THE SAN DIEGO CARE TRANSITIONS PARTNERSHIP Transforming Care Across the Continuum Brenda Schmitthenner, MPA County of San Diego Aging & Independence Services.

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Presentation transcript:

THE SAN DIEGO CARE TRANSITIONS PARTNERSHIP Transforming Care Across the Continuum Brenda Schmitthenner, MPA County of San Diego Aging & Independence Services

COMMUNITY-BASED CARE TRANSITIONS PROGRAM (CCTP) Section 3026 of the ACA  Reduce all-cause, 30-day readmissions for fee-for-service (FFS) Medicare patients by 20%  Reduce readmissions for high-risk patients  Reduce Medicare spending  Test models for improving care  Links Community-Based Organizations to hospitals San Diego Care Transition Partnership (SDCTP)  Partnership between County of San Diego and 11 hospitals  Largest CCTP in the country  Coordinating care across settings 2

SAN DIEGO CARE TRANSITIONS PARTNERSHIP (SDCTP) Great Opportunity for San Diego County Demonstrate to the rest of the country how to:  Design and implement a patient-centered system of care  Scale up a comprehensive care transitions program  Test new care transition interventions and share data and best practices  Improve the health of the community  Innovate with clinical and social service partners

SAN DIEGO CARE TRANSITIONS PARTNERSHIP (SDCTP) The SDCTP Care Transitions Program Design Patients receive specific care transition services tailored to their individual needs:  In-patient nursing support  Medication reconciliation and education  Care Transitions Intervention (CTI)  Care Enhancement (CE)  Telephonic CTI  Follow-up Phone Calls

SAN DIEGO CARE TRANSITIONS PARTNERSHIP (SDCTP) *RCA = Root Cause Analysis *TNS = Transitions Nurse Specialist *IN = Inpatient Navigator *HRHC = High-Risk Healthcare Coach *CE = Care Enhancement *CTI = Care Transitions Intervention *PAN = Post-Acute Navigation The SDCTP in Action

SAN DIEGO CARE TRANSITIONS PARTNERSHIP (SDCTP) Accomplishments January 2013 to January 2015  Target Group baseline: CCTP participants 30 day readmission rate from 2012  CCTP Participants: Those who completed services (CCTP Completers) and those who did not complete all aspects of the program 13.4% estimated readmission rate 66.3% less than the SDCTP’s 2012 Target Group baseline. 1,281 prevented 30-day readmissions for CCTP participants. $13,163 average readmission cost in San Diego County $7.2M overall Medicare savings $50M decrease in Medicare spending 13.4%

SAN DIEGO CARE TRANSITIONS PARTNERSHIP (SDCTP) Coming together is a beginning Keeping together is progress Working together is success - Henry Ford