Chronic Disease Transitional Care Northridge Hospital Medical Center Health Services Advisory Group 10/20/17 Dr. Jeremy Grosser Medical Director Transitional & Palliative Care

Disclosure I have no financial relationships with commercial interests

Social Determinants of Health Source: Institute for Clinical Systems Improvement, Going Beyond Clinical Walls: Solving Complex Problems (October 2014)

Transitional Care Department Educate Build Trust Transitional Care Department Palliative Care Pain Management Frail Elderly Chronic Diseases Diabetes Management Mitigate Communicate 65 and older CHF COPD CVA ESRD CANCER CJR

Why Care Coordination? Patient safety Safe transition home by improving patient and family preparation for discharge Ensure follow up with Physicians after discharge Improve flow of information between hospital, providers, patient, and families Increase safety by improving the transition for discharge, and mitigating risk for adverse advents Home Visit- conducting home safety check Follow up phone calls to ensure access & continuity of care

Chronic Disease /Transitional Care Dept. Clinical Team is composed of: Nurse Practitioners (7.5) Social Workers (2) Clinical Pharmacists (2) Physicians – Provides clinical oversight for NP’s (2.0) and pain management staff Diabetes NP (1.0) Registered Nurse (1.0) – Program Coordinator for Discharge Planning The Transitional Care Team works collaboratively with patients/care partners, medical staff, nursing, case management, pharmacy, ancillary services, SNF’s & Home health agencies towards safe patient discharge : The NP educates the patient and family about their chronic disease & red flags of their illness & provides clinical oversight and problem resolution for 30-90 days post discharge. The Pharmacist conducts Medication reconciliation & education. The NP conducts home & SNF visits ensuring a safe discharge and that required supplies and equipment are in place. The Social Worker provides psychosocial support, makes referrals for support groups, community services, spiritual services, hospice support.

Internal Collaboratives: Pharmacy Medication reconciliation for all chronic disease & pain management patients enrolled in program Physicians Automatic consultation for all 30 day readmits ED icon for readmission potential, notification of cardiologist & surgeon Cardiology Co-management auto consult orders Neurology auto consult orders for Stroke patients Family Medicine/Foundation MD’s: RN Coordinator ensuring access to medications & follow up appointments Nursing Units Daily ICU rounds & Palliative Care consultation Glycemic Management FY 18 Goals Pharmacy review of Pain Management Regimens Case Management Collaboration between Case Management &Transitional Care for discharge Planning Specialized populations: Medications in hand at discharge & appointments with PCP within 7 days of discharge

Pharmacist Medication Mitigation Categories August 2016 – July 2017

External Collaboratives Skilled nursing facilities (SNFs) Must maintain Star rating at 3+ Narrowed network of 8 facilities Weekly NP driven patient rounds at the SNF’s Weekly clinical calls with Medical Director & NP’s Monthly collaborative meetings Review of SNF readmission outcomes Identify best performers Adjustments to narrowed network as needed Home health Narrowed network of 8 vendors NP’s coordinate care with HHA

SNF Readmission Rates from CDTC

Northridge Hospital: Readmission RIR* Q1 2014–Q1 2017 Desired Direction RIR: Target: 12% RIR by Q3 2018 Source: Medicare Fee for Service Claims Data. Baseline period: CY 2014. *The formula for Relative Improvement Rate (RIR) is (Baseline-Current)/Baseline.

Readmission Data Q2 2016–Q1 2017 Patients Discharged Home With Home Health Patients Discharged Home Without Home Health Location 30-Day Readmission Rate Readmissions within 0–7 Days Northridge Hospital (n=106) 16.4% (n=36) 34.0% Los Angeles 21.1% 36.1% California 19.3% 36.0% Location 30-Day Readmission Rate Readmissions within 0–7 Days Northridge Hospital (n=315) 19.2% (n=122) 38.7% Los Angeles 20.6% 38.7% California 17.4% 37.6%

Readmission Data Q2 2016–Q1 2017 Patients Discharged to Nursing Homes Location 30-Day Readmission Rate Readmissions within 0–7 Days Northridge Hospital (n=237) 22.5% (n=83) 35.0% Los Angeles 24.9% 33.1% California 21.6% 32.9%

Thank You