In Illinois, major stakeholders are collaborating to reduce the state’s high rate of readmissions. The goal: to achieve upper-quartile performance on readmissions by improving care delivery, transitions, discharge, and more.
At a Glance
Three core programs have helped reduce readmissions in Illinois hospitals:
- Project BOOST (Better Outcomes by Optimizing Safe Transitions), which focuses on redesigning hospital discharge processes and improving transitions of care
- HP3: Hospitalist Program Peak Performance, which provides educational resources, motivation, and a process improvement structure for hospitalist programs
- Communications and Palliative Care, which teaches physicians and clinicians how to work with patients to define their goals of care and identify options to improve their quality
In 2009, when the Commonwealth Fund released Aiming Higher: Results from a State Scorecard on Health System Performance, the news was not good for the state of Illinois. The state ranked 44th out of 50 states and the District of Columbia on 30-day Medicare readmissions as a percentage of admissions.
Strong interest in reducing readmissions resulted in a unique, statewide collaboration among BlueCross BlueShield of Illinois (BCBSIL), the Division of Hospital Medicine at Northwestern University’s Feinberg School of Medicine, and the Illinois Hospital Association (IHA)—along with strategic partners at the Society of Hospital Medicine (SHM)—to bring down the state’s readmissions rate.
In 2011, this group launched the Preventing Readmissions through Effective Partnerships (PREP) initiative. The initiative has five objectives:
- Redesign hospital discharge processes.
- Improve transitions of care.
- Enhance the delivery of patient-centered care.
- Strengthen hospitalist programs.
- Measure reductions in readmissions using standard metrics.
The initiative’s goal is to raise the state’s performance on readmissions from the bottom quartile to upper-quartile performance by 2014. To date, nearly 89 percent of IHA members have participated in the PREP initiative—and many have experienced increases in follow-up care appointments, contributing to significant reductions in readmission rates and costs.
How the Initiative Began
IHA was well aware that the Centers for Medicare & Medicaid Services (CMS) would soon begin imposing penalties on many IHA members for high readmission rates under the Hospital Readmissions Reduction Program established by the Affordable Care Act (ACA). BCBSIL, too, had identified readmissions as a key indicator of quality of care at state hospitals and saw a strong business case for dedicating resources to reduce readmissions. Meanwhile, Northwestern’s Division of Hospital Medicine and SHM had developed the expertise and toolkits to effectively engage hospitals in the types of quality improvement needed to reduce readmissions.
These partners saw a clear logic in focusing on hospitalist programs to address the state’s high rate of readmissions. SHM already had experience in engaging hospitalists in reducing readmissions through its Better Outcomes by Optimizing Safe Transitions project (Project BOOST), a nationwide, mentor-led initiative launched in 2008.
For its part, BCBSIL had worked with 12 medical groups with certified hospitalist programs and found that the groups’ readmission rate was 81 percent of the predicted readmission rate, based on Healthcare Effectiveness Data and Information Set methodology.
At the core of the PREP initiative are three mentoring programs that are being funded by BCBSIL, which has invested nearly $8 million in the initiative so far. The mentoring programs consist of Project BOOST, the Hospitalist Program Peak Performance (HP3) program, and the Com-munication and Palliative Care (CPC) program.
To date, 54 Illinois hospitals have participated in one or more of PREP’s three mentoring programs. Hospitals that participate in these programs receive direct funding from BCBSIL to help cover the costs of participation. Hospitals are not required to meet performance improvement metrics or report individual data to BCBSIL. Instead, funding is contingent on rigorous documentation of a hospital’s active participation and Northwestern’s endorsement that the participating hospital has met the program requirements.
BCBSIL sees only aggregate data on hospitals participating in the program. Kelly Tarpey, director of clinical excellence for Sherman Health, which has participated in two of the three mentoring programs to date, praises the program and BCBSIL’s “no strings attached” approach. “To receive funding and know that it’s all right if you make mistakes is rare,” Tarpey says. “It is very freeing for the organization to know that it can take risks and ask questions freely. This spirit of innovation is how we will eventually accomplish the aims of healthcare reform.”
BCBSIL’s investment also includes a grant to fund the development of a statewide readmissions database, maintained by the IHA’s Institute for Innovations in Care and Quality, and to fund programs that expand outreach to critical access hospitals, provide educational support to hospitals not yet ready to commit to the more intensive mentoring programs, and strengthen hospital and community connections. Today, 88.8 percent of IHA’s member hospitals are participating in the PREP initiative in some way.
Although all three of the PREP initiative’s core programs include a mentoring component, each takes on different goals of the initiative.
Project BOOST—an SHM national initiative that was adopted as the backbone of Illinois’s PREP initiative—directly addresses two of PREP’s five goals: redesigning hospital discharge processes and improving transitions of care. Mark Williams, MD, a professor of medicine and chief of the division of hospital medicine at Northwestern’s Feinberg School of Medicine, serves as principal investigator for Project BOOST and played a leadership role in SHM’s development and implementation of the
Project BOOST is based on several key tenets.
The importance of mentoring. Hospitals that decide to participate in the project receive a full year of mentoring from an experienced faculty of hospitalists.
The need to start small, learn, and disseminate learning. Hospitals are asked to begin by working with a defined inpatient subpopulation, consistent with the project’s emphasis on specific, measurable, achievable, relevant, and time-defined (SMART) goals.
The importance of a patient-centered approach to care transitions and patient communications. Project BOOST encourages implementation of “teach-back,” in which patients or family members who will be serving as caregivers demonstrate their ability to teach-back postdischarge instructions by responding to a series of open-ended questions correctly before leaving the hospital.
Richard Gayes, MD, a medical director for BCBSIL and also a member of SHM, was well aware of the potential of hospitalists to reduce readmissions. Five years ago, Gayes had launched a promotion of hospital medicine with Illinois medical groups and had worked with hospitalists to establish criteria that would identify strong hospitalist programs, including readmissions rates that are lower than predicted.
Sherman Hospital, the flagship facility of Sherman Health, based in Elgin, Ill., is one of 27 Illinois hospitals that have participated in the Project BOOST component of the PREP initiative. Sherman focused its initial efforts on a medical telemetry unit that served many of the hospital’s patients with heart failure. The implementation team—consisting of a physician champion, executive sponsor, operational leader, staff champions, and performance improvement expert—trained unit staff in teach-back techniques to be used at discharge and in postdischarge follow-up calls.
Incorporating teach-back into the follow-up calls required several process changes. First, Sherman centralized discharge calls for patients with heart failure. Second, it changed the purpose of the calls from service to clinically focused questions, and gave nurses responsibility for making the calls. Open-ended questions such as “Tell me which medications you took this morning?” provided nurses with a clear sense of whether the patient was following discharge instructions or whether additional support was needed.
To measure progress, Sherman tracked results on HCAHPS discharge education questions and overall readmissions for heart failure from the telemetry unit. From the fourth quarter of 2011, when teach-back was implemented on the unit, to the third quarter of 2012, scores on the HCAHPS discharge information question rose from 84 percent to 94 percent, as shown in the exhibit on page 81. Even more significant, Sherman has seen readmission rates for all heart failure patients drop from 26 percent in 2009 to 11 percent at the beginning of 2013.
Tarpey of Sherman Health acknowledges that the hospital was somewhat reluctant to take on another initiative. Several factors drove the decision to sign on for Project BOOST. First was the realization that, although readmission reduction had been given prominence on the national level, there was little guidance on how hospitals should proceed. “The federal government was talking carrots and sticks, but there were no benchmarks and no well-worn paths to improvement already identified,” Tarpey says. “We realized that we had the need—and the opportunity—to innovate and identify best practices.”
Second, Sherman was looking for solid, smart partners to assist in its performance improvement efforts. Project BOOST, with its national faculty of mentors, offered such partners.
Third, participation in all three of the PREP initiative mentoring programs is supported by funding from BCBSIL, with the only requirement being a commitment to see the program through. Based on its success in Project BOOST, Sherman has already signed up for another PREP initiative offering, the CPC program.
HP3: Hospitalist Program Peak Performance
The PREP initiative’s HP3 program brings together two of the initiative’s strategic partners—Northwestern’s Feinberg School of Medicine and SHM—with John Nelson, MD, and Leslie Flores, nationally recognized hospitalist practice management consultants, in a program designed to strengthen hospitalist programs. SHM adds the mentored implementation model to facilitate training and support of mentors.
The requirements for participating in HP3 include identifying a project team with both an executive champion and a hospitalist champion and committing to the completion of three improvement projects to work on over the course of the program year. One of the three projects must focus on care transitions.
All participating hospitals—25 to date—complete an online assessment of their hospitalist practice to identify existing practice strengths and opportunities for improvement. Project teams also meet with teams from other HP3 sites at a kickoff meeting to review their assessment results, exchange ideas with colleagues from other sites, and select and develop action plans for site-specific goals and performance measures. Throughout the year, each project team is paired with an experienced mentor who provides individualized coaching, phone support, and a site visit. SHM hosts a series of webinars, a web-based e-community for idea exchanges and networking among project teams, and an online toolkit for the program.
Nelson and Flores, the HP3 program directors, equate the program to having a personal trainer at the gym. HP3 provides educational resources, motivation, and a process improvement structure, but the site-based project teams must do the actual improvement work. As teams work together over the year on their performance improvement projects, they build a foundation that will enable them to take on additional projects after the HP3 year ends.
The need to build a culture of ownership within the hospitalist program is the basic philosophy behind the HP3 program’s approach. Hospitalist groups that enroll in the program want to develop a sense of their strengths and weaknesses and identify areas that would benefit from improvement. They have, in other words, already taken a significant step toward the ownership mindset that the program hopes to instill.
Northwest Community Hospital (NCH), based in Arlington Heights, Ill., formed its hospitalist practice within NCH Medical Group just three years ago. Since then, the practice has grown from two to eight physicians and will be moving to 10 employed hospitalists in the near future. As a new and growing group, the NCH hospitalists saw in HP3 an opportunity to demonstrate their value and establish a foundation for further growth. The three performance improvement projects they chose for their year of participation in HP3 included:
- Measuring the value of the hospitalist program beyond relative value units
- Preparing an orientation manual to assist in the onboarding of new hospitalists
- Improving the group’s patient discharge protocol
With the help of the hospital’s chief medical officer, NCH hospitalists identified a combination of data on patient admissions (hospitalist group admissions compared with admissions for all other groups) and average length of stay to calculate variable costs savings based on patient days saved. Based on these data, the hospitalist group was able to demonstrate more than $1 million in savings.
Perhaps even more impressive are the results the group has achieved with its new patient discharge protocol. As primary care has expanded within NCH Medical Group, varying patterns of communication with the primary care physicians have initially affected these physicians’ satisfaction survey results. The hospitalist group standardized communication with primary care physicians upon discharge, developed guidelines regarding when a hospitalist would be expected to call a primary care physician, and created a new discharge packet, including contact information for the discharging hospitalist that can be electronically transmitted or faxed to the discharged patient’s primary care physician. The group also equipped its assistants with iPads to schedule follow-up primary care physician visits at patient bedsides to ensure that such appointments would work for both the patients and the physicians.
As a result of the initiative, NCH saw its follow-up show rates for all patients discharged to home increase from 42.2 percent during the period before the new protocols were implemented (July-September 2011) to 83.4 percent in the period following implementation (July-September 2012), as shown in the exhibit on page 83. For patients who were specifically instructed to follow up with their primary care physicians, the follow-up percentage hit 92.4 percent, as shown in the exhibit below. Meanwhile, NCH Medical Group’s readmission rates have dropped from 15 percent in the last fiscal year to 11.5 percent in the first half of the current fiscal year.
“Getting buy-in from all the hospitalists was a bit of a challenge at first,” says Michael Grzelak, MD, lead hospitalist for NCH Medical Group. “But once they saw the data coming in, everybody quickly got on board.” Building on its success with the HP3 program, NCH has now signed on for Project BOOST.
Communications and Palliative Care
With its CPC program, the PREP initiative is taking on one of the most sensitive issues in health care: working with patients to define and understand their goals of care and identifying options to improve their quality of life, whether the patient is being treated for a curable illness, living with a chronic condition, or nearing the end of life. The CPC program is led by Eytan Szmuilowicz, MD, director of the section of palliative medicine within the division of hospital medicine at the Northwestern University Feinberg School of Medicine.
As with Project BOOST and HP3, CPC is a mentoring-based program. Hospitals begin their time in the program with a two-day kickoff meeting. One day of orientation is devoted to skills practice around patient communications, using standardized patients in a simulation center at Northwestern; the second is devoted to learning how to encourage the development of enhanced communication skills and a culture focused on understanding patient goals of care throughout an organization. Quality improvement projects continue the focus on building these skills and culture within the participating hospitals over the course of the program year.
A recent article in the New England Journal of Medicine emphasized the need for broad-based, basic skills in aligning treatment with patient goals and understanding basic symptom management.a The article notes that an increasing demand for palliative care will soon outpace the available number of specialist providers. Moreover, a greater understanding of basic symptom management and patient psychosocial support needs—regardless of physician specialty—helps avoid the fragmentation of care that can result when a specialist is brought in to treat these specific patient needs.
The greatest challenge the CPC program faces involves the incentives within the current payment system, which encourage physicians to provide more care; palliative care typically requires more time spent with the patient and fewer intensive care options. “It’s easier to talk about the next round of interventions,” says Szmuilowicz. “Palliative care conversations can be emotionally difficult, especially with long-term patients.”
The fifth cohort of hospitals is currently entering the CPC program (22 hospitals have participated to date). Among hospitals that have completed the program, there have been some successes in reducing readmissions within targeted groups of patients, but there also have been broader ripple effects resulting from increased understanding of palliative care’s value and strengthened relationships among hospitals and palliative care organizations and hospices. Most important, the program has been well received by patients.
Sherman Hospital has focused on goals of care for patients in its oncology unit. “So many readmissions come from patients in their last year of life,” says Sherman’s Tarpey. “If we were better about asking patients what they would like to accomplish in that last year, their plans of care would likely be very different.”
Several additional factors have supported the success of hospitals participating in the PREP initiative—and the lessons learned could be applied to performance improvement initiatives undertaken by other hospitals.
Executive champions. Hospitals participating in the initiative’s programs demonstrate the need for the C-suite’s engagement in efforts such as this, says PREP initiative leader Mark Williams. “Hospital change is very difficult unless the leadership is involved,” Williams says. “It requires a senior level commitment to change.”
Access to data. A portion of the grant BCBSIL gave to IHA was used to fund development of the Illinois Readmissions Activity Profile, a database resource that offers a statewide lens on readmission activity. The database creates a unique identifier for each patient, which allows facilities to see where patients are coming from, where they are being discharged to, and when and how often patients are readmitted to other facilities. Hospitals can view data by service line or physician and can see how many emergent visits to the ED are attached to readmission activity. The resource also computes expected-versus-actual readmissions and allows comparison of readmission rates with peer facilities.
“Hospitals are encouraged to look beyond the numbers in the database and see what other information they can find about relationships, what is being done in the community, and what other resources are available after patient transitions,” says Cathy Grossi, vice president of IHA’s Institute for Innovations in Care and Quality. “We’re seeing access to the data inspiring new coalitions and prompting regular meetings between hospitals and long-term care facilities to improve care coordination.”
Support of finance and administrative staff. When PREP initiative programs were first presented to finance leaders, some were concerned about the financial impact that reducing readmissions would have on their organizations. These leaders have come to realize that readmitted patients are often not a good source of revenue because of their complicated health status and longer lengths of stay. With added concerns about new penalties from the Hospital Readmissions Reduction Program, finance leaders across the state are now embracing the initiative and committing staff resources to assist hospitalists. “We had full support from all, including information on financials,” says NCH’s Grzelak. “It really helped us get the data we needed to bring all the hospitalists onboard.”
Williams is currently working with colleagues at Northwestern University’s Kellogg School of Management on a new ROI calculator for Project BOOST to further define the value of readmission reductions.
Collaboration of multiple stakeholders. Perhaps the most important factor behind the success of the PREP initiative is the collaborative effort by hospitals, physicians, payers, academic researchers, and associations to help solve the problem of readmissions in Illinois.
“Whether you are a provider or an insurer, this is a brave new world for all of us,” says Bobbi Berg, MBA, RN, BCBSIL’s divisional vice president for quality and clinical outcomes management. “The only way we’re going to solve the problems in health care is by joining hands and jumping into the pool together.”
James H. Landman, JD, PhD, is director, thought leadership initiatives, HFMA, Westchester, Ill.
a. Quill, T.E., and Abernethy, A.P., “Generalist Plus Specialist Palliative Care—Creating a More Sustainable Model,” The New England Journal of Medicine, March 8, 2013.
Reducing Exposure to Readmission Penalties
Using CMS’s formula for projecting estimated penalties under the Hospital Readmissions Reduction Program, the Illinois Hospital Association has calculated the progress the 128 affected hospitals in Illinois have made on readmissions since the PREP initiative was launched in 2011.
If CMS’s program had been in place in the following fiscal years, based on rolling three-year readmissions figures for the 128 affected hospitals, the following financial penalties could have been incurred:
- In FY11, the projected penalty would have been $30.3 million.
- In FY12, the projected penalty would have been $25.3 million.
Actual total aggregate penalties statewide for FY13 were $20.9 million.