the intervention Currently, many draft intervention plans are missing key components, such as metrics Possibility of external, independent evaluation of ARR ARR: Intervention Plans and Budgets 11/17/2011 17 HSCRC Staff Developed Intervention Plan Requirements and a Template In a hospital intervention plan, HSCRC staff expects to find the following information for each major intervention: Brief summary, selection rationale Target population(s) (e.g., diagnosis, admission through ED) Initiation date/planned initiation date

Types of staff associated with the intervention, FTE allocation Partners (e.g., NFs, external case managers, retail pharmacies) Technologies employed Approximately two metrics HSCRC staff anticipates receiving no more than 10 major interventions in a hospitals/systems plan Hospitals are not required to use the template, but may find it helpful If there is variation in interventions for hospitals within a system, provide information for each hospital separately or designate to which hospital(s) the intervention applies ARR: Intervention Plans and Budgets

11/17/2011 18 Hospitals are Implementing a Range of ARR Interventions Care management teams Nurse home visits within 1 week of discharge Patient education Comprehensive discharge planning Linkage with primary care providers Care transition center for patients

with no primary care provider Nursing facility protocol partnerships Continuum of care tracking software Pharmacy reconciliation upon discharge Many interventions focus on high risk patients such as: CHF COPD/Asthma Septicemia End Stage Renal Disease (ESRD) Diabetes (DM) Sickle Cell Gastric Paresis Discharged to SNF ARR: Intervention Plans and Budgets

11/17/2011 19 Metrics Provide a Quantitative Assessment of the Intervention and Impact For each major intervention, hospitals are to define one or two metrics. Metrics should provide: A quantification demonstrating that the hospital has implemented the intervention (Measuring the intervention) As assessment of the impact of the intervention (Measuring the results) On a quarterly basis, the ARR hospitals will report the results of each metric to the HSCRC to track ARR progress and substantial changes in their interventions ARR: Intervention Plans and Budgets 11/17/2011 20

Hospitals are Implementing a Range of Metrics Percent of patients provided detailed instructions at discharge Percent of patients provided postdischarge primary care services Percent of patients receiving discharge medication reconciliation Number of patients logged into a daily monitoring software Often these will be percentages or counts Assessment of the impact of the intervention Examples Examples Quantification that the

hospital has implemented the intervention Changing rate of readmissions from each long-term care facility in the service area Comparing patients post-discharge service utilization patterns for those provided additional services (phone calls, SNF visits, home visits, etc.) with patients not receiving additional services: Readmission rate 30 days post discharge Use of other services (ED and OBS) for 30 days post discharge ARR: Intervention Plans and Budgets 11/17/2011 21

Hospital Intervention Plan Example Hospital/System Name: St. Elsewhere 1. Intervention Name: Follow up for Patients Discharged to Skilled Nursing Facilities 2. Brief Summary of the Intervention (2-3 sentences), rationale for selection: Provide a description of the intervention including the problem(s) or process(es) it is addressing. Patients discharged to nursing homes are at particularly high risk for readmission with rates exceeding 20%. Members of the main hospitalist group assume care of their patients discharged to one of the local nursing homes to avert preventable readmissions and to coordinate nursing home post discharge care and follow up as needed. 3. Target population: Describe the intended target of the intervention. While patients from St. Elsewhere go to a number of area SNFs, the hospital discharges approximately one third to three local facilities owned by ABC Nursing Homes. The target population for this intervention is patients discharges to ABC Nursing Homes. ARR: Intervention Plans and Budgets 11/17/2011 22

Hospital Intervention Plan Example Hospital/System Name: St. Elsewhere 4. Intervention Implementation Status/Date: Indicate when the hospital/hospital system initiated the intervention. For interventions not fully implemented, indicate percent of work toward implementation completion and estimated implementation date. Follow up of patients has been in place since X date, and will be expanding the activities as of Y date. The initiative is 70% implemented. 5. Intervention Staffing FTEs: Specify dedicated or partially dedicated numbers by title/type of staff for this intervention. Staff Title/Type FTEs Allocated Annually RN for home visits 0.25 Case manager 1.0 Nurse Practitioner- SNF 1.25 Program oversight- Nurse Manager 0.25

ARR: Intervention Plans and Budgets 11/17/2011 23 Hospital Intervention Plan Example Hospital/System Name: St. Elsewhere 6. Intervention Partners: Identify any partnerships with entities outside the hospital/hospital system. St. Elsewhere is collaborating with XYZ Hospitalist Group and ABC Nursing Homes to implement this intervention. 7. Technologies Employed: Identify any technologies for which the intervention relies. St. Elsewhere has implemented CARE CONTINUUM TRACKING software with features that include embedded, customizable detailed discharge plans, post discharge encounter tracking and real time reporting capabilities. ARR: Intervention Plans and Budgets

11/17/2011 24 Hospital Intervention Plan Example Hospital/System Name: St. Elsewhere Metrics to Track Success of the Intervention: Provide information about one or two specific metrics the hospital/system will use to establish a baseline and then use to track progress over time for each of the ARR interventions. The HSCRC notes that a metric may be used for more than one intervention. Measuring the intervention 8. Metric 1 Name: Percent of patients discharged to ABC Nursing Homes for whom discharge summaries are transmitted within X hours of discharge 9. Rationale for Selection: Specify relevance/importance for the measure in improving patient processes or outcome(s) and ultimately, reducing readmissions, and the intervention(s) to which this measure applies. Timely communication during handoffs between settings of care can reduce preventable readmissions.

ARR: Intervention Plans and Budgets 11/17/2011 25 Hospital Intervention Plan Example Hospital/System Name: St. Elsewhere 10. Metric 1 Numerator Definition: Count of patients discharged to ABC Nursing Homes whose discharge summaries were transmitted within X hours of discharge 11. Metric 1 Numerator Data Source(s): Hospital administrative discharge data merged with EHR data 12. Metric 1 Denominator Definition: Count of patients discharged to ABC Nursing Homes 13. Metric 1 Denominator Data Source(s): Hospital administrative discharge data ARR: Intervention Plans and Budgets 11/17/2011 26

Hospital Intervention Plan Example Hospital/System Name: St. Elsewhere Measuring the impact 14. Metric 2 Name: Rate of 30 day Urgent/Emergent Encounters for Patients Discharged to SNF with and without the intervention 15. Rationale for Selection: Specify relevance/importance for the measure in improving patient processes or outcome(s) and ultimately, reducing readmissions, and the intervention(s) to which this measure applies. Effective care coordination efforts should reduce the rate of urgent/emergent encounters 30 days post discharge to a SNF. ARR: Intervention Plans and Budgets 11/17/2011 27 Hospital Intervention Plan Example Hospital/System Name: St. Elsewhere

16. Metric 2 Numerator Definition: All patients discharged to a SNF with an ER visit or readmission within 30 days of initial discharge Patients discharged to ABC Nursing Homes with an ER visit or readmission within 30 days of initial discharge 17. Metric 2 Numerator Data Source(s): Hospital administrative data merged with CARE CONTINUUM TRACKING system data 18. Metric 2 Denominator Definition: All patients discharged to a SNF Patients discharged to ABC Nursing Homes 19. Metric 2 Denominator Data Source(s): Hospital administrative discharge data ARR: Intervention Plans and Budgets 11/17/2011 28 Hospitals are Likely to Collect Other Data to Improve Interventions In addition to the intervention metrics, hospitals data collection may be aimed at

improving/refining interventions Survey of patients/families readmitted within 30 days Survey of/feedback from long-term care facilities The HSCRC will be interested in learning about these findings in the hospitals ARR annual report ARR: Intervention Plans and Budgets 11/17/2011 29 ARR Budgets Must Account for All Seed Funding Provision Dollars While the intervention plans should include major interventions, ARR budgets represent all interventions for which hospitals are expending seed funding dollars Budgets for ARR interventions may reflect more dollars than those allocated in the seed funding provision

ARR: Intervention Plans and Budgets 11/17/2011 30 Next Steps CRISP Update Other ARR Implementation Next Steps ARR: Intervention Plans and Budgets 11/17/2011 31 HSCRC Will Leverage CRISPs MPI to Track Readmissions Across Hospitals Chesapeake Regional Information System for Our Patients (CRISP) is Marylands state designated Health Information Exchange (HIE) CRISP creates a master patient index (MPI) for each

unique patient using a probabilistic matching algorithm ARR: Intervention Plans and Budgets 11/17/2011 32 CRISP Provides Reports to the HSCRC at the Patient Level Reports include at least the following fields: Enterprise MPI Number (Encrypted) Date of Admission Hospital/Facility ID Date of Discharge Medical Record Number ARR: Intervention Plans and Budgets 11/17/2011

33 HSCRC is Testing with CRISP to Monitor Readmissions Across Hospitals HSCRC staff matched HSCRCs case mix data to records compiled from ADT (Admissions Discharges and Transfer) data sent to CRISP by the hospitals Matching rates indicate of how well the ADT messages are aggregated into single discharge records and the completeness of the CRISP data Initial HSCRC Inpatient Case Mix to CRISP Data Match Tests, FY 2011 Q3 Data Hospital Total Number of Records Matching Rate to HSCRC Montgomery General 2,642 96.6%

Shady Grove Adventist 7,358 89.7% Washington Adventist 4,385 95.6% ARR: Intervention Plans and Budgets 11/17/2011 34 HSCRC and CRISP Continue to Collaborate and Test All acute care hospitals must establish connectivity with CRISP by December 1, 2011 We continue to test ADT data sent to CRISP against

HSCRC Inpatient case mix data as more hospitals are connected to the HIE. Each hospitals ADT data will be tested to ensure consistent matching rates. Once testing is complete, the MPI number will be linked to the inpatient discharge abstract. ARR: Intervention Plans and Budgets 11/17/2011 35 Next Steps Intervention plans and budgets are due to the HSCRC by November 30, 2011 Issuing weights Reporting and monitoring development Visit the ARR website for continued updates http://www.hscrc.state.md.us/init_ARR.cfm ARR: Intervention Plans and Budgets

11/17/2011 36 Questions? ARR: Intervention Plans and Budgets 11/17/2011 37

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