Using your Patient Tally Report to Create your Agency's Risk Profile for Acute Care Hospitalization May 16, 2005 Presented by Cindy Struk - PhD, BSN, MSN, PNP VISITING NURSE ASSOCIATION HEALTHCARE PARTNERS of OHIO cstruk@vnacleveland.org and OASIS ANSWERS, INC. Sponsored by the Colorado Foundation for Medical Care VNAHPO PROFILE • Voluntary Communitybased • Urban and rural • JCAHO Accreditation • Medicaid and Ohio Department Mental Health Certified • Home Health, Private Duty, and Hospice Objectives • To identify high risk indicators for rehospitalization • To describe how a patient risk profile may be developed for predicting re-hospitalization • To describe how to use the CMS Patient Tally worksheet as a tool for risk profiling • To describe how best practice actions can be developed for risk indicators • To describe how progress can be audited and measured A look at Re-hospitalization Diagnosis, Caregiver support, Risk factors, Medications and Non-clinical data Clinical care delivery Re-hospitalization State National Risk factors for Hospitalization…the research • Falls….falls injuries > 65 age group lead to health care utilization – HCHS 2004 • Medications…..studies show that patients with >9 meds have at least a 22% incidence of medication errors which contribute to adverse reactions and hospitalization – Center for Policy and Research, 2002 • Physician oversight…hospitalization likelihood is reduced with close PCP monitoring and intervention – Division of Health care Finance and Policy, 2002 • Well being…studies indicate mental health, social support, cognitive functioning and morale all have significance in predicting hospital or ambulatory utilization – Steel et al. 1982 – Shapiro & Roos 1985 • Patient perceived quality…..quantification of patients’ health care needs and monitoring the effectiveness of interventions at selected intervals may reduce emergent care and/or hospitalization as it engages persons in their own health care – Agency for Health Research and Quality, 2004 • Financial resources…financial or perceived resources is an indicator linked to health care utilization – Diez-Rous et al 2001 – Epstein & Cumella, 1988 Home health profile • Functional: Needed greater assistance with ADLS/IADLS and medications • Chronic conditions with difficulty breathing • More than 2 secondary diagnoses • Lacked primary caregivers • Dual eligibility • Referred from inpatient setting – Rosati, et al, 2003 JHQ Predicting factors for Hospitalization…OASIS Risk adjustment model • Method to estimate the relationship between an outcome and a set of risk factors • Predictors that were statistically significant in predicting outcome of hospitalization • Uses an odds ratio which are values that indicate the likelihood of the outcome occurring given the OASIS predictor and taking into account all the other predictors for that outcome…logistic regression Interpreting the odds ratio • For the outcome of Acute Care Hospitalization …patient lives alone has an odds ratio of 1.09 so patient is 1.09 (or 9%) more likely to go to the hospital than someone who is not living alone. • Odds ratios less than one indicates that the patient characteristic is less likely to lead to re-hospitalization. • Set thresholds for reviewing the ratios..one approach is to use a 25% rule where the odds ratios for OASIS indicators less than .75 and greater than 1.25 are influential • Some of these factors include – Inpatient discharge from hospital – Urinary catheter – Acute condition mental/emotional – Neoplasms Predicting factors for Hospitalization…Other sources • Home health publications with data or benchmarks – Home Healthcare Nurse – Home Health Line • Agency focus group of clinicians managers • Focused chart review of patients who are hospitalized • State reports..patient tally report • State case mix report…profile of patient population • Transfer to IP facility OASIS…reason for transfer • Literature Analyzing Re-Hospitalization FOCUS GROUP Referral Source Diagnosis Payor Source Geographic location RESEARCH Functional Limitations Medications Mental Status PREDICTING RE-HOSPITALIZATION OASIS Inpatient Stay Bowel Ostomy Urinary Catheter Acute Condition Mental/Emotional DX Neoplasms CHART REVIEW General Assessment Visit Frequency Visit Pattern Communication for Hospitalization Psych Nursing Medication Mgmt Respiratory Assessment & Treatment Rehabilitation Therapy Assessment & Mgmt Testing the Predictors for Re-hospitalization • Focus group – Analyzed our own non –clinical data – Found diagnosis to the the only significant predictor • Research – Examined the charts of patients who were rehospitalized for mental status, medications, caregiver support, financial indicators – Found mental status, medications, and caregiver issues to be significant • OASIS data – Examined inpatient stay, bowel ostomy, urinary catheter, and neoplasms (lung cancer) – Found inpatient stay and urinary catheter as significant factors • Chart review – Analyzed clinical interventions, visit frequency, medication management, and physician communication – Found Visit freq, medication mgm, communication were significant factors • Summarized the results of our analysis looking at predictors that could be influenced and easily identified by the clinician – Medications >10 – MO 175 Discharge from a hospital or SNF – MO 490 SOB – MO 580 Anxiety – Reporting MO 230/MO 240 primary/secondary dx – Reporting MO 560 Cognitive – Reporting MO 780 Medication management – Reporting MO 640-700 ADL • Utilized the Patient Tally Report – Validate predictors – Monitor monthly outcome as a proxy measure of re-hospitalization since the state reports are delayed – Ongoing analysis of predictors Using the Patient Tally report • Step 1 Obtain instructions from the QIES Technical Support Office at www.qtso.com • Step 2 Download the CMS Tally Template and the Tally Workbook instructions • Step 3 Download Home Care Agency’s User Guide Appendix A Casper Reporting • Step 4 Print the instructions • Step 5 Save the tally template as a Microsoft Excel file on a disc or your hard drive • Step 6 Open the Excel Tally Template • Step 7 Go to the CMS State Web Site and go to the HHA OBQI reports menu page 2 • Step 8 Select the Tally Case Mix and Tally Outcome (select the date frame of interest) • Step 9 The reports will be queued (run) and then will be available in your Inbox • Step 10 Select the reports for download this may take several minutes… • Step 11 Save reports as Excel Files by right clicking mouse …save rows as option and saving as Excel or Excel with headers file (.xls) • Step 12 Open the file named CMS Tally Template.xls and click on enable macros when the workbook opens you will have four options • Step 13 Click on import new data. • Step 14 Click the browse button to find the spread sheet file for the case mix tally and the outcome tally report. Click finished when both files have been selected. • Step 15 Save as a new workbook • Step 16 Open the Workbook with the imported data. Go to the outcome tab on the worksheet. • Step 17 Click on the large button in the worksheet or select tools from the main tool bar and select the Macro option. • Step 18 Select the outcome of interest rehospitalization, achieved. Then run query when completed you will get a message • Step 19 Two new worksheets will be created for the utilization outcome re-hospitalization – Query outcomes – Query case mix • Step 20 Create new queries on the existing data based on predictors identified by selecting the Macro and selecting the radio button for “create new query on existing spreadsheet” (Note a patient must meet all the criteria to be selected) • New worksheets will be created each time you run query • Other ways to analyze the data – Recode the spread sheet Y and N to numerical values – Use the Find and Replace function – Tabulate predictors of interest – Calculate percentages on predictors of interest Using the Predictors for Improving Re-hospitalization GLOBAL“ORGANIZATION” AGENCY MONITORING INDIVIDUAL “CLINICIAN” CASE MANAGEMENT TOOLS FOR CLINICAL CARE • Validated our predictors based on the patient tally report over several months • Worked with a group of clinicians and managers to develop interventions that could target some of the high risk indicators • Developed a report to identify the high risk patients at admissions • Developed an audit tool to monitor compliance with the intervention model • Developed care guidelines/education materials for the 2 top risk diagnoses CHF and COPD • Rollout – Developed a written plan and performance monitoring measures…submitted to our QIO – Education of clinical staff and managers…CEU on COPD management – Reinforcement of risk factors in team meetings and through risk identification in patients – Monitoring of OBQI results and internal audit results – Development of proxy measures of re-hospitalization to monitor progress 9 Month Progress Using Risk Factors • Re-hospitalization percentage has improved slightly • Staff are much more aware of the problem and the relationship of re-hospitalization to outcomes • Resulted in improved interdisciplinary communication • Improved OASIS accuracy (internal consistency and profiling the true patient assessment) • The telemonitoring program has reduced rehospitalization and improved dyspnea, anxiety, and medication mgm especially in Stage III and Stage IV CHF Re-Hospitalization in Home Care IT IS IMPORTANT TO REMEMBER . . . • Identify possible predictors of rehospitalization that can be addressed • Validate your “hunches” • Develop interventions to address predictors • Involve staff in process and education • Monitor progress and outcome OASIS & OBQI Resources… OASIS resources: OASIS Implementation Manual OASIS Q&A’s OASIS web-based training Your state OASIS Education Coordinator • www.cms.hhs.gov/oasis OBQI resources: OBQI Implementation Manual • www.cms.hhs.gov/oasis Medicare Quality Improvement Community • www.medqic.org QIO • www.cfmc.org Thanks to the Colorado Foundation for Medical Care