Kern County Care Coordination A Collaborative Journey Michael

Kern County Care Coordination: A Collaborative Journey Michael Smith, RN, MSN Ed, PHN BPCI Program Manager Dignity Health Bakersfield Market October 13, 2015

Objectives • Convene Kern County hospitals, nursing homes, home health organizations, and community-based organizations to engage and reduce readmissions by improving transitional care • Feature community progress through presentations • Discuss barriers and implement or redesign process to maximize readmission reduction strategies. 2

Kern County Providers Connected by a Minimum of 30 Transitions 3

How to Start? • It takes a village, but the first step is mine • Identification of Key Stakeholders, Executive Sponsors, State Quality Improvement Organizations, Hospital Councils • Development of Steering Committee • What is my Mission? – What objectives should be included to achieve our Mission 4

Centers for Medicare & Medicaid Services (CMS) Care Coordination Community Expectations Engage communit y partners Evaluate interventio ns Select interventio ns Sustainabl e Communit y Refresh root cause analyses Develop coalition charter Develop leadership structure 5

Kern County Medicare Fee-for-Service Hospital Readmission Rates Hospital A B C D E F G H I J 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. 6

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

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 30 -Day Readmit Rate 22. 1% 20. 6% 19. 3% 20. 1% 8

Kern County Medicare Fee-for-Service Hospital Readmission Rates (cont. ) Calendar Year Readmission Rate 2010 22. 3% 2011 21. 3% 2012 20. 3% 2013 20. 3% 2014 (Q 1 -Q 3) 19. 9 % CA State Rate 2014 (Q 1 -Q 3) 17. 6% 10. 8% 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. 9

Sub-Committee Workgroups (focus Care Coordination and Medication Safety) • Partners in Care (CMMI Demonstration Project) • Hospital to Home – Lead by Community Pharmacist • Online Directory for Clinical Transitions • Home Health Data Collection Tool • Hospital to Skilled Nursing – Handoff Communication Tool – Piloting ER Badge Program • Medication Reconciliation Committee in works 10

Conclusion • Begin building Networks • Identify Community Resources – Provide staff/leadership education if necessary • Research National Evidence-Based Care Transitions Model • Plug into existing sub-committees or workgroups to understand current state, and where “gaps” exist • Lead with a vision 11

References • Statistical graphs on slides 3, 5, 6, 7, 8, and 9 courtesy of HSAG and collaboration on Kern County Care Transitions Collaborative 12

Thank You