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 5 Sustainabl e Communi ty Engage communit y partners Develop coalition charter Develop leadershi p structure Refresh root cause analyses Select interventio ns Evaluate interventio ns

Kern County Medicare Fee-for-Service Hospital Readmission Rates HospitalReadmission Rate Q to Q A 27.70% B 21.40% C 21.10% D 20.40% E F 19.90% G 19.70% H 18.30% I 17.10% J 11.10% 6 The ASAT data file representing Q to Q 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 7 California Nation Kern County

30-Day Readmission Rate by Setting After Inpatient Hospitalization for All Causes: Q3 2013–Q Setting Discharged To 30-Day Readmit Rate Nursing Home22.1% Home with Home Health20.6% Home19.3% Total20.1% 8

Kern County Medicare Fee-for-Service Hospital Readmission Rates (cont.) Calendar YearReadmission Rate % % % % 2014 (Q1-Q3)19.9 % CA State Rate 2014 (Q1-Q3) 17.6% % relative improvement rate The ASAT data file representing calendar year 2010 to Q 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.

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