Coordinating Care to Improve Healthcare in Kern County

Coordinating Care to Improve Healthcare in Kern County Jennifer Wieckowski, MSG State Program Director Health Services Advisory Group (HSAG) May 2015

HSAG: Your Partner in Healthcare Quality • HSAG is California’s Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO). • QIN-QIOs in every state and territory are united in a network administered by the Centers for Medicare & Medicaid Services (CMS). • The QIN-QIO program is the largest federal program dedicated to improving health quality at the community level. 2

HSAG’s QIN-QIO Responsibility Nearly 25 percent of the nation’s Medicare beneficiaries HSAG is the Medicare QIN-QIO for California, Arizona, Florida, Ohio, and the U. S. Virgin Islands. 3

Centers for Medicare & Medicaid Services (CMS) Care Coordination Community Expectations Engage community partners Develop coalition charter Evaluate interventions Sustainable Community Develop leadership structure Select interventions Refresh root cause analyses 4

Kern County Medicare Fee-for-Service Hospital Readmission Rates Hospital A B C D E F G H I J 5 Readmission Rate Q 2 2013 to Q 1 2014 27. 70% 21. 40% 21. 10% 20. 40% 19. 90% 19. 70% 18. 30% 17. 10% 11. 10% The ASAT data file representing Q 2 2013 to Q 1 2014 was used for the analyses in this report. The ASAT data file is provided to Health Services Advisory Group (HSAG) by the Centers for Medicare & Medicaid Services (CMS). The ASAT data file includes Part-A claims for Fee-for-Service beneficiaries.

Kern County Medicare Fee-for-Service Hospital Readmission Rates (cont. ) 6 Calendar Year Readmission Rate 2010 22. 3% 2011 21. 3% 2012 20. 7% 2013 20. 8% July 2013 to June 2014 20. 1% 9. 9% relative improvement rate The ASAT data file representing calendar year 2010 to Q 2 2014 was used for the analyses in this report. The ASAT data file is provided to Health Services Advisory Group (HSAG) by the Centers for Medicare & Medicaid Services (CMS). The ASAT data file includes Part-A claims for Fee-for-Service beneficiaries.

Kern County’s Progress: All-Cause, 30 -Day Readmission Rate Kern County 7 California Nation

30 -Day Readmission Rate by Setting After Inpatient Hospitalization for All Causes: Q 3 2013–Q 2 2014 Setting Discharged To Nursing Home with Home Health Home Total 8 30 -Day Readmit Rate 22. 1% 20. 6% 19. 3% 20. 1%

Kern County Providers Connected by a Minimum of 30 Transitions 9

Kern County Workgroups Focused on Medication Safety • Hospital to Nursing Home • Hospital to Home/Home Health • Nursing Home to Home/Home Health 10

HCAHPS® Measures of Interest 16. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? 17. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand? 25. When I left the hospital, I clearly understood the purpose for taking each of my medications. 11 HCAHPS=Hospital Consumer Assessment of Healthcare Providers and Systems

Patients Who Reported That Staff "Always" Explained About Medicines Before Giving it to Them 70 63 66 66 60 60 54 57 54 59 50 40 30 20 10 0 12 Bakersfield Memorial Hospital Good Samaritan Hospital Mercy Hospital Kern Medical San Joaquin Center Community Hospital Delano Regional Medical Center Bakersfield Heart Hospital Tehachapi Hospital

While Great Strides Have Been Accomplished… Further Progress on Behalf of Our Patients Is Essential. 13 Creative Commons/Flicker. BXP 135677. Tableatny, August 5, 2013. https: //www. flickr. com/photos/53370644@N 06/4976497160/

Thank you! Health Services Advisory Group quality@hsag. com 818. 409. 9229

This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for California, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U. S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. CA-11 SOW-C. 3— 05292015 -01