Hospital to Home Initiative—Reviewing the Goals and Challenges
To address transitions of care, the federal government has included this in its current healthcare referendum. Beginning on October 1, 2012, hospitals with a higher than expected readmission rate will experience a decrease in Medicare payments. The decrease in payments will accelerate through the ensuing years. While there is a complicated formula that determines this, it is easiest to think about the maximum penalty to understand the impact. For the fiscal year 2013, the largest reduction could be 1 % in overall hospital payments from Medicare; in 2014, 2 %; and in 2015, 3 %. There are essentially two numbers that will be calculated—an expected 30-day readmission rate for all hospitals and an actual 30-day readmission rate for a particular hospital. If you exceed this expected rate of readmissions by a certain percentage (that percentage has not been released by Centers for Medicare and Medicaid Services [CMS]), then Medicare payments will be reduced.5
In the fiscal year 2015, it is expected that CMS will expand the number of conditions that will be tracked in terms of readmission and the Congressional Budget Office estimates that this strategy could save as much as $ 7.1 billion over 10 years.
Beginning in 2012, there will be three medical diagnoses addressed for readmissions: myocardial infarction (MI), heart failure, and pneumonia. These diagnoses have been part of publicly reported hospital quality data used for annual payment updates. It is expected that these data will be risk-adjusted, so that facilities treating more difficult and less adherent patients are not unfairly penalized. Yet risk-adjusted readmission rates are not reported on the CMS Hospital Compare website.6
CathKIT® (KIT stands for Knowledge and Improvement Tools).10 Developed in response to the evolution of the cardiac catheterization laboratory from a diagnostic facility to a treatment facility, the goal of CathKIT was to provide cardiac catheterization laboratory administrators and physician champions with the tools necessary to identify opportunities for improvement in their cath lab using a series of self-evaluation checklists and a quality scorecard. Ultimately, the CathKIT became a part of the National Cardiovascular Data Registry (NCDR) to help participants use their data for quality improvement.
Lessons learned from the GAP project and the CathKIT were applied to the ACC Door-to-Balloon (D2B) Alliance, which launched in 2006. From the GAP Project, the ACC learned the benefit of having guideline implementation tools. CathKIT demonstrated that knowledge of quality improvement could be increased through an online tool. D2B took these lessons a step further by building a quality improvement learning community committed to applying guideline-based best practices. As a national campaign to improve the timeliness of reperfusion therapy in patients with heart attacks, D2B facilitated the adoption of six evidence and guideline-based best practices shown to reduce door-to-balloon time.11,12
D2B is a national initiative to enlist
clinicians, administrators, other healthcare professionals, hospitals, and other partners to work together and provide coordinated diagnosis and treatment in patients with ST-segment elevation myocardial infarction (STEMI).
Focusing on rehospitalizations right now is a priority because healthcare reform represents not only an economic, but a political and societal issue. Unnecessary and preventable readmissions are harmful to patients, costly, and represent a flaw in our healthcare system where we could clearly perform better. It is an ideal time for the ACC and IHI H2H initiative to help hospitals and clinicians address this issue by sharing best practices nationwide and advocating for quality innovation.
Lessons Learned from Previous Quality Improvement Initiatives
The ACC has a history of developing and implementing quality improvement initiatives. One of the most well known is the Guidelines Applied in Practice (GAP) quality improvement initiative which started in ten hospitals in Michigan.7
The GAP project sought to improve care for
acute myocardial infarction (AMI) patients by increasing the use of evidence-based therapies using a toolkit. The toolkit could be customized, and consisted of an AMI standard order set, clinical pathway, pocket guideline and pocket card, patient information form, AMI-specific patient discharge forms, GAP chart stickers to identify patients included in the project, and hospital performance charts showing performance over time on key AMI metrics. GAP developed a variety of quality care indicators and measurement tools and eventually, after embedding these guidelines into practice, showed an improvement in 30-day and one-year mortality in patients with MI.8
This
benefit was most marked when patients were cared for using standardized evidence-based clinical care tools.9
To expand on the idea of providing evidence-based clinical care tools, the ACC developed an online quality improvement product called
US CARDIOLOGY
Like the ACC quality initiatives before it, H2H is a learning community, committed to quality improvement and the identification and sharing of best practice strategies to address a timely environmental issue. Unlike its predecessors, however, H2H is starting with an evidence base that is less clear about proven best practices shown to reduce hospital readmission rates, which presents opportunities for innovation and challenges as well.
Developing the Hospital to Home Goals H2H was born as a collaborative effort between the ACC and the IHI in 2009. By the end of 2010, the community consisted of over 1,000 organizations, more than 1,600 individual participants, 34 partners with two strategic partners, 25 quality improvement organizations, and a small amount of grant money for support. There have been more than 25 presentations nationwide, including two national webinars: one in February 2010 addressing the readmission problem and the second one in May 2010 which addressed a legislation briefing around the Obama administration’s health plan and how readmissions would be affected in the future. There have been a total of eight best-practice webinars, with approximately 900 attendees per webinar. A best-practice study with Yale supported by the Commonwealth Fund is currently in progress.
In 2011, H2H proceeded to engage the community by introducing the H2H Challenge as a community call to action around the three H2H core improvement areas: early follow-up, post-discharge medication management, and patient recognition of signs and symptoms. Over a period of six months, H2H community members are challenged to address one of these core improvement areas and are supported with four webinars, two surveys, and a collection of tools and strategies
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