Impressive Avoidable ER Visit and Readmission Reduction Results
Al Hammonds, Executive Director, Millennium Collaborative Care, (photo above) welcomes Hospital Best Practice Meeting participants.
Spirited collaboration was the order of the day as hospital partners from Brooks Memorial Hospital – TLC; Erie County Medical Center; Buffalo General Medical Center; Niagara Falls Memorial Medical Center; and Olean General Hospital convened recently at Millennium Collaborative Care offices to engage in detailed sharing of best practices, results and lessons learned on route to reducing avoidable emergency department visits and hospital readmissions.
Best Practice Meeting participants included:
• Gail Bagazzoli, BSN, RN, Vice President of Quality and Chief Nursing Officer, Olean General Hospital
• Desiree Clarke, Data Analyst, Brooks Memorial Hospital /TLC
• Holly DeGolyer, DSRIP Project Manager/Case Manager, Brooks Memorial Hospital /TLC
• Becky Del Prince, Vice President, Systems & Integrated Care, Erie County Medical Center
• Sarah Gatti, MS-HIT, LPN, PMP, Quality Assurance Project Leader, Niagara Falls Memorial Medical Center
• Sheila Kee, Executive Vice President & Chief Operating Officer, Niagara Falls Memorial Medical Center
• William Loeffler, PharmD, MBA, Pharmacy Director, Buffalo General Medical Center
• Brian Meade, Director, Healthcare Analytics & Value Based Programs, Kaleida
• Michelle Nance, RN, Assistant Nurse Case Manager, Erie County Medical Center
They were joined by Millennium team members including Alicia Gizzi, Population Health Engagement Manager; Laura Kennedy, Provider Practice Relationship Manager; Steve Nelson, Director, Value Based Payment and Performance; Liz Thelen, Manager, Project Management Office and Karen Blount, Consultant.
As the impressive presentations demonstrated, there are indeed many roads to helping Medicaid patients decrease both avoidable emergency department visits and avoidable hospital readmissions. Please read on for a synopsis of the following presentation highlights:
• Best Practice: Emergency Department High Utilizer Management
• Hospital Partner: Brooks Memorial Hospital – TLC Hospital System
• Best Practice: Patient Progression Huddles Overview & Bridger Program
• Hospital Partner: Erie County Medical Center
Becky Del Prince and Michele Nance of the Erie County Medical Center.
• Best Practice: Medication Documentation Specialists/Importance of Accurate Medication History
• Hospital Partner: Buffalo General Medical Center
• Best Practice: 7-Day Pledge Program
• Hospital Partner: Niagara Falls Memorial Medical Center
• Best Practice: Behavioral Health Delivery Service Discharge Program
• Hospital Partner: Olean General Hospital
Gail Bagazzoli, BSN, RN, Vice President of Quality and Chief Nursing Officer, Olean General Hospital
Best Practice: Emergency Department High Utilizer Management
Hospital Partner: Brooks Memorial Hospital – TLC Hospital System, Inc. (BTLC)
Location: 529 Central Ave., Dunkirk, NY 14048
Holly DeGolyer DSRIP Project Manager/Case Manager, Brooks Memorial Hospital /TLC
In 2018, Brooks Memorial Hospital recorded 20,190 visits to the Emergency Department (ED); while TLC logged 10,999 visits. (Brooks Memorial Hospital – TLC defines a “High Utilizer” as an individual who has had 4+ visits to the (ED) in 6 months.)
Brooks Memorial – TLC began reduction efforts by first “getting organized” including collecting information and creating a spreadsheet that listed patients by provider and ranked by number of visits, high to low. Next, they began communicating! The Brooks memorial-TLC team contacted the top three Primary Care Providers with the greatest number of High Utilizers and scheduled initial face-to-face meetings to share findings, and ultimately, collaborate with Primary Care Providers to educate and redirect the High Utilizers to the appropriate medical setting. The team also welcomed feedback from Providers who shared 1) they were not getting all ED alerts; 2) assisted with refinement of patient lists and processes.
Examples of Brooks Memorial-TLC communications to providers, above, and patients, below.
In partnership with Primary Care Providers, Brooks Memorial-TLC next worked with the Providers to identify a “Point Person” from each Primary Care office; establish a secure mode to transfer information; send new spreadsheet every 6 months; provide educational material to the ED Discharge Packet; and evaluate progress every 6 months and make changes as needed.
From April thru September 2019, Brooks Memorial-TLC saw reductions in both the number of High Utilizers, and hospital utilization as demonstrated by the following charts. To sustain this momentum, the team is continuing to analyze latest data; continuing to provide 6-month spreadsheets; continuing to meet with provider groups as needed to collaborate care; and continuing to call patients with more than 4 or more monthly visits.
Best Practice: Patient Progression Huddles Overview & Bridger Program
Hospital Partner: Erie County Medical Center
Location: 462 Grider St, Buffalo, NY 14215
Laura Kennedy, Millennium Provider Practice Relationship Manager listens to presentation by ECMC’s Becky Del Prince.
The Erie County Medical Center established five key objectives of ECMC’s new Patient Progression Huddles Overview & Bridger Program including 1) Provide context for how Patient Progression Huddles fit into broader goals; 2) Review the importance of identifying patients who are at risk for a 30 day readmission and measures implemented to ensure successful patient outcomes during huddles; 3) Establish an understanding of the current state and goals of demonstration; 4) Introduce Patient Progression Huddles along with readmission risk scores and why they matter; 5) Develop an understanding of huddle objectives, process, tools, and roles.
The Importance of Proactive Communication and Multidisciplinary Approaches to Care Facilitation
At ECMC, Patient Progression Huddles occur away from the bedside. with all members of the Care Team present. This allows for rapid, structured discussion of patients and barriers to discharge, ultimately driving patient progression. To maximize huddle effectiveness, the ECMC team has identified key tools and huddle characteristics including:
White Board: reminds team of patient discharge status and ensures all team members have awareness of patient progression.
Scripts: standardizes discussion items to keep meeting focused on patient progression.
Checklists: ensures that all steps required for discharge are completed.
Multi-disciplinary Participation: facilitates easier and better communication and coordination
Timing: Focuses attention on progressing patients and minimizes disruptions to other day to day activities
Facilitation Resources -Whiteboards
In addition, ECMC has established PPH Ground Rules to maintain the focus of the conversation and ensure that huddles are action oriented, and not simply a patient update. These include:
• Timeliness: PPHs must begin and end on time to minimize impacts to patient care. Consequently, individual updates are brief.
• Preparation: All participants should arrive prepared to discuss patient care progression, including changes in status, barriers to discharge, and resolutions to those barriers.
• Relevance: Scripts and structures are only guidelines, only discuss those items which are relevant and significant to a patient’s care progression.
• Accountability: Responsible parties should be assigned for all follow-up items, and the facilitator should check the status of outstanding items after each report.
• Attendance: If a role is unable to attend, a substitute should be sent in their stead who is prepared and equipped to discuss patients.
For high level discussion topics, the ECMC team has differentiated presentations based on the where the patient is in the course of their hospitalization.
The ECMC team has also developed a Readmission Risk Tool that is required to be filled out for each patient at admission. This tool enables a Case Manager Risk Score that is totaled from following questions:
• Admission Diagnosis – Each Diagnosis equals 1 point
• Polypharmacy – Yes equals 1 point
• Taking increase risk Medications – Yes equals 1 point
• Dietary Restrictions – Yes equals 1 point
• History of Non-Compliance – Yes equals 1 point
• Currently receiving Palliative care – Yes equals 1 point
• Eligible for Palliative care – Yes equals 1 point
Total 0 -10 points
• Does the patient live alone – Yes equals 1 point
• Does living area have stairs – Yes equals 1 point
• Are there Stairs to Enter Home – Yes equals 1 point
• Recent Hospitalizations: 1 = 1 point, 2 = 2 points 3 = 3 points 4+ = 4 points
• Income Source Limited or No income equals 1 point
• Health Insurance Self Pay and Medicare Only equals 1 point
• Health Literacy Limitations Any response equals 1 point
• Other Substance Abuse – Yes equals 1 point
• Mental Health Diagnosis – Yes 1 point
Total 0 –12
For patients identified as at risk for readmission referral process, the ECMC team has developed a Community Referral Process as illustrated by the following “Transitions of Care” workflow chart:
Outcomes: Length of Stay Compared to CMS Target-Post Implementation
To date, ECMC’s Patient Progression Huddles Overview & Bridger Program is yielding great improvement in closing the gap with the Geometric Length of Stay (LOS) and the Average LOS; and Readmission Rates and High Risk Patient Support Service Outcomes as exhibited by the following charts:
Ineffective care progression rounds diminish the ability of care team members to engage in collaborative patient progression planning, leading to uncertainty about the overall care plan, challenging the efficient execution of the care plan, and increasing LOS. Improvement in the communication and standardizing these rounds has led to a decreased LOS compared to CMS target.
Ineffective care progression rounds also diminish the ability of care team members to identify patients at risk for readmission. Improvement in the communication and standardizing these rounds has led to a decreased overall readmission rate from 11.2% to 8.2%, and increase in compliance of patients attending their follow-up appointments.
Post Discharge phone contact and follow-up appointment compliance for patients identified at high risk for readmissions:
Baseline data for phone contact post-discharge: 8%, 60 days after start of program increased to 57%
Baseline data for patients who were compliant with PCP: 22%, 60 days after start of program increased to 50%
Best Practice: Medication Documentation Specialists/Importance of Accurate Medication History
Hospital Partner: Buffalo General Medical Center
Location: 100 High St, Buffalo, NY 14203
William Loeffler, PharmD, MBA, Buffalo General Medical Center Pharmacy Director presents BGMC’s Best Practice program.
According to data presented by William Loeffler, PharmD, MBA, Buffalo General Medical Center Pharmacy Director; medication errors are the 8th cause of death in the United States.
• ~60% of patients have at least 1 error in admitting medication history.
• 6% experience a complication.
• 27% of all hospital prescribing errors can be attributed to incomplete admission medication histories.
To improve this care process, the BGMC Pharmacy Team established a primary goal to develop a successful Medication History Team at BGMC that would be focused on safety and quality metrics; and that would continually assess financial metrics.
Once established, the new BGMC Medication History Team would strive to 1) Reduce medication errors/adverse events; 2) achieve Quality improvements (Complications, Mortality); 3) Reduce unnecessary inpatient readmissions; 4) Reduce inpatient costs-program sustainability; 5) Improve patient experience.
To establish the Medication History Team, BGMC Pharmacy followed a timeline as follows:
• Dec. 2017 – Formal appeal to create Medication History Team
• Jan. 2018 – Senior leadership approval
• Feb. 2018 – Creation of MHS and Supervisor job descriptions
• Mar. 2018 – Review/approval/addition of job descriptions
• May 2018 – Add Med HxSupervisor, Create Med Hxworkgroups, draft training documents and design workflows
• June 2018 – Post 3 day shift MHS, 1 filled
• Late June 2018 – Team supervisor position vacated –replacement recruiting began
• July 2018 – Modification to MHS JD to improve recruitment
• Aug. –Sept 2018 – On-going recruitment for MHS and supervisor
• Oct. 2018 – Filled supervisor role and 2 day shift MHS, 1 day shift vacated
• Nov. 2018 – Filled 1 evening shift MHS
• Dec. 2018 – Filled 1 day shift MHS –Started Jan 7th(in training)
• Feb. 2019 – Filled 1 evening shift MHS –Started Mar 4th(in training)
The team also implemented a Medication History Team training progression as illustrated by the following chart:
With the Medication History Team in place and trained, the MHT implemented a process to perform medication histories on patients admitted via the emergency department to inpatient status. (Inpatient admission order triggers patient to populate on the MHS patient list.) Furthermore, priority is given to 1) Unassigned ED patients; 2) Assigned ED patients; 3) Patients with incomplete admission medication reconciliation.
Example of BPMH Guide.
Overall, the MHS Workflow is as follows:
• Patient appears as “Task” on patient list
• MHS performs pre-interview workup
• Patient demographic info, location PTA, basic HPI
• Fill out Med List Workup Collection Form
• Assessment of external fill history (if available)
• Generate questions to clarify discrepancies during interview
• MHS interviews patient/caregiver
• MHS completes “Document Med By Hx Form” in Powerchartusing current version of BPMH Guide
• MHS contacts provider if applicable
• MHS marks “Task” complete and refreshes patient list
• MHS repeats steps above for next patient
• Data tracking/sign-out to next shift
In 2019, the new Buffalo General Medical Center Medication History Team completed 6,640 patient medication histories. Of these histories, they found 97% had preventable medication errors as illustrated by the following chart:
Armed with this data, in 2019 the new Buffalo General Medical Center Medication History Team prevented 44,822 Medication Hx Errors (6.7 errors per patient).
In addition, the Buffalo General Medical Center Medication History Programs and Readmissions achieved the following Program Results: Readmission Rates Jan. – June 2019:
Program Results: Mortality Rates Jan. –June 2019
Program Results: Direct Cost Per Case Jan. –June 2019 (What about program sustainability?)
Measured financial impact by comparing direct cost per case relative to benchmark expected cost per case between med hx team vs control group
Best Practice: 7-Day Pledge Program
Hospital Partner: Niagara Falls Memorial Medical Center
Location: 621 10th St, Niagara Falls, NY 14301
The primary goal of the Niagara Falls Memorial Medical Center “7-Day Pledge Program” is to provide timely access to primary care after a hospital stay or Emergency Department visit to manage and improve the health of NFMMC patients.
The key program objectives are to remove barriers to rapid primary care follow-up including 1) Inability to secure timely appointments;2) Transportation issues;3) Lack of patient knowledge about importance of primary care.
At the heart of NFMMC’s best practice is the “7-Day Pledge Imperative” which states:
“One quarter of hospital readmissions are preventable and inadequate post discharge follow-ups is a key factor in readmissions. By facilitating connections to primary care, the 7-Day Pledge program works to ensure that patients secure necessary care within 7-days after leaving the hospital.”
Sarah Gatti, MS-HIT, LPN, PMP, Quality Assurance Project Leader, and Sheila Kee, Executive Vice President & Chief Operating Officer, Niagara Falls Memorial Medical Center (left side of table) present NFMMC’s 7 Day Pledge Program.
According to NFMMC presenters Sheila Kee, Executive Vice President & Chief Operating Officer, and Sarah Gatti, MS-HIT, LPN, PMP, Quality Assurance Project Leader, the 7-Day Pledge Program was originated in Camden, New Jersey in 2014 when a coalition of nine primary care centers and six hospitals in Camden, New Jersey formed a collaborative to improve primary care connections after hospitalization.
The 7-Day Pledge Program is evidence-based as supported by research published by the American Medical Association’s JAMA Journal in January 2019 reporting that the project reduced 30-day readmission rates for Medicaid patients by 4.8%. The Study also found that 90-day readmission rates for Medicaid patients were reduced by 10.7%. Other research indicates that rapid primary care follow-up from the ED is a critical strategy for reducing preventable ED visits.
Niagara Falls Memorial Medical Center is taking a two-pronged approach to the implementation of the NFMMC 7-Day Pledge Program including: 1) Primary Care after a Hospital Stay; 2) Primary Care after an ED Visit.
Under this two-pronged approach, a 7-Day Pledge Coordinator is focused on serving Medicaid inpatients including:
• Attending daily interdisciplinary team huddles
• Visiting patients at bedside and informing them about importance of follow-up care
• Scheduling patients’ 7-Day Pledge primary care appointments at the patient’s preferred date and time
• Assisting patients with removing barriers, e.g. transportation, that would prevent them from attending their 7-Day Pledge appointments
• Informing Care Manager in Primary Care about the inpatient encounter and forwarding patient’s discharge summary and 7-Day Pledge appointment (a primary care-based care plan is subsequently developed)
• Calling patients to remind them of primary care appointments
In addition, a second NFMMC 7-Day Pledge Coordinator is focused on serving Medicaid ED Patients including:
• Visiting patient at bedside in the ED
• Assessing clients Social Determinant of Health screen and assists with removing barriers
• Scheduling 7-Day Pledge appointment at the patient’s preferred date and time,
• Sending Telephone Encounter to the Primary Care Coordinator using eCW.
• Forwarding ED Discharge Summary to Primary Care Coordinator
• Documenting all follow up appointments with provider name, date and time
• Making reminder calls.
Overall, building bridges with Primary Care is essential to the success of NFMMC’s 7-Day Pledge program. To ensure these connections, NFFMC strives to ensure:
• All six NFMMC Primary Care Centers are on board with making 7-day appointments
• All providers have been trained to use the 7-Day checklist that itemizes key issues to cover during the first primary care visit after a hospital stay or ED encounter (e.g. medication reconciliation, follow-up on test results, self-management)
• Care Manager in Primary Care develops care plans for all 7-Day Pledge inpatients
To date, early – first month – results of the NFMMC 7-Day Pledge program is gaining positive traction. Patients have expressed they feel special when they receive a 7-Day Pledge pin, they acknowledge this is good customer service.
Patients seem more inclined to attend follow-up primary care appointments:
-65% of inpatients attended primary care appointments within 7-days
-60% of ED patients attended a primary care appointment within 7-days
Best Practice: Behavioral Health Delivery Service Discharge Program
Hospital Partner: Olean General Hospital
Location: 515 Main St, Olean, NY 14760
Gail Bagazzoli, BSN, RN, Vice President of Quality and Chief Nursing Officer, (third from right side of table) presents Olean General Hospital’s Behavioral Health Delivery Service Discharge Program.
The Behavioral Health Delivery Service Discharge Program launched by Olean General Hospital is modelled off a Niagara Falls Memorial Medical Center initiative that was presented at a Millennium Behavior Health Workgroup meeting in 2018.
According to presenter Gail Bagazzoli, BSN, RN, Vice President of Quality and Chief Nursing Officer, Olean General Hospital, reliable transportation –a key social determinant of health –is also a critical element in a Medicaid patient’s successful discharge from OGH’s Behavioral Health Unit. Yet, many patients have challenges with transportation to Pharmacies to pick up prescribed medications.
Gail reported that between May, 2018, and April, 2019, OGH Behavioral Health had a total of 53 readmissions. To address this trend, in April 2019 OGH launched the OGH Behavioral Health Delivery Service Discharge Program with assistance of the Millennium Collaborative Care’s Innovation Program.
Under the OGH Behavioral Health Delivery Service program, a Pharmacy Courier now supports communication of prescriptions to OGH partner pharmacies, and then drives a Caravan supported by the MCC Innovation Program to personally pick up and hand deliver medications directly to the unit.
In addition to removing the transportation barrier, The Lyle F. Renodin Foundation (affiliated with the Franciscan Sisters of Allegany) provides assistance for patients who are unable to pay co-pays.
To date, patient interest in the new OGH program has been robust with 188 patients asking to use the program; and 91 patients actually taking advantage of the service. The impact on Readmissions has been as follows:
Readmission data January 2018 -April 2019
• 66 readmissions (16 months)
• Avg. 4.125 per month
Readmissions November 2018 –April 2019
• 29 readmissions (6 months prior to implementing medication delivery program.)
• Avg. 4.83 per month
Medication delivery started May 2019
• 22 BHU readmissions May – Oct. 2019.
First six months of medication delivery program
• Avg. 3.67 per month
• 24.14% improvement over previous six months
In addition -7 and 14 day appointments are being made prior to discharge.