1. Jennifer Mangosong-Shankle, MS Quality Improvement Specialist, HSAG
Welcome! Greater Sacramento Care Coordination Learning and Action Network Hosted in Partnership With Los Angeles Right Care Initiative
Mary Fermazin, MD, MPA Chief Medical Officer, Health Services Advisory Group (HSAG)
Hattie Hanley, MPP Director, Right Care Initiative, UC Berkeley School of Public Health
Jennifer Mangosong-Shankle, MS Quality Improvement Specialist, HSAG
October 9, 2017
Dr. Mary Fermazin welcomes the audience and introduces the program

2. Today’s Objectives
Demonstrate successful strategies to reduce readmissions.
Measure seven-day readmission rates as an indicator of hospital quality.
Describe how targeting patients on a high-risk medication can reduce readmissions and prevent adverse drug events.
Describe the best practices of Advanced Illness Management as a method to improve care coordination.
Review program objectives

3. Thank You
For the hard work you are doing to improve and transform our nation’s healthcare system
For your commitment to improving the care of the patients we serve
For your leadership, collaboration, and results in California
Thank the audience for their time, dedication and commitment

4. We Need Your Feedback!
Remind the audience to fill out the evaluations.
We need your feedback!
For those needing CEUs (nurses and administrators), please fill our the evaluation.
Link to the evaluation is in your packet.

5. In Your Packet… Hospital Checklist Prescriber Quick Tips
Anticoagulants
Diabetic Agents
Opioids
Organizational Assessment
Review items in packet. In particular, mention:
Prescriber Quick Tips
Anticoagulants
Diabetic Agents
Opioids

6. Thank you Greater Sacramento Care Coordination Steering Committee
Deborah Kania, RN | Post-Acute Care Program Manager, Sutter Health Valley Area
Melanie Segar | Administrator, ACC Care Center
Terry Hill, MD, FACP | Vice President for Performance Strategy, Hill Physicians Medical Group
Ed Fink, MHSM | Director, Strategic Initiatives and Analytics, Quality and Safety, UC Davis
Tory Starr, MSN, PHN, RN | Vice President for Care Management, Sutter Health Valley Area
Jennifer Mangosong-Shankle, MS | Quality Improvement Specialist, Health Services Advisory Group
Vanessa Mandal, MD, MS, CMD | Dignity Health, Mercy Medical Group, HCR Manor Care
Marilyn Kirby | Executive Director, Eskaton Home Health Care
Thank you to the Greater Sacramento Care Coordination Steering Committee

7. Right Care Initiative Greater Sacramento University of Best Practices
Thank our partners
Right Care Initiative University of Best Practices
Hand over to Hattie Hanley

8. Greater Sacramento Medicare Fee-for-Service (FFS) Readmission Data
Thank you, Hattie and the Greater Sacramento Care Coordination Steering Committee
Now let’s go over a few Greater Sacramento Medicare Fee-for-Services Readmission data points. 8

9. Medicare FFS All-Cause, 30-Day Hospital Readmission Rates
National: 18.4%
vs.
CA Rate: 18.9%
Community
Readmission Rate
By Calendar Year
2012
17.3%
2013
2014
17.4%
2015
17.2%
2016
2017 Q1
16.9%
We seem to love to linger around the 17% readmission rate for Greater Sacramento, although the first Quarter of 2017 looks promising at 16.9%. In comparison, we are below both the National and California rate.
The ASAT data file representing calendar year 2012 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 Medicare Fee-for-Service beneficiaries.

10. Medicare FFS Community Readmission Rate Comparison
Readmit Rate Q2 2016–Q1 2017
Sacramento
17.20%
Contra Costa
17.80%
Orange County
18.00%
San Diego
18.30%
Ventura County
Kern
18.50%
Riverside
18.60%
San Francisco
19.00%
Antelope Valley
21.40%
San Bernardino
San Fernando
21.60%
Los Angeles
23.20%
In comparison to the rest of the California communities that we are analyzing, we are looking good in the #1 spot at 17.2%
The data covers readmission rates over the past 4 quarters of the data period.
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.

11. Greater Sacramento FFS All-Cause, 30-Day Readmission Rate: Q2 2016–Q1 2017
Group
Discharged To
Discharges
Readmissions
Readmission Rate
Sacramento
Home
22,166
3,574
16.1%
Skilled Nursing Facility (SNF)
9,603
1,894
19.7%
Home Health Agency (HHA)
10,006
1,812
18.1%
Hospice
1,221 44
3.6%
Other
2,031
437
21.5%
Total
45,027
7,761668
17.2%
State
733,939
138,654
18.9%
Here are the readmission rates for Greater Sacramento by setting.
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.

12. Greater Sacramento FFS Days to Readmission: Q2 2016–Q1 2017
Setting
0–7
8–14
15–21
22–30
Count
Rate
Home
1,334
37.3%
851
23.8%
691
19.3%
698
19.5%
SNF
628
33.1%
492
26.0%
388
20.5%
386
20.4%
HHA
677
37.4%
482
26.6%
338
18.7%
315
17.4%
Hospice 20
45.4% 9 6
13.6%
Other
200
45.7% 99
22.7% 66
15.1% 72
16.5%
Total
2,859
36.9%
1,933
24.6%
1,492
19.2%
1,477
19.0%
Dr. Romano will elaborate more on the 7-day readmission rate, but essentially we like to point out the 7-day readmission rate as it is the timeframe in which we can potentially look at the most unavoidable readmissions and where we can potentially affect the most change with our interventions.
Here, greater Sacramento’s readmission rate is 36.9% within the first week of discharge.
36.9% returning within one week of discharge
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.

13. Greater Sacramento Hospital Readmission Rates: Q2 2016–Q1 2017
Overall Facility Readmission Rate
Readmissions
Discharges A
20.30%
1778
8757 B
18.60%
149
801 C
18.03%
933
5175 D
18.01%
655
3637 E
17.77%
161
906 F
16.90%
403
2384 G
16.80%
142
845 H
16.24%
109
671
Blinded hospital readmission rates
Data files provided to Health Services Advisory Group (HSAG), by the Centers for Medicare & Medicaid Services (CMS), were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries.

14. Overall Facility Readmission Rate
Greater Sacramento Hospital Readmission Rates: Q2 2016–Q (continued)
Hospital
Overall Facility Readmission Rate
Readmissions
Discharges I
15.95%
351
6588 J
16.22%
332
1689 K
14.18%
1031
557 L
13.15%
120
259 M
14.21%
865 N
12.81%
209 O
10.99% 59 P
4.94% 13
Data files provided to Health Services Advisory Group (HSAG), by the Centers for Medicare & Medicaid Services (CMS), were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries.

15. Overall Facility Readmission Rate
Hospital Readmission Rates by Hospital for Patients on High-Risk Medications (HRMs)
Hospital
Overall Facility Readmission Rate
Opioid
Diabetic
Agent
Anticoagulant A
20.30%
23.30%
22.82%
25.56% B
18.60%
32.38%
32.71%
32.50% C
18.03%
20.98%
22.49%
20.70% D
18.01%
22.14%
25.00%
24.55% E
17.77%
14.29%
18.57%
16.81% F
16.90%
22.64%
21.79%
16.42% G
16.80%
36.00%
29.87%
30.77% H
16.24%
21.05%
17.65%
11.76%
Data sources are Medicare Fee for Service (FFS) Part A and Part D claims.
Beneficiaries are considered on a HRM if they have more than 30 days of HRM coverage (opioids, anticoagulants, or diabetic agents) during the time period of interest.
Beneficiaries may qualify as being on a HRM for more than one drug class.
Adverse Drug Events (ADEs) are evaluated in both the inpatient (IP) and emergency department (ED) setting based on the beneficiary’s HRM drug classification.
-If a beneficiary is on an opioid, and has a claim identified as an ADE related to opioids, this is counted in the numerator.
Data files provided to Health Services Advisory Group (HSAG), by the Centers for Medicare & Medicaid Services (CMS), were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries.

16. Overall Facility Readmission Rate
Hospital Readmission Rates by Hospital for Patients on High-Risk Medications (con’t.)
Hospital
Overall Facility Readmission Rate
Opioid
Diabetic Agent
Anticoagulant I
15.95%
16.18%
20.82%
22.10% J
16.22%
21.84%
25.23%
15.64% K
14.18%
19.07%
16.72%
15.52% L
13.15%
15.82%
13.67%
12.00% M
14.21%
20.02%
18.81%
16.00% N
12.81%
14.75%
12.44%
10.71% O
10.99%
15.79%
9.52%
17.31%
Data sources are Medicare Fee for Service (FFS) Part A and Part D claims.
Beneficiaries are considered on a HRM if they have more than 30 days of HRM coverage (opioids, anticoagulants, or diabetic agents) during the time period of interest.
Beneficiaries may qualify as being on a HRM for more than one drug class.
Adverse Drug Events (ADEs) are evaluated in both the inpatient (IP) and emergency department (ED) setting based on the beneficiary’s HRM drug classification.
-If a beneficiary is on an opioid, and has a claim identified as an ADE related to opioids, this is counted in the numerator.
Data files provided to Health Services Advisory Group (HSAG), by the Centers for Medicare & Medicaid Services (CMS), were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries.

17. Readmissions for Beneficiaries on an HRM
Hospital A
These figures represent the total number of readmissions at the example facility for HRM beneficiaries for the specified time period. They depict the percent of readmissions that were due to adverse drug events (ADEs) versus those readmissions which were not attributed to an ADE.
Obviously we want to see the pie shrink all around, but the smaller the orange slice gets, the lesser amount of ADE readmissions in comparison to non-ADE readmissions. Infer that initiatives/attention to ADEs may be in effect.
In this hospital’s example, we see that the percentage has decreased for ADE readmissions from 10.15% to 8.51%
These figures represent the total number of readmissions at your facility for HRM beneficiaries for the specified time period. They depict the percent of readmissions that were due to adverse drug events (ADEs) versus those readmissions which were not attributable to an ADE.
Data files provided to Health Services Advisory Group (HSAG), by the Centers for Medicare & Medicaid Services (CMS), were used for analysis in this report. The data files include Part-A and Part-D claims for Medicare Fee-for-Service beneficiaries.

18. Greater Sacramento 12-Month Challenge: RIR Readmissions Trend
These readmission rates are based on the actual count of readmission per 1,000 beneficiaries. We start with where we are now. Q We actually put our data from Q here because that is the most recent data we have available and we’ll start with that to project our future improvement needs. Our current readmission count per 1,000 beneficiaries is and in order to meet the goal of a 10% improvement in 18 months, we’ll need to reduce that count to or almost 4 less readmissions per 1,000 beneficiaries.
*Q data is actually Q data that is being used as a proxy and projecting
forward. The formula for Relative Improvement Rate (RIR) is (Baseline-Current)/Baseline.

19. Number of readmissions
Greater Sacramento 12-Month Challenge: Reduce Readmissions by 12% by Q3 2018
Number of readmissions
to avert per month= 78
1400
1200
1000
800
600
400
These readmission rates are based on the actual count of readmission per 1,000 beneficiaries. We start with where we are now. Q We actually put our data from Q here because that is the most recent data we have available and we’ll start with that to project our future improvement needs. Our current readmission count per 1,000 beneficiaries is and in order to meet the goal of a 10% improvement in 18 months, we’ll need to reduce that count to or almost 4 less readmissions per 1,000 beneficiaries.
Secondary vertical axis
* Q data is actually Q data that is being used as a proxy and projecting forward. The formula for Relative Improvement Rate (RIR) is (Baseline-Current)/Baseline.
** Number of readmission to reduce from CY 2014 to meet goal.

20. Roundtable Discussions

21. Roundtable Discussions
Intensive patient case management programs have been shown to be effective?
Is this a sustainable model?
Dr. Tong
Heart Failure Care Coordination

22. Roundtable Discussions
Do your providers currently have resources to assist with DOAC management?
Is there a process during transitions of care
to ensure patients receive
the appropriate follow up?
Dr. Teresa Kwong
Anticoag med management
Direct-acting oral anticoags

23. Roundtable Discussions
How do opioid safety initiatives, like RADEO or CURES, impact your care setting?
What opioid safety initiatives would you like to see developed?
Dr. Ashley Trask
Opioids - RADEO

24. Thank you! Mary Fermazin, MD, MPA mfermazin@hsag.com
Jennifer Mangosong-Shankle, MS

25. We Need Your Feedback!

26. CMS Disclaimer
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.