Reducing Hospital Readmissions: Obstacles and Solutions Presented by the RWJF Human Capital Network March 31, 2014 RWJF Human Capital Network •  Easily locate and communicate with your peers and Foundation staff •  Join discussions, discover career opportunities and events http://www.rwjf.org/humancapitalnetwork Presenters Susan Mende, BSN, MPH RWJF Senior Program Officer Matthew McHugh, PhD, JD, MPH, RN, FAAN RWJF Nurse Faculty Scholar Susan Mende, BSN, MPH RWJF Senior Program Officer The Challenge We Face: Avoidable Readmissions Bleak Stats –       Nationwide 1 in 5 Medicare patients back to hospital within 30 days 12% of Medicare patients with surgery readmitted within 30 days Impact •  Negatively affect patients' health •  Burden on families and caregivers •  Costs a lot – to the tune of $17 billion a year National Problem   CMMS calls avoidable readmission one of the leading problems facing the U.S. health care system   The Affordable Care Act increases hospitals' financial accountability for preventable readmissions   Hospitals penalized a % of Medicare reimbursements for excess readmissions for AMI, heart failure, & pneumonia patients   CMS estimates 2,225 hospitals will be penalized $227 million because of excess readmissions, representing 0.2 percent of total Medicare base payments to hospitals Why are People Readmitted?   Problems with inpatient care   Inadequate or late discharge planning   Untimely assessment and coordination of physical, mental health and social needs at home   Poor care coordination hospital and community clinicians   Incomplete communication with patients and families   Lack of medication reconciliation •  hospital and home Community Problem Not a hospital problem – a community problem Solution outside the walls of the hospital   Patients and their families   Hospitals   Primary care providers   Post-acute care facilities   Behavioral health providers   Community-based social services   Partners outside of health care   Need to weave a fabric of coordinated care, information and services for patients after discharge. www.CareAboutYourCare.org Matthew McHugh, PhD, JD, MPH, RN, FAAN RWJF Nurse Faculty Scholar Associate Professor, University of Pennsylvania School of Nursing Associate Director, Center for Health Outcomes & Policy Research BACKGROUND Many programs developed to reduce hospital readmissions often focus on deploying scarce and costly services or redesigning care processes for select high-risk patients* Less research has focused on the effect of the features of hospital nursing organization which virtually all patients are exposed to during hospitalization *Naylor, M. D., Brooten, D., et al. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA, 281(7), 613-620. Jack, B. W., V. K. Chetty, et al. (2009). "A reengineered hospital discharge program to decrease rehospitalization." Annals of Internal Medicine 150(3): 178-187. Coleman, E. A., C. Parry, et al. (2006). "The care transitions intervention: results of a randomized controlled trial." Archives of Internal Medicine 166(17): 1822. OBJECTIVE Determine the relationship between hospital nursing; i.e. nurse work environment, nurse staffing levels, and nurse education, and 30-day readmissions among Medicare beneficiaries with heart failure, acute myocardial infarction, and pneumonia METHODS Linked data from a survey of 20,585 hospital staff nurses from California, New Jersey, and Pennsylvania, beneficiary discharge data, and the American Hospital Association (AHA) Annual Survey from 2005-2006. The features of hospital nursing measured from the nurse survey: •  nurse work environment (poor, mixed or good) •  nurse staffing (patient-to-nurse ratio) •  nurse education (proportion of nurses holding BSNs or above) Condition-specific risk-adjusted robust logistic regression models were used to estimate the relationship between the organization of hospital nursing and patients’ likelihood of 30-day readmission. READMISSIONS BY CONDITION PATIENT CHARACTERISTICS READMISSIONS WITHIN 30 DAYS HEART FAILURE (N =171,883) MYOCARDIAL INFARCTION (N = 62,394) NO. (%) NO. (%) 39,954 23.2% 12,131 19.1% PNEUMONIA (N = 141,404) NO. (%) 25,169 17.8% RESULTS Each additional patient per nurse associated with a 7% increase in the odds of readmission for heart failure and pneumonia patients, and a 10% increase for myocardial infarction patients Care in a hospital with a good versus mixed work environment (or mixed vs. poor) was associated with 4% lower odds of readmission for heart failure and myocardial infarction patients, and 6% lower odds for pneumonia patients OBJECTIVE To examine the relationship between registered nurse staffing levels and performance in the HRRP Rationale: Increasing nurse staffing levels is a straight forward solution that has also been shown to improve outcomes and patient satisfaction. Does it also help hospitals avoid financial penalties post-ACA? METHODS Linked data for 2,976 non-federal acute care hospitals subject to HRRP from: •  •  •  •  CMS HRRP Supplemental Data File for FY2013 (July 2008- June 2011) 2009 American Hospital Association Annual Survey 2009 MedPAR and Medicare BASF 2006-2010 American Community Survey Staffing measured as full time equivalent registered nursing hours per adjusted patient day Optimal nonbipartite matching to match pairs of hospitals that were similar in terms of structural and patient case mix characteristics but differed greatly by registered nurse staffing. McNemar’s tests and conditional logistic regression to estimate the effect of high versus low staffing levels on the odds of HRRP penalty EACH HOSPITAL IS PAIRED WITH A SIMILAR HOSPITAL IN A DIFFERENT RN STAFFING CATEGORY Hospital A Technology Level Bed Count Ownership Teaching Status Profit Margin Urban/Rural Socioeconomic Status Proportion Medicaid Proportion Black Proportion Hispanic High RN Staffing Group Hospital B Low RN Staffing Group Well Staffed Hospital Poorly Staffed Hospital Readmissions Performance? Readmissions Performance? POST-MATCHING DISTRIBUTIONS Assign better staffed hospital in pair to “high” staffing group and worse staffed to “low” group The majority of our matched pairs differed by > one staffing level — 64% differing by ≥ 2 levels, 23% differing by ≥ 3 staffing levels. Standardized matching score by staffing group Registered nurse hours per patient day by staffing group M= 8.0 (2) M= 5.1 (1.5) HOSPITALS WITH HIGHER NURSE STAFFING HAD 25% LOWER ODDS OF PENALTY VS. LOWER STAFFED MATCHED COUNTERPARTS Odds of Penalty for Better Staffed Hospitals! Primary Analysis (unadjusted) Primary Analysis (adjusted) Excluding SNF Variable (unadjusted) Excluding SNF Variable (adjusted) FY 2013—Sept 2012 Revision (unadjusted) FY 2013—Sept 2012 Revision (adjusted) FY 2012 (unadjusted) FY 2012 (adjusted) POTENTIAL INTERVENTIONS AND IMPLICATIONS Differences in nursing resources matter even when we account for vulnerable service populations and teaching status Policies interventions: minimum staffing requirements, public reporting (e.g., Hospital Compare), and internal hospital level policies Add nurse work environment factors to public reporting requirements and benchmarking data The Magnet Recognition program is an evidence-based organizational re-design intervention that provides a blueprint for creating a work environment that supports excellence in nursing practice Combine system-level policy mechanisms with effective transitional care, discharge planning, telehealth, and care coordination program CONCLUSION Improving the hospital nursing work environments and staffing levels should be considered by policy makers and hospital administrators as potentially effective system-level inventions for preventing readmissions for Medicare beneficiaries and reducing readmissions-associated penalties Questions? Susan Mende, BSN, MPH RWJF Senior Program Officer Matthew McHugh, PhD, JD, MPH, RN, FAAN RWJF Nurse Faculty Scholar RWJF Human Capital Network •  Easily locate and communicate with your peers and Foundation staff •  Join discussions, discover career opportunities and events http://www.rwjf.org/humancapitalnetwork Reducing Hospital Readmissions: Obstacles and Solutions Presented by the RWJF Human Capital Network March 31, 2014