Chronic Disease Transitional Care Northridge Hospital Medical Center

Chronic Disease Transitional Care Northridge Hospital Medical Center Health Services Advisory Group 10/20/17 Dr. Jeremy Grosser Medical Director Transitional & Palliative Care

Disclosure • I have no financial relationships with commercial interests 2

Social Determinants of Health Source: Institute for Clinical Systems Improvement, Going Beyond Clinical Walls: Solving Complex Problems (October 2014)

uild B Ed st u r T uc ate Transitional Care Department Palliative Care Frail Elderly Diabetes Management 65 and older te a c ni Co u m m Chronic Diseases CHF COPD CVA ESRD CANCER CJR Pain Management Mi tig ate

Why Care Coordination? Patient safety v Safe transition home by improving patient and family preparation for discharge v Ensure follow up with Physicians after discharge v Improve flow of information between hospital, providers, patient, and families v Increase safety by improving the transition for discharge, and mitigating risk for adverse advents v Home Visit- conducting home safety check v Follow up phone calls to ensure access & continuity of care 5

Chronic Disease /Transitional Care Dept. Clinical Team is composed of: – Nurse Practitioners (7. 5) – Social Workers (2) – Clinical Pharmacists (2) – Physicians – Provides clinical oversight for NP’s (2. 0) and pain management staff – Diabetes NP (1. 0) – Registered Nurse (1. 0) – Program Coordinator for Discharge Planning The Transitional Care Team works collaboratively with patients/care partners, medical staff, nursing, case management, pharmacy, ancillary services, SNF’s & Home health agencies towards safe patient discharge : – The NP educates the patient and family about their chronic disease & red flags of their illness & provides clinical oversight and problem resolution for 30 -90 days post discharge. – The Pharmacist conducts Medication reconciliation & education. – The NP conducts home & SNF visits ensuring a safe discharge and that required supplies and equipment are in place. – The Social Worker provides psychosocial support, makes referrals for support groups, community services, spiritual services, hospice support. 6

Internal Collaboratives: Pharmacy • Medication reconciliation for all chronic disease & pain management patients enrolled in program Physicians Nursing Units • Daily ICU rounds & Palliative Care consultation • Glycemic Management FY 18 Goals Pharmacy review of Pain Management Regimens • Automatic consultation for all 30 day readmits • • ED icon for readmission potential, notification of cardiologist & surgeon Case Management • • Collaboration between Case Management &Transitional Care for discharge Planning • Specialized populations: Medications in hand at discharge & appointments with PCP within 7 days of discharge Cardiology Co-management auto consult orders • Neurology auto consult orders for Stroke patients Family Medicine/Foundation MD’s: • RN Coordinator ensuring access to medications & follow up appointments 7

Pharmacist Medication Mitigation Categories August 2016 – July 2017 N = 770 Average Monthly Mitigation 36% 6% 4% 17% 4% INCORRECT DOSE 6% DUPLICATE MED MISSING MED 11% D/C MED REQUIRED OTHER 11% INSURANCE NO RX PROVIDED DRUG INTERACTION MED HISTORY 12% 30% 8

External Collaboratives Skilled nursing facilities (SNFs) • Must maintain Star rating at 3+ • Narrowed network of 8 facilities • Weekly NP driven patient rounds at the SNF’s • Weekly clinical calls with Medical Director & NP’s • Monthly collaborative meetings o Review of SNF readmission outcomes o Identify best performers o Adjustments to narrowed network as needed Home health • Narrowed network of 8 vendors • NP’s coordinate care with HHA • Weekly clinical calls with Medical Director & NP’s • Monthly collaborative meetings 9

SNF Readmission Rates from CDTC 30% 28% 25% 20% 15% 10% 12% 11% 9% 6% 5% 0% Average rate Linear(Average rate) 9% 4% Jan - Mar Apr - Jun July- Sept Oct- Dec Jan - Mar April-June July 2017 2016 2017 10

Northridge Hospital: Readmission RIR* Q 1 2014–Q 1 2017 25, 0% 20, 90% 20, 49% 21, 80% 21, 50% 19, 97% 19, 89% Desired Direction RIR: Target: 12% RIR by Q 3 2018 15, 0% 10, 0% 5, 0% 0, 0% Target RIR Actual RIR Readmission Rate Region Rate Target RIR Jan 2014 -Dec 2014 12, 0% 0, 00% 20, 49% 20, 90% Actual RIR 2, 54% Oct 2015–Sep 2016 12, 0% 2, 54% 19, 97% 21, 50% Readmission Rate 2, 95% Apr 2016–Mar 2017 12, 0% 2, 95% 19, 89% 21, 80% Region Rate Source: Medicare Fee for Service Claims Data. Baseline period: CY 2014. *The formula for Relative Improvement Rate (RIR) is (Baseline-Current)/Baseline.

Readmission Data Q 2 2016–Q 1 2017 • Patients Discharged Home With Home Health Location Northridge Hospital Los Angeles California 30 -Day Readmission Rate (n=106) 16. 4% 21. 1% 19. 3% Readmissions within 0– 7 Days (n=36) 34. 0% 36. 1% 36. 0% • Patients Discharged Home Without Home Health Location Northridge Hospital 30 -Day Readmission Rate Readmissions within 0– 7 Days (n=315) 19. 2% (n=122) 38. 7% Los Angeles 20. 6% 38. 7% California 17. 4% 37. 6% 12

Readmission Data Q 2 2016–Q 1 2017 Patients Discharged to Nursing Homes Location Northridge Hospital Los Angeles California 30 -Day Readmissions within Readmission Rate 0– 7 Days (n=237) 22. 5% (n=83) 35. 0% 24. 9% 21. 6% 33. 1% 32. 9% 13

Thank You