1. Central Valley Care Coordination Meeting Joseph Marc A. de Veyra, MSN, RN, PHN, PCCN, CNL Health Services Advisory Group (HSAG) May 17, 2016

2. Background July 2015: hospital and home health representatives agreeing that coordination of care was the main barrier to executing safe transitions. Discussions also led to the creation of a Home Health Medication Safety Measures Tool, which prompted active surveillance to determine which home health patients had updated medication lists upon hospital d/c 2

3. Background Through the use of this online tool, members could identify gaps in medication reconciliation across transitions and formulate interventions to enhance patient safety. In addition, all home health agency partners agreed to collect data for the Collaborative. 3

4. Home Health Medication Safety Measures 4

5. Kern County Tool Presented at the CMS National Coordinating Center’s Monthly Sharing Call for Care Coordination in September 2015 As a result of her input, QIN-QIO representatives requested for information on how to replicate the interventions in their geographical areas. HSAG has sent the tool to CMS. 5

6. Filled Medications - HH admission 6

7. Reasons for Unfilled Medications 7

8. Updated Medication List - HH admission 8

9. Questions ??