1. Kern County Care Coordination: A Collaborative Journey Michael Smith, RN, MSN Ed, PHN BPCI Program Manager Dignity Health Bakersfield Market October 13, 2015

2. 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

3. Kern County Providers Connected by a Minimum of 30 Transitions 3

4. 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

5. 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

6. Kern County Medicare Fee-for-Service Hospital Readmission Rates HospitalReadmission Rate Q2 2013 to Q1 2014 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 Q2 2013 to Q1 2014 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.

7. Kern County’s Progress: All-Cause, 30-Day Readmission Rate 7 California Nation Kern County

8. 30-Day Readmission Rate by Setting After Inpatient Hospitalization for All Causes: Q3 2013–Q2 2014 Setting Discharged To 30-Day Readmit Rate Nursing Home22.1% Home with Home Health20.6% Home19.3% Total20.1% 8

9. Kern County Medicare Fee-for-Service Hospital Readmission Rates (cont.) Calendar YearReadmission Rate 201022.3% 201121.3% 201220.3% 201320.3% 2014 (Q1-Q3)19.9 % CA State Rate 2014 (Q1-Q3) 17.6% 9 10.8% relative improvement rate The ASAT data file representing calendar year 2010 to Q2 2014 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.

10. 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

11. 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

12. References Statistical graphs on slides 3, 5, 6, 7, 8, and 9 courtesy of HSAG and collaboration on Kern County Care Transitions Collaborative 12

13. Thank You