Preventing Avoidable Readmissions: A Systems Approach for Improving Health Outcomes

Submitted by
Team P.A.R.

For the

Department of Systems and Information Engineering

School of Engineering and Applied Sciences
University of Virginia

To the

CENTER FOR TELEHEALTH

P.O. BOX 800707
CHARLOTTESVILLE, VA 22908-0707

25 April 2013

TABLE OF CONTENTS

1. Disclaimer & Acknowledgments.............................................................................................

2. Executive Summary................................................................................................................
3. Background............................................................................................................................

Page | 1
 Preventing Avoidable Readmissions: A Systems Approach for Improving Health Outcomes

4. Study Objective......................................................................................................................
5. Technical Approach................................................................................................................
6. Systems Analysis...................................................................................................................
6.1 System Context................................................................................................................
6.1.1 Stakeholders.............................................................................................................
6.1.2 Decision Makers........................................................................................................
6.1.3 Assumptions..............................................................................................................
6.1.4 Describe the System and Define the Scope............................................................
6.2 System Framework........................................................................................................
6.2.1 Descriptive Scenario...............................................................................................
6.2.2 Risk Assessment.....................................................................................................
6.2.3 Data Sources...........................................................................................................
6.2.4 Data Analysis..........................................................................................................
6.2.5 Normative Scenario.................................................................................................
6.3 Develop and Evaluate Alternative Solutions..................................................................
6.3.1 Develop Alternatives...............................................................................................
6.4 Implementation Plan......................................................................................................
6.4.1 Action 1.......................................................................................................
6.4.2 Action 2......................................
6.4.3 Action 3.................................................................
6.5 Institutional/Legal/Regulatory Considerations................................................................
6.5.1 Identify Barriers and Possible Mitigations...............................................................
7. Findings and Recommendations..........................................................................................
8. References...........................................................................................................................
9. Appendices...........................................................................................................................
9.1 Appendix A: ..................................................................................
9.2 Appendix B: Interview Notes........................................................................................
9.3 Appendix C: Literature Review.....................................................................................

FIGURES

Figure 1-1

Figure 1-2

Page | 2
 Preventing Avoidable Readmissions: A Systems Approach for Improving Health Outcomes

TABLES

Table 1-1

Table 1-2

Page | 3
 Preventing Avoidable Readmissions: A Systems Approach for Improving Health Outcomes

1. Disclaimer & Acknowledgements

The study described herein is primarily for the purpose of enabling students in the University of Virginia
Accelerated Master’s Program in Systems Engineering to demonstrate mastery of systems engineering
skills and methods and the application of these skills and methods to a large-scale problem of major
significance to clients and other stakeholders.

All information provided in this document was prepared by the Accelerated Master’s Program in Systems
Engineering as guidance to students, drawing on UVA Health System and other open source documents
and data. No proprietary data are used in this study and none of the findings or results that proceed from
this study will be proprietary to any of the students or the organizations that employ them or to the
Program. Results will be provided to UVA Health System for their use and, if desired, further
dissemination. Should UVA Health System determine that any of the findings or results is sensitive or
proprietary, it will be handled in accordance with UVA Health System guidance.

Accelerated Master’s Program in System Engineering (AMP) is indebted to the University of Virginia
Health System for its support in allowing students in the program to study this problem using open source
documents and data related to the Cancer Center’s Clinic operational processes.

Our team is grateful and would like to acknowledge the expert advice and support provided by:

2. Executive Summary
Abstract: The UVA Health System requested assistance from students in the Accelerated Master’s
Program in Systems Engineering…

Purpose:

Conclusions:

Page | 4
 Preventing Avoidable Readmissions: A Systems Approach for Improving Health Outcomes

3. Background

In an effort to reduce cost and improve health outcomes, the Affordable Care Act introduces incentives
and penalties that will encourage health care providers to reassess how they treat patients both while they
are hospitalized and after they are discharged.

Effective with the 2012 federal fiscal year, Medicare is reducing reimbursement to hospitals for avoidable
readmissions related to three diagnoses―Acute Myocardial Infarction (AMI), Heart Failure (HF), and
Pneumonia (PN).

The driver behind this reduction in Medicare reimbursement to hospitals is the growing evidence that
avoidable readmissions is driving up the cost of health care and these readmission reflect, in many cases,
inadequate attention to patient health before, during, and immediately following discharge.

Source: “Reducing Readmissions – Top Ways Technology Can Help”, The Hospital Readmission
Workgroup, Management Engineering – Process Improvement Committee, Hospital Information and
Management Systems Society.

The UVA Office of Telemedicine is a pioneer and international leader in telemedicine having launched a
comprehensive program in 1994 with a mission to provide excellence and innovation in specialty medical
care and distance learning to underserved regions. Through its program, the clinical specialties of the
UVA Health System have been made available throughout Virginia and many regions of the
world. Services range from clinical consultations, medical education for providers and patients, and
many outreach projects occurring locally and internationally.

Using broadband technology, the University of Virginia’s Office of Telemedicine seeks to facilitate the
UVa Health System’s mission of providing excellence and innovation in clinical care, teaching, research
and public service. The Office of Telemedicine is a pioneer and international leader in telemedicine
having launched a comprehensive program in 1994. Through its program, forty clinical specialties and
sub-specialties at UVa are made available throughout Virginia and many regions of the world.

Source: http://www.healthsystem.virginia.edu/pub/office-of-telemedicine

Page | 5
 Preventing Avoidable Readmissions: A Systems Approach for Improving Health Outcomes

4. Study Objective
With the advent of healthcare reform and the increasing age of the nation’s population, two major focus
points in telehealth will be: 1) ways in which health systems can prevent readmissions to the hospital
within thirty days of discharge using remote monitoring; and, 2) providing telemedicine resources to
ensure patients in nursing facilities have easy, cost-efficient and effective access to services. This second
element will also provide opportunities to prevent readmissions.

As these are emerging opportunities, a systems analysis is needed of the application of telemedicine
technology to nursing facilities with a particular focus on efficiencies, timely access to care, cost
reductions and the impact on readmissions post hospital discharge. Currently, the UVa Office of
Telemedicine does not have existing contracts with regional nursing facilities to provide either remote
monitoring or traditional telemedicine.

A systems analysis process is therefore needed to:

 determine existing practices using telemedicine to provide services to nursing homes;

 review best practice models;
 examine cost and technology requirements as well as potential volumes, conduct an analysis of
regional facilities; and,
 identify potential pilot projects.

Using a systems approach, determine how best to improve health outcomes for patients discharged to
nursing homes through the use of telemedicine and related services such that they are less likely to require
readmission to the hospital for related causes within the thirty day period immediately following
discharge.

Page | 6
 Preventing Avoidable Readmissions: A Systems Approach for Improving Health Outcomes

5. Technical Approach

Determine the Goals of the System

Establish Criteria for Ranking Alternative Candidates

Develop Alternative Solutions

Iterate

Action

Page | 7
 Preventing Avoidable Readmissions: A Systems Approach for Improving Health Outcomes

6. Systems Analysis

6.1. Systems Context

*Insert System State Diagram for the UVA Health System*

6.1.1. Stakeholders

6.1.2. Decision Makers

- VA Legislative (Medicaid)

- CMS (Medicare): Penalties/Urban Eval

- UVA CEO: Telehealth Program

- Nursing Homes:
6.1.3. Assumptions

Assumption 1

Assumption 2

6.1.4. Describe the System and Define the Scope

6.1.4.1. System Context

6.1.4.2. System Description

6.1.4.3. General Overview

6.1.4.4. System Boundaries

6.1.4.5. System Model

Inputs:

State Variables:

Decision Variables:

Page | 8
 Preventing Avoidable Readmissions: A Systems Approach for Improving Health Outcomes

Outputs:

Constraints:

Exogenous Variables

6.1.4.6. Environment

6.1.4.6.1. Urban

6.1.4.6.2. Rural

6.1.4.7. Goals and Objectives

6.1.4.8. Axiological Component

Patients:
Hospital Staff
Nursing Home Staff
Physicians
Families
UVA Health System

Page | 9
 Preventing Avoidable Readmissions: A Systems Approach for Improving Health Outcomes

6.2. System Framework

6.2.1. Descriptive Scenario

6.2.2. Risk Scenario

6.2.2.1. HHM

Levels of the System:

- Level 1: Head Topics (dimensions/perspectives) of the system

- Level 2: Subtopics of the Head Topics
- Level 3: Risk Scenarios related to each Subtopic:

*Describe the HHM Diagram*

*Insert Diagram*

6.2.2.2. Scenario Filtering, Temporal Domain and Label of Decision-Making

6.2.2.3. Bi-Criteria Filtering and Ranking
*Insert Chart*
6.2.2.4. Multi-Attribute Evaluation

Criteria:
Redundancy
Resilience
Robustness

6.2.2.5. Quantitative Ranking

*Insert Chart*
6.2.2.6. Risk Management
6.2.2.7. Safeguarding Against Missing Critical Items
6.2.2.8. Operational Feedback

6.2.3. Data Sources

6.2.4. Data Analysis

6.2.5. Normative Scenario

The ideal situation for the patient
The ideal situation for the hospital
Other scenarios to consider

6.2.5.1. Establish Criteria for Ranking Alternatives

Page | 10
 Preventing Avoidable Readmissions: A Systems Approach for Improving Health Outcomes

For the purpose of evaluating the alternatives we produced from our analysis, we developed the
following evaluation criteria.

6.2.5.2. Identify Indices of Performance

As we describe how to move the system from the descriptive through the transitional scenario into the
normative scenario, we use an index of performance to measure how well our alternatives and
solutions are doing in reaching the normative scenario. Ideal indices of performance have four
characteristics:

 Measurable or quantifiable: measurable indices of performance allow analysts and

managers to see how much progress has been made towards desired thresholds.
 Objective: objectivity simply means that all observers will agree on the observed quantity.
 Nonrelativistic: non-relativistic indices of performance are defined using clear, objective
reference points
 Meaningful: indices of performance measure the quantities that are relevant to the problem
at hand
 Understandable: The indices of performance should be easily comprehensible by individuals
at all levels of an organization.

Page | 11
 Preventing Avoidable Readmissions: A Systems Approach for Improving Health Outcomes

6.3. Develop and Evaluate Alternative Solutions

6.3.1. Develop Alternatives
6.3.1.1. Alternative A
6.3.1.2. Alternative B
6.3.1.3. Alternative C

6.4. Implementation Plan

6.4.1. Alternative A
6.4.2. Alternative B

6.5. Institutional/Legal/Regulatory Consideration

6.5.1. Identify Barriers and Possible Mitigations

Page | 12
 Preventing Avoidable Readmissions: A Systems Approach for Improving Health Outcomes

7. Findings and Recommendations

Page | 13
 Preventing Avoidable Readmissions: A Systems Approach for Improving Health Outcomes

8. References
1.
2.
3.

Page | 14
 Preventing Avoidable Readmissions: A Systems Approach for Improving Health Outcomes

9. Appendices
9.1. Appendix A:
9.2. Appendix B:
9.3. Appendix C:

Page | 15