1. Seeing the Unseen Barb Averyt, BSHA Director, Care Coordination Health Services Advisory Group

2. Arizona Readmission Rates Arizona Region Average Rate Northern AZ12.9% Southern AZ15.1% Western AZ16.7% Central Valley Phoenix16.4% East Valley Phoenix16.9% West Valley Phoenix17.0% 2013 National Readmission Rate for Medicare Fee-For-Service (FFS) is 18% Arizona rates: Medicare FFS, Hospital Readmissions: Quarter 2 (Q2) 2013–Q1 2014 2

3. Arizona—Working Well With Each Other Most improved readmission rate in the country Hospital, nursing home, and home health agency collaboratives across the state Adopted Advancing Excellence readmission tracking tool statewide 3

4. But Still More to Do 36% 60% 28% of patients who were readmitted returned within 7 days of hospital discharge. of those who were readmitted within 7 days did not have home health ordered when they left the hospital. of those who were readmitted within 7 days were on a high-risk medication (anticoagulant, diabetic agent, or opioid). They did not have home health ordered. In Phoenix, West Valley… 4

5. A Patient’s Story 3:00 a.m.Room spinning 7:00 a.m.Explosive headache 10:00 a.m.Took vicodin for headache. 12:00 p.m.Realizes problem and need to be evaluated at the hospital. 1:00 p.m.Registered at emergency department (ED). 3:30 p.m.Threw up—Left lobby and taken to ED treatment area. 4:00 p.m.Saw ED physician assistant (PA) in the ED. 5:30 p.m. Morphine sulfate (MS) IV, 4 mg given. 7:00 p.m.CT scan 8:15 p.m.Saw ED attending physician 8:30 p.m. Lumbar puncture (LP)—failed 9:30 p.m. MS 4 mg given. 10:00 p.m. Second LP performed in radiology. Lay flat for 5 hours. 12:00 a.m. LP results shared by ED PA. Large amount of blood. Will admit to observation and work-up. 1:00 a.m. MS 4 mg given.

6. A Patient’s Story (cont.) 2:30 a.m.Admitted and transferred to “good bed.” 3:30 a.m.Nurse admitted. First time patient is asked about meds. 4:30 a.m. Saw Observation PA. 5:30 a.m. Saw hospitalist #1. MS 4 mg given. 7:30 a.m. Saw neurologist. 7:30 a.m. Husband offers his version of medications (warfarin/voltaren) to neurologist. 8:00 a.m. Given “migraine cocktail” that was ordered by neurologist. Does not contain MS. 9:00 a.m.Ativan given in prep for magnetic resonance imaging (MRI). 9:30 a.m.MRI/MR angiography (MRA) 10:30 a.m. Back in room. Saw hospitalist #2. 12:30 p.m. MRI/MRA results shared. OK’d for discharge (DC). 2:30 p.m. Check out. Given prescriptions. Going home.

7. 24-Hour Drug Timeline Vicodin taken MS 4 mg IV 10:00 a.m. 5:30 p.m. 9:30 p.m. 1:00 a.m. 5:30 a.m. 8:00 a.m. 9:00 a.m. DC Instruction provided Ativan IV MS 4 mg IV Migraine Cocktail IV 7

8. Why Does This Story Matter? Because I’m 57. Just wait until I’m 77! My husband was my “advocate” and he got confused (warfarin vs. voltaren). High anxiety does that. After all the pain medication I received, was I really capable of understanding my discharge instructions? 8

9. Looking at the Opportunities 36% 60% 28% of patients who were readmitted, returned within 7 days of hospital discharge. of those who were readmitted within 7 days did not have home health ordered when they left the hospital. of those who were readmitted within 7 days were on a high-risk medication (anticoagulant, diabetic agent, or opioid). They did not have home health ordered. In Phoenix, West Valley… 9

10. Questions?

11. Thank you! Barb Averyt, BSHA baveryt@hsag.com

12. This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, 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. AZ-11SOW-C.3-02102015-01