Last month in NN&I, we presented the case study of Western Maryland Regional Health System in Cumberland, Md., which opened a new, 275-bed comprehensive regional referral center in 2010 with a 12,722 sq. ft., 35-station outpatient dialysis facility. In 2011, WMHS entered an agreement with the Maryland Health Services Cost Review Commission to adopt the Total Patient Revenue System, which provides hospitals with a financial incentive to manage their resources efficiently and effectively in order to slow the rate of increasing health care costs. The basic concept embodied in the TPR constraint system is the assurance of a certain amount of revenue each year, independent of the number of patients treated and the amount of services provided to these patients. The hospital therefore has the incentive to reduce length of stay, ancillary testing, and unnecessary admissions and readmissions.
At the same time, WMHS was preparing for the new bundled payment system for its dialysis patients, starting in January 2011. In doing so, an internal analysis of the WMHS dialysis program revealed two significant areas of concern:
- Higher-than-industry average utilization of previously billable drugs, an average of $98.07 per treatment, most specifically the cost associated with the use of erythropoiesis-stimulating agents (ESA) in its outpatient dialysis program
- A high incidence of readmissions–27%–to WMHS among its ESRD patients within the 30 days of discharge with the same medical diagnosis code
In Part 1, we reviewed results from our first charter initiative, improving anemia management. In this article, we will explore our second initiative: high incidence of readmissions among ESRD patients to WMHS within 30 days of discharge.
In May 2012, WMHS established two committees: 1) A Dialysis Administrative Team (DAT) to meet monthly comprised of the nurse manager and medical director of the outpatient dialysis program, director of nursing. director of registration and billing, and director of financial operations/patient care services; and 2) a Nephrology Executive Committee (NEC) to meet quarterly comprised of representatives from senior management (chief operating officer/chief nursing executive, vice president revenue cycle and physician enterprise for WMHS, director of nursing), the three independent nephrologists with privileges in the outpatient dialysis unit, and the nurse manager of the outpatient dialysis unit.
The purpose of the Dialysis Administrative Team is to monitor and trend the financial performance (revenue and cost management) as well as monitor regulatory compliance. The role of the administrative assistant in the outpatient dialysis unit was expanded to include the monthly collection, tracking, trending, and reporting of expected net revenue and cost per treatment data to the DAT. Shared information among the team members would enable problems with billing and/or collections to be identified and a plan of action would be developed and tracked monthly. Cost improvement strategies would be identified, tracked, and trended monthly to enable the outpatient dialysis program to monitor both financial and clinical targets for the outpatient dialysis program and respond accordingly. The medical director of the outpatient dialysis program was an important contributor to this committee.
The purpose of the NEC is to establish the foundation upon which key providers of renal-related services work together in defining the future structure of the Western Maryland Renal Service Management Program. The NEC provides a centralized focus in the management of the WMHS Renal Service Line necessary to identify, integrate, and manage clinical outcomes, cost efficiencies and customer satisfaction under a disease management model. Two key initiatives were identified for implementation in FY 2013 (7/1/12-6/30/13):
- Establish an anemia management workgroup to address the high utilization and cost of ESAs (Part I of this article).
- Establish an ESRD Care Coordinator position to address the high incidence of readmissions within 30 days of discharge among the ESRD population and seek opportunities to significantly reduce the incidence of “avoidable” admissions
ESRD Care Coordination Charter Initiative
Thirty-three percent of hemodialysis patients are rehospitalized within 30 days, compared to 24% of patients with CKD and 17.4% in the general Medicare population. Among hemodialysis patients, the overall hospitalization rate in 2011 reached 1.84 admissions per patient year — down from 1.90 in 2010 and 1.87 in 2009. Total hospital days per year fell to 11.7 from 12.1 in 2009 and the average length of stay dropped from 6.47 in 2009 to 6.36 in 2011. There is an increase in rehospitalization rates as CKD patients approach dialysis, to a level of 44% in the month prior to initiation — more than double the rate noted in the general Medicare population.
An analysis of hospitalizations during FY 2011 at Western Maryland Regional Medical Center for patients with a primary or secondary diagnosis of ESRD was used to compare to the data from the United States Renal Data System 2013 Annual Report. In FY 2011, WMHS had a total of 243 patient admissions from 101 ESRD patients.
- Average number of admits per patient per year was 2.4 compared to 1.84 in the U.S. in 2011
- Average length of admission days was 8.3 compared to 6.36 in the U.S. in 2011
- Average days in the hospital per ESRD patient per year was 19.9 compared to 11.7 in the U.S. in 2011
- Readmission rate within 30 days was 29.58% for hemodialysis patients compared to 33% for ESRD patients and 18% for the general Medicare population in the U.S. in 2011
Care coordination and ESRD
In October 2012, WMHS transitioned the role of the Clinical Coordinator in the outpatient dialysis unit to that of an ESRD Care Coordinator who would participate as a member of the interdisciplinary care plan team in the outpatient dialysis clinic and act as a liaison to the nephrologist, primary care physicians, and care teams in the hospital, nursing facilities, rehab facilities, and home care to ensure all health care needs of the ESRD patient were addressed in a timely, cost effective manner. It was through this collaborative framework that operational processes and procedures would be defined to promote 1) effective management of significant complications and comorbidities of dialysis (e.g., anemia, infections, hospitalizations etc.); efficient management of patient care across care settings (e.g. inpatient, outpatient, skilled nursing), and efficient use of resources (e.g., appropriate use of ESAs, elimination of duplicative laboratory testing).
The following charter initiative to address the high incidence of readmissions was presented to the NEC in October 2012:
- WMHS is at risk financially due to:
- ESRD bundled payment
- Total Patient Revenue System (TPR)
- Readmission rate that is higher than the national average for the general Medicare population and is a publicly reported indicator.
- In FY 2012, there were 120 readmissions among 405 dialysis patient admissions within 30 days of discharge with the same MDC.
- The average total charge per case for the ESRD patient readmission within 30 days with the same MDC was $25,636.
- Average length of stay (LOS) for these readmissions was 8.42 days
- Annualized, the 120 readmissions equated to a cost of approximately $3,076,342 under the Total Patient Revenue System (TPR)
- Potential savings if readmission rate is reduced from 120 cases (30%) to 100 cases (25% target) is $519,133.
The project scope looked at the number of primary or secondary admission/readmissions tied to fluid overload or hyperkalemia related to ESRD patients. Processes were identified to minimize the incidence of admissions and readmissions included the following:
- Follow up appointment with MD scheduled prior to discharge for 95% of total renal discharges or schedule MD visit within one to two weeks of discharge
- Rehabilitation vs. skilled nursing home facility referral for patients who need extended physical therapy or long-term care
- Home health referral for 50% of readmitted renal discharges who are discharged to home
- Complete “teach back” of critical information/survival skills on 75% of patients prior to discharge
- The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey tool should be used by staff to collect information in regard to symptoms/problems to look for after discharge: Ranking for 2,400 > 65th percentile.
- Discharge medication reconciliation completed 100% of discharged patients
- Comprehensive discharge instructions distributed to patient, skilled nursing facilities, and dialysis units
- Follow up contact with skilled nursing facilities and outside dialysis units on recently discharged HD patients to review discharge instructions, medication reconciliation, diet orders, MD follow up appointments, and ancillary service appointments (physical therapy, wound care, etc.) post discharge (all hospitalization and dialysis information to be faxed and report called to these units).
Target: 100% of patients
- Follow up with skilled nursing facilities / home care on recently discharged WMHS hemodialysis (HD) patients to check on patient’s progress post discharge.
Target: 100% of patients
- Weekly follow up for 30 days with recently discharged WMHS HD patients by ESRD Care Coordinator / Primary RN to evaluate patient’s progress / compliance with discharge plan / instructions post discharge.
Target: 100% of patients
- Report any patient issues (WMHS HD patients) to PCP and/or nephrologist for early intervention to help prevent readmission.
Outcomes from readmission initiative: Year one
Comparison of FY 2012 ESRD (585.6 primary or secondary) admission data to FY 2013 noted a 22.7% in reduction in the overall admission rate for ESRD patients from FY 2012 to FY 2013 (see Table 2). Total admissions decreased from 405 in FY 2012 to 330 in FY 2013 while the number of readmissions within 30 days decreased from 120 in FY 2012 to 85 in FY 2013 with readmission rates at 29.6% and 25.8%, respectively. A reduction of 75 total admissions in FY 2013 realized a savings to the Total Patient Revenue System of $1,508,850, of which $704,130 represented the decrease in readmissions.
The WMHS Renal Care Management Program achieved its target in reduction of readmissions within 30 days of discharge and exceeded the targeted savings tied to readmissions within 30 days.
The reduction of hospital ESRD patient admissions or readmissions due to fluid overload or hyperkalemia (our targeted group) was a result, in part, due to the following:
- A protocol was established to screen ESRD patients who presented to the emergency department (ED) with shortness of breath, as an example, for any other cause requiring an inpatient stay. If the ED physician determines the only need is for a dialysis treatment, the patient is transferred to the outpatient dialysis unit when the unit is open and a station is available for treatment. If the unit is not open, or a station is not available, the patient is dialyzed in a room in the ED that is set up to accommodate a dialysis treatment. Treatments performed in the outpatient dialysis unit are billed as a chronic treatment; however, the cost of providing the treatment in the ED is billed with the ED charges.
- When an ESRD patient requires hospitalization, the ESRD Care Coordinator communicates with the ESRD patient’s primary nurse verbally and in writing upon the patient’s discharge from the hospital. The ESRD Care Coordinator, nephrologist, and the patient’s primary nurse agree on a treatment plan to address the reason for a patient’s recent hospitalization and steps to be taken to ensure the patient does not require a readmission. Although it is the primary nurse’s responsibility to implement and update the action plan, the ESRD Care Coordinator makes rounds on all patients in the dialysis unit at least once a week and assists the primary nurse when needed.
- The ESRD Care Coordinator participates in the education of patients admitted to the hospital with ESRD (ICD 9 code 585.5), who have not yet started chronic dialysis therapy. As a result of this education, readmissions due to fluid overload and non-adherence to dietary restrictions, which in the past have resulted in a readmission before the patient could start chronic dialysis, have been significantly reduced. This process has also helped to make patients less apprehensive about starting outpatient dialysis therapy and provides the new patient with a “familiar face” when the patient is admitted to the outpatient dialysis unit.
The formation of the Nephrology Executive Committee strengthens the relationship between senior management and the nephrologists who support the renal program (outpatient and inpatient services) and has resulted in a shared vision for the WMHS Renal Service Management Program. Under the direction of the Nephrology Executive Committee, the Dialysis Administrative Team addressed the challenges that faced the WMHS renal program and was successful in achieving the financial and clinical goals defined in the two initiatives.
The ongoing success of the Dialysis Administrative Team (DAT) is contingent on the monthly tracking, trending, and reporting of revenue and cost per treatment data. The DAT supports an environment whereby issues with claims processing and/or collections are identified with a plan of action formulated. As noted by WMHS nurse manager Troy VanMeter, monthly updates of active action plans are imperative to ensure a proactive approach toward “real time” clinical and financial management of the renal program. Melissa McCloskey, ESRD Care Coordinator, noted, “in addition to the ESRD Care Coordinator position helping to prevent both admissions, and readmissions (which has been a big cost savings) the patients seem to like having someone ‘check up’ on them to make sure things are going okay at home. Patients feel more confident in the care they receive and that things are not falling through the cracks. In addition, patient satisfaction with WMHS and the outpatient dialysis unit is at an all-time high as dialysis patients appreciate the goal of the collaboration across care settings is for the patients to achieve an optimal health status post discharge.
“Furthermore, the skilled nursing facilities and outside dialysis units have commented that getting both verbal and faxed discharge information / instructions has been very helpful to them in their continuation of the patients care post hospital discharge.”
Care Management Initiative for 2014
Since congestive heart failure (CHF) is one of the core measures for WMHS, a business case will be developed to address dialysis patients with CHF. Although WMHS has a CHF clinic, patients from the outpatient dialysis unit seldom participate due to the additional time that would be involved above the typical nine to twelve hours per week they are already in the outpatient unit. The business case will explore opportunities to incorporate care strategies developed by the CHF clinic in the management of dialysis patients with CHF in order to prevent both “avoidable” admissions and readmissions of this population.
1. USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md., 2013.