1. Reaching Outside the Hospital to Create Community Partnerships Marcia Colone, Ph.D., MS, LCSW, ACM System Director, UCLA Health, Los Angeles, CA Patient Flow Summit Tuesday, October 13, 2015 San Francisco, CA 1

2. UCLA Health Hospitals located in Los Angeles and Santa Monica, CA Comprised of Ronald Reagan UCLA Health: Ronald Reagan- 520 Beds, Santa Monica-266 beds, Resnick Neuropsychiatric Hospital- 74 beds, Mattel Children's Hospital-100 beds, and the UCLA Medical Group with its wide-reaching system of primary-care and specialty-care offices throughout the region. Ronald Reagan-Level 1 Trauma Center 25,000 admissions and over 45,000 ED visits 2

3. Post-Acute Network under Development 3

4. UCLA’s Mandate to Build a PAC Too few beds Occupancy rates consistently exceed 95% LOS increasing Queueing in ED High patient acuity and complex discharges Over 50% of discharges occur after 4:00pm Significant homeless population Discharge barriers 4

5. UCLA’s Occupancy by Month (Excluding Nursery, Psychiatry) 5

6. SNF & HH Placements RR & SM-Calendar Year 2012 to 2015 (as of 9/10/15) 6

7. Bed Reservation Program (Est. 2011) 2011 Site visits: Selected 2 SNFs - 6 leased beds 2015- 25 leased beds in two SNF facilities 7

8. Bed Reservation Program (BRP): 2011 Established daily bed lease rate to hold bed- based on acuity to facilitate discharges for unfunded/underfunded patients Funded care includes board/care, medications, PT/OT Established concept of “Backfill” to reduce daily bed lease costs SNF can deny patient admission if criteria is not met Started funding post SNF transitions in 2012 8

9. Crown Jewel of the BRP Two Nurse Practitioners 9

10. Bed Reservation Program 10 2012 = 91 patients 2013 = 163 patients 2014 = 261 patients 2013 to 2014 = 60% increase in # of patients placed 2015 = 126 patients

11. 11 New Vista Occupancy Rates September 2014 to August 2015

12. 12 BRP Readmissions Compared to Health Services Advisory Group (HSAG) All cause 30 day Readmissions Q4 2013 to Q3 2014 HSAG Report 30 Day Readmit Rate Region 24.2% California 20.8%

13. Post SNF Funded Services March 2015 to August 2015 ServicesTotal Recuperative Care$24,625.00 Home Health$505.00 Medications$217.03 DME$2,211.00 Total Amount$27,558.03 Avg Cost Per Patient (21 patients)$1,312.00 13

14. Lessons Learned from BRP Program Invest in relationships & training over the long term Build a training program for SNF staff & visit quarterly NPs are essential for clinical quality Develop a process to review metrics, address referral and refusal patterns and readmissions Constantly review referral process/handoffs, especially during non- business hours Daily identification of BRP patients Claims reconciliation system Standard reporting system 14

15. Home Health Enhanced Program-November 2013 Develop a strategy to ensure the delivery of reliable and consistent home health services across the continuum of UCLA Health (inpatient and ambulatory) and identify actionable steps for quality improvement and readmission reductions 15

16. Opportunities Communication: external/internal providers To/from PMD Inpatient teams Lack of accountability infrastructure High number of patient refusals at time of service Differences in referral processes from inpatient and outpatient setting Absence of electronic home health orders 16

17. 717

18. Improving Quality Outcomes Enhanced Home Health Quality Council-3 contracted home care vendors Components 1st touchpoint in the inpatient setting (in-person or phone) 7 touchpoints in first 2 weeks post hospital discharge Measurement 30-day all-cause readmission % of patients who refuse home health services % of patients who were unable to be located post-discharge % of patients who had a delayed start of care 18

19. 19 Enhanced Home Health Readmissions November 2013 (Baseline) vs. FY 2015 Totals Home Health AgencyBaselineFY 2015 TotalDifference Western States20.99%18.95%2.04% AccentCare22.09%15.42%6.67% Intracare28.49%12.68%15.80% % Readmissions25.07%15.24%9.83% Baseline = Start of EHH Program

20. Lessons Learned in HH Enhanced Program Invest in the relationships over the long term Establish quality standards Develop a process to review metrics, address issues (denials, refusals, etc) and readmissions Establish a quality review process to review real-time failures Establish a claim reconciliation system for funded patients Constantly improve referral processes/handoffs, especially for referrals that occur during non-business hours 20

21. Thank You! Marcia Colone System Director, UCLA Care Coordination 310-267-9711 mcolone@mednet.ucla.edu 21