1. Greater Los Angeles Care Coordination Conference
Joseph de Veyra, DNP, RN, PHN, PCCN, CNL Executive Director Health Services Advisory Group (HSAG)
July 14, 2017

2. HSAG: Your Partner in Healthcare Quality
HSAG is California’s Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO).
QIN-QIOs in every state and territory are united in a network administered by the Centers for Medicare & Medicaid Services (CMS).
The QIN-QIO program is the largest federal program dedicated to improving health quality at the community level.
Committed to improving quality of healthcare for more than 35 years
Provides quality expertise to those who deliver care and those who receive care
Engages healthcare providers, stakeholders, Medicare patients, families, and caregivers
Provides technical assistance, convenes learning and action networks, and analyzes data for improvement

3. HSAG’s QIN-QIO Responsibility
Nearly 25 percent of the nation’s Medicare beneficiaries
Drives quality by providing technical assistance, convening LANs, collecting and analyzing data for improvement
Works on initiatives to improve patient safety, reduce harm, improve clinical care
Engages healthcare providers, stakeholders, and beneficiaries to improve health quality, efficiency, and value.
We Serve…
25 percent of our nation’s Medicare population.
45 percent of our nation’s Medicaid population.
19 percent of our nation's dialysis population.
HSAG is the Medicare QIN-QIO for California, Arizona, Florida, Ohio, and the U.S. Virgin Islands.

4. CMS Care Coordination Community Expectations
Sustainable
Community
Engage community partners
Develop coalition charter
Develop leadership structure
Refresh root cause analyses
Select interventions
Evaluate interventions

5. National: 18.5% vs. CA Rate: 18.8%
Your Hospital Medicare Fee-for-Service (FFS) 30-Day, All-Cause Hospital Readmission Rates
Calendar Year
Greater Los Angeles
2012
23.5%
2013
22.3%
2014
21.8%
2015
22.0%
Q1 2016
22.7%
Q2 2016
23.2%
Q3 2016
23.3%
National: 18.5%
vs.
CA Rate: 18.8%
The ASAT data file representing calendar year 2013 to Q 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 Medicare Fee-for-Service beneficiaries.

6. Medicare Fee-For-Service (FFS) All-Cause Hospital Readmission Rates
Greater Los Angeles, California, and U.S.
The ASAT data file representing calendar year 2010 to Q 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 Medicare Fee-for-Service beneficiaries.

7. Community Medicare FFS Readmission Rate Comparison
Readmit Rate Q4 2015–Q3 2016
Los Angeles
22.8%
San Fernando
21.6%
Antelope Valley
20.9%
San Bernardino
San Francisco
18.6%
Orange County
17.5%
Riverside
18.5%
San Diego
18.3%
Kern
Ventura County
18.2%
Sacramento
17.0%
Contra Costa
The ASAT data file representing Q to Q 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.

8. Greater Los Angeles FFS All-Cause, 30-Day Readmission Rate: Q4 2015–Q3 2016
Group
Discharged To
Discharges
Readmissions
Readmission Rate
Greater Los Angeles
Home
16,618
3,616
21.8%
Skilled Nursing Facility (SNF)
11,381
2,861
25.1%
Home Health Agency (HHA)
7,991
1,778
22.3%
Hospice
741 34
4.6%
Other
3,313
861
26.0%
Total
40,044
9,150
22.8%
State
731,484
136,397
18.6%
Data to follow
The ASAT data file representing Q to Q 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.

9. to a Different Hospital
Greater Los Angeles FFS Hospital Readmissions to Same Hospital vs. Different Hospital: Q3 2015–Q2 2016
Group
Setting Discharged to
30-Day Readmissions
to the Same Hospital
to a Different Hospital N %
Greater Los Angeles
Home
2,058
56.9%
1,558
43.1%
SNF
1,670
58.4%
1,191
41.6%
HHA
1,305
73.4%
473
26.6%
Hospice 19
55.9% 15
44.1%
Other
378
43.9%
483
56.1%
Total
5,430
59.3%
3,720
40.7%
California
92,405
67.7%
43,992
32.3%
The ASAT data file representing Q to Q 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. Greater Los Angeles Physician Follow-Up Visits: Patients Discharged from Hospital Directly to Home
Number of Patients Discharged
From Hospital
to Home
Number of Patients Completing Physician
Follow-Up Visit
in 30 Days
% of Discharged Patients Completing Physician
Follow-Up Visits
Were Patients Readmitted?
12,770
8,113
63.5% No
9,966
6,939
69.6%
Yes
2,804
1,174
41.9%
Data to follow
58.1% of readmissions did not complete a 30-day follow-up visit
The ASAT data file representing Q to Q 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.

11. Greater Los Angeles FFS Days to Readmission: Q3 2015–Q2 2016
Setting
0–7
8–14
15–21
22–30
Count
Rate
Home 78
32.70% 57
23.8% 60
25.1% 44
18.4%
SNF 33
25.60% 38
29.5% 27
20.9% 31
24.0%
HHA
24.40%
36.5% 28
17.9%
21.2%
Hospice
0.00%
0.0% 1
100.0%
Other 23
48.90% 10
21.3% 3
6.4% 11
23.4%
Total
172
30.00%
162
28.3%
119
20.8%
Data to follow
30% returning within one week of discharge
The ASAT data file representing Q to Q 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.

12. Greater Los Angeles SNF Rankings
Discharges to SNF with a 30-Day Hospital Readmission
Number of Discharges to SNF
Readmission Rate 1 25 71
35.2% 2 40
124
32.3% 3 50
158
31.6% 4 30 98
30.6% 5 39
128
30.5% 6 83
30.1% 7 61
203
30.0% 8 34
115
29.6% 9 36
126
28.6% 10 43
154
27.9% 11
153
26.1% 12 24 92 13 51
25.5% 14 20 80
25.0% 15 87
349
24.9% 16 26
105
24.8% 17 19 77
24.7% 18 23 95
24.2% 46
191
24.1%
Data to follow
The ASAT data file representing Q to Q 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 Medicare Fee-for-Service beneficiaries.

13. Greater Los Angeles Home Health Rankings
Discharges to HHA with a 30-Day Hospital Readmission
Number of Discharges to HHA
Readmission Rate 1 63
302
20.9% 2 28
135
20.7% 3 14 72
19.4% 4 65
364
17.9% 5
123
700
17.6% 6 49
281
17.4% 7 26
152
17.1% 8 50
16.0% 9 10
15.4% 18
121
14.9% 11
350
14.3% 12 17
122
13.9% 13 59
13.6% 52
13.5% 15
107
13.1% 16 22
169
13.0%
114
12.3%
126
11.9% 19 33
280
11.8% 20
113
11.5%
Data to follow
The ASAT data file representing Q to Q 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 Medicare Fee-for-Service beneficiaries.

14. HSAG Projects in Different Communities
Hospital to
Nursing Home
Hospital to
Home
Monthly meetings
Discuss local needs and opportunities
Develop an action plan and timeline; identify interventions and measurement strategy
Share best practices and lessons learned during the bi-annual learning and action network (LAN) event

15. SNF Transfer Checklist Review

16. Physician Engagement Progress in Kern
Collaborative held two physician engagement meetings in 2016
Bakersfield Memorial Hospital (BMH)
San Joaquin Community Hospital (SJCH)
The July 14 in-person Kern County Care Transitions Collaborative – Hospital to Home Subcommittee Meeting featured a 200% increase in Home Health Agency Membership. Furthermore, during this meeting, both hospital and home health representatives agreed that coordination of care was the main barrier to executing safe clinical transitions. As a result, the subcommittee decided to utilize Google Docs as a platform to share information such as a community directory that documented the “Primary Contact for Clinical Transitions,” to increase efficiency during transfers across levels of care. This online document was made available to members on August 10, 2015.
According to Christine A. Lollar, Director of Homelessness of United Way of Kern County, Memorial, Mercy AND KMC have all pursued and received training on the Quick Referral Tool as a direct result of Collaborative meetings

17. Physician Engagement SJCH—February 25, 2016 BMH—March 31, 2016
Attendance: 40
18 Providers: 16 physicians, 1 nurse practitioner, and 1 physician’s assistant.
BMH—March 31, 2016
Attendance: 45
15 providers: 13 physicians, 1 nurse practitioner, and 1 physician’s assistant.
The July 14 in-person Kern County Care Transitions Collaborative – Hospital to Home Subcommittee Meeting featured a 200% increase in Home Health Agency Membership. Furthermore, during this meeting, both hospital and home health representatives agreed that coordination of care was the main barrier to executing safe clinical transitions. As a result, the subcommittee decided to utilize Google Docs as a platform to share information such as a community directory that documented the “Primary Contact for Clinical Transitions,” to increase efficiency during transfers across levels of care. This online document was made available to members on August 10, 2015.
According to Christine A. Lollar, Director of Homelessness of United Way of Kern County, Memorial, Mercy AND KMC have all pursued and received training on the Quick Referral Tool as a direct result of Collaborative meetings

18. Findings
Provided a platform for collaborative members and community physicians to start a dialogue for collaboration
Evaluation revealed positive feedback
Recruited 13 physicians from various settings such as federally qualified health centers
The July 14 in-person Kern County Care Transitions Collaborative – Hospital to Home Subcommittee Meeting featured a 200% increase in Home Health Agency Membership. Furthermore, during this meeting, both hospital and home health representatives agreed that coordination of care was the main barrier to executing safe clinical transitions. As a result, the subcommittee decided to utilize Google Docs as a platform to share information such as a community directory that documented the “Primary Contact for Clinical Transitions,” to increase efficiency during transfers across levels of care. This online document was made available to members on August 10, 2015.
According to Christine A. Lollar, Director of Homelessness of United Way of Kern County, Memorial, Mercy AND KMC have all pursued and received training on the Quick Referral Tool as a direct result of Collaborative meetings

19. Home Health Data Collection Tool

20. Home Health Data Collection Tool Update
Home health data collection tool findings (January to June 2016):
1,602 screened Medicare beneficiaries
57 discharged to home health without an updated medication list
39 cases of unfilled medications by first home health visit
Tool identified 96 potential adverse drug events
The July 14 in-person Kern County Care Transitions Collaborative – Hospital to Home Subcommittee Meeting featured a 200% increase in Home Health Agency Membership. Furthermore, during this meeting, both hospital and home health representatives agreed that coordination of care was the main barrier to executing safe clinical transitions. As a result, the subcommittee decided to utilize Google Docs as a platform to share information such as a community directory that documented the “Primary Contact for Clinical Transitions,” to increase efficiency during transfers across levels of care. This online document was made available to members on August 10, 2015.
According to Christine A. Lollar, Director of Homelessness of United Way of Kern County, Memorial, Mercy AND KMC have all pursued and received training on the Quick Referral Tool as a direct result of Collaborative meetings

21. Filled Medications—Home Health Admissions
The July 14 in-person Kern County Care Transitions Collaborative – Hospital to Home Subcommittee Meeting featured a 200% increase in Home Health Agency Membership. Furthermore, during this meeting, both hospital and home health representatives agreed that coordination of care was the main barrier to executing safe clinical transitions. As a result, the subcommittee decided to utilize Google Docs as a platform to share information such as a community directory that documented the “Primary Contact for Clinical Transitions,” to increase efficiency during transfers across levels of care. This online document was made available to members on August 10, 2015.
According to Christine A. Lollar, Director of Homelessness of United Way of Kern County, Memorial, Mercy AND KMC have all pursued and received training on the Quick Referral Tool as a direct result of Collaborative meetings

22. Reasons for Unfilled Medications
The July 14 in-person Kern County Care Transitions Collaborative – Hospital to Home Subcommittee Meeting featured a 200% increase in Home Health Agency Membership. Furthermore, during this meeting, both hospital and home health representatives agreed that coordination of care was the main barrier to executing safe clinical transitions. As a result, the subcommittee decided to utilize Google Docs as a platform to share information such as a community directory that documented the “Primary Contact for Clinical Transitions,” to increase efficiency during transfers across levels of care. This online document was made available to members on August 10, 2015.
According to Christine A. Lollar, Director of Homelessness of United Way of Kern County, Memorial, Mercy AND KMC have all pursued and received training on the Quick Referral Tool as a direct result of Collaborative meetings

23. Updated Medication List— Home Health Admissions
The July 14 in-person Kern County Care Transitions Collaborative – Hospital to Home Subcommittee Meeting featured a 200% increase in Home Health Agency Membership. Furthermore, during this meeting, both hospital and home health representatives agreed that coordination of care was the main barrier to executing safe clinical transitions. As a result, the subcommittee decided to utilize Google Docs as a platform to share information such as a community directory that documented the “Primary Contact for Clinical Transitions,” to increase efficiency during transfers across levels of care. This online document was made available to members on August 10, 2015.
According to Christine A. Lollar, Director of Homelessness of United Way of Kern County, Memorial, Mercy AND KMC have all pursued and received training on the Quick Referral Tool as a direct result of Collaborative meetings

24. California Comparison of Relative Improvement Rates
Check out Sacramento!
The number of beneficiaries for each community and the percentage of beneficiaries within the cohort are displayed next to the community name. The data source for the beneficiary counts is the NCC Scorecard.

25. California Comparison of Relative Improvement Rates (cont.)
The number of beneficiaries for each community and the percentage of beneficiaries within the cohort are displayed next to the community name. The data source for the beneficiary counts is the NCC Scorecard.

26. Kern Medicare Fee-for-Service (FFS) Hospital Readmission Rates
Year
Readmit rate
2010
22.3%
2011
21.3%
2012
20.2%
2013
20.4%
2014
19.8%
2015
19.0%
Q1 2016
18.2%
Q2 2016
19.2%
Q3 2016
17.3%
22.42% relative improvement rate
The ASAT data file representing calendar year 2010 to Q 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 Medicare Fee-for-Service beneficiaries.

27. Next Steps/Conclusion
Assist on improving key systems to prevent unnecessary readmissions by:
Providing educational opportunities
Diabetes training
Antibiotic stewardship
Medicare Access & CHIP* Reauthorization Act (MACRA)
Convening outcome-focused workgroups
Engage your post-acute care providers
Providing specialized data reports
Assisting in best-practice interventions
We need YOU!
*Children’s Health Insurance Program

28. While Great Strides Have Been Accomplished…
Further Progress on Behalf of Our Patients is Essential.

29. Thank you!
Joseph de Veyra, DNP, RN, PHN, PCCN, CNL Executive Director, HSAG O: | C: | F:

30. CMS Disclaimer
This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for California, 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. CA-11SOW-C