S4E8: Improving Your CMS STAR Rating (ft. Anne Flynn, Northwell Health)

Jordan Cooper   0:59
High risk patients. Now here's the interesting part. We're going to be approaching this story today through the lens of Northwell's acquisition of Nuvance Health in Connecticut and how Ann has extended Northwell's solution in Nuvance Health. So Ann, please walk us through it. How have you done that?

Anne F Flynn   1:14
OK, great. Well, let me just start with a little bit of background for Northwell in terms of our journey through readmission reduction. We really started this in 2017 and it's been you know a long process, but we're we're very, we've been very successful improving our star ratings which 22%.

Jordan Cooper   1:14
Yeah. Sure.

Anne F Flynn   1:33
Of is readmission reduction along with reducing our readmission penalties significantly. So we we feel you know we have a, we have a great product and a great way of doing things. And there is certainly technology involved in that and I know this is the the data podcast, so I will add you know bring that up as well. But basically you know we acquired Nuvance which is which is Northwell acquired Nuvance last year. It's six hospitals and three are in New York, a little north of our previous footprint and three are in Connecticut. So as you can imagine, a lot has a lot of people are working on this integration on every level, for instance. My my bosses at the Institute of Community Health and Wellness, Dr. Deb Salas, Lopez and Eddie Frazier have been very involved in the community work with Nuvance in introducing Northwell's presence and the work that we can do in the community and then on every other level. You know, from technology to finance to patient experience, et cetera. So readmission reduction and quality is one piece of the puzzle in terms of this integration with Nuvance. And I think where we are is, you know, you want to think about. These things like in phases, but in reality they aren't really phases. You know, they they kind of go up and down. So, you know, phase one would ideally be let's figure out the footprint, let's figure out what all the data is, the culture and everything, but which we're certainly doing. I think that's now.

Jordan Cooper   3:12
And I'll bleed together, yeah.

Anne F Flynn   3:28
Now kind of merged with in addition to getting to know each other, just starting starting to apply some of some of the ways that we have reduced reemissions at Northwell and you know it really started of course you have to be very mindful. Of change management issues, you always have to have that in the back of your mind. You know, in terms of some people being resistant or having change fatigue, you know, it's a it's a lot, it's a lot to take in and you know.

Jordan Cooper   4:01
So, Ann, I think what I'd love, I think what our listeners would love to hear you. I know that you have a prediction model and you leverage a lace score for risk and mortality regarding readmissions. I'd love for you to walk through the model. All right, we've acquired Nuvance Health. They have six hospitals, Dan. Health Danbury, CT based system and we have this very special way of improving intractable readmission scores. It's very difficult for health systems across the country to reduce their 30 day readmissions and at Northwell we found a very innovative way to doing this and now we're tasked with.

Anne F Flynn   4:23
Mm-hmm.

Jordan Cooper   4:41
Bringing our innovative approach to improving our star score to the star score that Nuance previously did on its own. What's the first step when you first acquire a new health system? What's the first step that you took in order to say, here's how how we're going to improve the star ratings at Nuance?

Anne F Flynn   5:01
Yes, you know, absolutely. It's really sort of understanding what processes they do or do not have in place right now and how we can help them with any processes that we have found to be successful. So to jump into what you were some of what you were referring to.

Jordan Cooper   5:09
Mhm.

Anne F Flynn   5:22
One of our processes called case finding or case creation and that is an effort between our analytics team, our pop health informatics team and others to apply a logic or rules to automatically finding the population that we would like. To find that's currently in the hospital. So we apply that and that produces a what we call a chase list and that chase list is sent out to the inpatient teams.

Jordan Cooper   5:44
Mhm. Mm-hmm.

Anne F Flynn   5:57
And that chase list is used so that they can apply this. That is also automated. Of course, the chase list comes to them every day, every morning, and they use that so they can apply this checklist methodology to these patients, which is really about best practice. Services for reemission reduction, you know, has this patient has CHF, do they need, have they had a cardiology consult? They are we scheduling an appointment for them? Are they, you know, they have a high lace score which is which is a risk stratification.

Jordan Cooper   6:27
2.

Anne F Flynn   6:36
Tool that predicts mortality and readmission after the discharge. So if they have a high lace score, we recommend a goals of care or a palliative consult. So that kind of thing is on the checklist and that is that is utilized and then. Once the patient gets discharged, there's all sorts of other methods that we use, one being an automated notification system. So if the patient is to return to the emergency room within the 30 days that we are deemed responsible for that patient.

Jordan Cooper   7:05
OK.

Anne F Flynn   7:15
And their readmissions, there's an automated notification that goes out to a certain team that we refer to as the SWAT team. And that SWAT team works to see if there's any other, you know, disposition other than readmissions. So I'll start with.

Jordan Cooper   7:22
Mhm.

Anne F Flynn   7:32
There's some others which I can get into as well, but so with New Vance, we presented to them all of this, you know, all of the work we do and the success we've had and we've presented that to quality and to other stakeholders.

Jordan Cooper   7:40
Mm-hmm. Yeah.

Anne F Flynn   7:48
And you know immediately there are some people that really want to get into this right and are really excited and and you know, so they are working and they've been great to work with really. They are working on #1 the case identification already so.

Jordan Cooper   8:01
Mm-hmm.

Anne F Flynn   8:08
The having a having a chase list in in the hospital and also using utilizing the checklist and they they are implementing that as we speak or they've even implemented the checklist already I think at all the hospitals.

Jordan Cooper   8:15
Thank you.

Anne F Flynn   8:25
And they, you know the next things that we really want to work on is the automated response which requires you know quite a technology lift in terms of integrating our systems and the and also buy in from the emergency room and the hospital hospitalists.

Jordan Cooper   8:43
OK.

Anne F Flynn   8:45
So we've you know discussed that and everyone seems on board with that and we also need to start implementing them into our dashboards of course in in any way we can. So when we're presenting, we're presenting as with our legacy new Vance hospitals as part of Northwell, so you know.

Jordan Cooper   8:52
Yes. So I'd like to drill right into what you just mentioned. You mentioned that integrating, there's an integration challenge in implementing the automated response. Can we dive in? What does that integration challenge look like and what kind of data sources are you pulling from and how?

Anne F Flynn   9:05
Um, yeah.

Jordan Cooper   9:24
Are you planning on addressing that data integration challenge?

Anne F Flynn   9:28
Right. They are not on the same platform as us. We are. We are currently on our Epic journey in adopting Epic as our EMR. They will also, but that will be a few years from now, so.

Jordan Cooper   9:33
Mhm. Mhm.

Anne F Flynn   9:46
The issue is is. The the complexity and I am not the IT person, so I'm not going to get this totally right, but the complexity of of bringing these systems together in some way so that we can exchange data and data exchange and that is where the complexity lies.

Jordan Cooper   9:52
Yeah. I.

Anne F Flynn   10:08
And how we can also. Provide the same sort of resource, the same sort of notification for these hospitals.

Jordan Cooper   10:17
Right. So from your perspective and and you know you're the medical director of of health management here. So from your perspective and we don't have to go into a too deeply into data since we'll just focus on your area of expertise, what do you think are the greatest challenges to the program? Is it change management?What are the greatest challenges, the program that you've been able to address with your area of expertise and how have you been doing that?

Anne F Flynn   10:46
Yeah, I think you know I haven't the challenges I would say are a lot in the technology if we want to go back to that. So you know because we are very reliant on data and we are have become very reliant on these systems that we're very used to and they do not have them so.

Jordan Cooper   10:51
Yeah, yeah. Mm-hmm. Right.

Anne F Flynn   11:06
That that is the biggest challenge that we are working through.

Jordan Cooper   11:09
So I think a lot of our listeners may say, you know, yeah, we have, you know, a two-star rating out of CMS. We're located in whatever area of the country we're in. And we also don't have the resources of a Northwell Health. We're not on Epic and you know, we can't afford it. And we don't have, you know, these incredible technological platforms that Northwell has access to. How should we go about improving our star rating? How can we reduce readmissions? What can they learn from you here? What lessons? Yeah.

Anne F Flynn   11:38
Right, yeah. Absolutely. I I think that, you know, I I think I started by saying we started in 2017 and we did not have many of these things either. So there are very, especially if you're a smaller hospital.

Jordan Cooper   11:45
OK. Mhm.

Anne F Flynn   12:00
It's it's not that difficult to identify your high risk patients. In a non-automated way, but even, you know, in a probably kind of an automated way that isn't as isn't as sophisticated than what we're doing because there's certain criteria in terms of the insurance and the age and the diagnosis and you can start there.

Jordan Cooper   12:17
Mhm. Mhm.

Anne F Flynn   12:25
We even had some of our hospitals start there because they, you know we've acquired hospitals along the way that are not on the same system. So and and that's pretty effective as it is and.

Jordan Cooper   12:38
Do you have any workarounds or hacks that you that you've seen work successful on a budget?

Anne F Flynn   12:43
Yeah. Yeah, I mean you can, you can print out a list in your hospital, you know, on each floor and see who has Medicare fee for service or managed Medicare and what their diagnosis is and is their diagnosis CHF, is their diagnosis pneumonia, COPD or AM I? There's your patients.

Jordan Cooper   12:59
Mhm. Right. So if it hits such a so, so yeah, I want to talk about that case finding in that in that chase list, you said that you're applying different logic and rules to find the at risk population. Are you able to delve more deeply into how that logic and what those rules are, what they look like and how they are? How you came to create those?

Anne F Flynn   13:28
Sure. They are basically the the CMS rules for who these patients are and who the cases are. The again like I said it's you look at insurance, you look at age and then you look at.

Jordan Cooper   13:32
Mm-hmm. OK.

Anne F Flynn   13:43
There's many, many diagnoses or ICD 10 codes that fall under one of these larger umbrella diagnoses. So CHF may have you know like 12 or 20 ICD 10 codes that do qualify. So you need to if you're going to really try and be as accurate as possible.

Jordan Cooper   13:46
You do. Mhm. OK.

Anne F Flynn   14:03
Captured as many people as possible and not overcatch. That's always a big problem. Then you need to be integrating these I CD10 codes in and you need to be monitoring it to see are we how many false positives are there? How many true positives are there?

Jordan Cooper   14:08
OK. Yeah.

Anne F Flynn   14:23
What percentage of which are we getting? There always seems to be 1 little piece that might put it over the edge into overcatching. So you you kind of have to monitor that. We did. Yes, question.

Jordan Cooper   14:27
Mhm. Mhm. So I was just thinking, so it sounds like CMS defines what the numerators and denominators are for their star program. So identifying the high risk patients should be somewhat straightforward, but yet you said that this is a very intractable problem. In fact. 22% of the star rating is dependent on reducing readmissions and this is a problem that many hospitals and health systems across the country do have challenges with. So you know what are some of the reasons? You know, I'm sure every hospital can import the numerators and denominators and just look is there congested heart failure. OK, here are the 20 ICD 10 codes associated with that.

Anne F Flynn   15:10
OK.

Jordan Cooper   15:17
OK, these are high risk patients and these are the best practices and the checklist. So why can't we just get our hospitalist to look at these four, you know, high risk patients on this floor and prevent them from being remitted in the next four weeks? What? Why is it so intractable if it seems like it's so straightforward?

Anne F Flynn   15:34
Yeah, great question. It's just not that straightforward. It's so and it is intractable because these are complex patients and these are complex chronic conditions that are you know.

Jordan Cooper   15:43
Mm-hmm. OK.

Anne F Flynn   15:51
Often readmitted, often being treated in the emergency room. And This is why CMS targets these patients, right? They don't just randomly target patients, they they target who are the most complicated patients or the the highest risk patients.

Jordan Cooper   16:06
Mm-hmm.

Anne F Flynn   16:09
And there's all sorts of reasons for readmissions. And a lot of that is in the transitions of care, which is why we also have a transitional care management team. So, you know, you leave the hospital and then what happens? Your medication reconciliation is wrong. You know you were supposed to be started.

Jordan Cooper   16:20
Mhm.

Anne F Flynn   16:29
on lay 680 but it says lay 620 and um is there going to be somebody there on the other end to pick that up or otherwise you're going to end up back at the ED in in three three days. So it's there's that's just one example. Did you get an appointment? Are you able to get to your appointment?

Jordan Cooper   16:31
N.

Anne F Flynn   16:49
There's all sorts of SDOH, you know, elements to it, and it's.

Jordan Cooper   16:52
Yeah. So on on that topic, in addition to pulling clinical diagnosis from the EHR, you're also pulling from surgical scheduling. You're identifying a patient scheduled for elective hip replacements, your schedule, you're pulling from payer status, who's on Medicaid fee-for-service, you know those data.

Anne F Flynn   17:09
OK.

Jordan Cooper   17:14
Sources are all feeding into your HIE analytics team to help produce that case finding automated report, right?

Anne F Flynn   17:21
Yes, correct. You know, it's depending on the population like the surgical scheduling would be the cabbage and now the team surgical bundles, which is the new mandatory bundles from CMS.

Jordan Cooper   17:22
And so. Right. So you're identifying you're you're pulling from all these different data sources and you're creating this analytics report that then is automatically sent to the inpatient teams and then they're they start implementing A checklist and and it sounds like a nuvance they have.

Anne F Flynn   17:37
OK.

Jordan Cooper   17:54
You had some of these and you had to go about identifying which metrics they were missing, which areas of their workflow they were missing, and just kind of plugging those holes and trying to do so without necessarily being able to extend the technological solutions that Northwell relies on to Nuvance. That's going to take time to roll out. Is that fair summary there?

Anne F Flynn   18:17
Yes, that's correct. So we're trying to make their case list as as accurate as possible. You know we're we're working towards the HIE notification. The other thing that we utilize is a platform with our skilled nursing facilities.

Jordan Cooper   18:23
Mhm. Mhm.

Anne F Flynn   18:35
And that allows our central OPS team, which is our skilled nursing facility care management team to monitor patients in skilled nursing facilities. So we have that on over 100.

Jordan Cooper   18:42
Which? Mhm.

Anne F Flynn   18:51
Skilled nursing facilities now that Northwell uses. So we are talking about implementing that in nursing homes around the new Vance hospitals and they're very excited about that because they've basically had one woman trying to track them.

Jordan Cooper   19:04
Yeah.

Anne F Flynn   19:08
You know, in by herself.

Jordan Cooper   19:11
Yeah. So a centralized platform to to do the work that it sounds. So look, we're approaching the end of this podcast episode and and I'd like to ask you if you could reflect back on your journey to reducing 30 day readmissions and improving our calls.

Anne F Flynn   19:16
Yeah.

Jordan Cooper   19:31
Star score and then do so and then also consider Nuvance's journey to improve their star rating as now as a subset of Northwell. What advice would you give yourself or what advice are you actively giving leadership over at Nuvance about how to go about? Achieving those goals.

Anne F Flynn   19:52
Yeah, I I mean, I think that it's a culture change in a lot of ways. Some of the things that we implemented, especially kind of the ED work and the SWAT process, you know, it means the hospitalist and the ED provider working together. In a way that, you know, traditionally they haven't always worked well together. So that that has been a culture change and a nice one. And it it takes time, you know, it really, it really takes time and they're they're.

Jordan Cooper   20:14
Mm-hmm. OK.

Anne F Flynn   20:25
You know, they have some things that we can learn from as well. You know, they have, they do something called a care partner huddle, which I which I love. It's just that there it's not clear how to scale it, you know, and that's what we do at Northwell, we scale so.

Jordan Cooper   20:30
OK. OK. Mm-hmm.

Anne F Flynn   20:42
I would, I would love to scale that and bring that to to Northwell. So it's it's a matter of being open to change and and you know we're open to hearing what they're doing and understanding that we've been very successful which which they seem to be very open to learning about our processes.

Jordan Cooper   20:48
I know. You know, and I want to just reflect and contextualize today's conversation for our listeners. Checklist began in the airline industry and it was initially Doctor Peter Pronovos and his team with the Michigan Keystone Project that began taking.

Anne F Flynn   21:02
Oh. Oh. Oops.

Jordan Cooper   21:18
Airline checklists and applying them for providers for central line associated bloodstream infections or CLABSI's. And then when he went to Johns Hopkins, began expanding that workout and there was always not only the importance of the checklist, but a culture change. They had to have an executive sponsor. They had to empower nurses in different.

Anne F Flynn   21:25
Mhm. Yes.

Jordan Cooper   21:38
Of clinicians to be able to speak up in the room and usurp somewhat the traditional power dynamic with the physician most important and not being challenged. The ability to speak up and say there could be a risk for an iatrogenic infection here or we left us. I didn't count all the surgical tools being removed from the.

Anne F Flynn   21:44
Mhm. Mhm. Yes.

Jordan Cooper   21:58
Open body cavity from the surgery right now and I think what you're really trying to say is not only is it about technology, not only is it about following guidelines and best practices which are openly available in the medical peer reviewed academic literature, but importantly there's culture change and when you.

Anne F Flynn   22:17
Yes.

Jordan Cooper   22:18
Acquire a new organization. It's not just about telling them you got to do steps AB and C, but it's making sure that the hospitalists and the Ed physicians can work well together. It's making sure that if they're working well with a care partner huddle, that maybe you don't need to impose a top down Northwell approach, but maybe.

Anne F Flynn   22:29
OK. Mhm.

Jordan Cooper   22:38
Let them work with what's continue to succeed with what's working on a local level. So I think being aware of people management and change management is incredibly important to the success, successful implementation of any technological intervention. Any thoughts?

Anne F Flynn   22:53
I couldn't agree more and that I think is, you know, I I love checklists. You know, you know the checklist manifesto is is is a favorite. Yeah, but you know, they really seem to work. But I can see because it's it's happened at Northwell also.

Jordan Cooper   23:04
Patrol on the wand, yeah.

Anne F Flynn   23:13
That people get nervous about that. It feels like it's more work. Why? This is something else I have to do. Who's responsible for this? You know, all of those things. And you can anticipate all of those things. So you need to be able aware of that, first of all, just conscious of that and then, you know, hopefully provide some quick wins.

Jordan Cooper   23:17
Mhm.

Anne F Flynn   23:32
You know, hopefully in a few months we'll be able to show them that this checklist has has helped already. You know, in terms of if that patient got that checklist, they're, you know, the readmission rate is lower, that type of thing.

Jordan Cooper   23:36
Mhm. Right, right. And then of course this is all, you know, payer directed efforts to change medical practices to improve outcomes, reduce cost and at the same time therefore by definition with the triple aim, improve value, so.

Anne F Flynn   24:00
Yes.

Jordan Cooper   24:01
And I'd like to thank you for joining us today.

Anne F Flynn   24:04
Thank you. OK.

Jordan Cooper stopped transcription