1. 1 Seven Home-Health Touch Points to Prevent Avoidable Re-hospitalizations Jennifer Wieckowski, MSG Program Director, Care Transitions Health Services Advisory Group of California, Inc. (HSAG of California)

2. 2 Statewide Readmission Reports Medicare Fee-For-Service (FFS) Data CY 2012 All-Cause 30-Day Readmission Rates Setting Discharged To Number of Discharges Number of Discharges Readmitted Within 30 Days 30-Day Readmit Rate % of 30-Day Readmits to Another Hospital Home 383,017 66,10217.3%26.6% Skilled Nursing Facility 173,919 38,31722.0%27.2% Home Health Agency 124,008 25,04520.2%22.0% Hospice 15,968 553 3.5%36.9% Other 53,449 10,82220.2%41.6% All 750,361140,83918.8%27.1%

3. 3 Statewide Readmission Reports Medicare FFS Data (cont’d) CY 2012 Number of Days from Discharge to Readmission Setting Discharged To Number of Readmissions 1–7 Days 8–14 Days 15–21 Days 22–30 Days Home 66,10236.0%24.9%19.5%19.6% Skilled Nursing Facility 38,31732.5%25.9%20.9%20.7% Home Health Agency 25,04536.3%26.1%19.0%18.5% Hospice 55344.5%26.2%15.4%13.9% Other 10,82238.2%22.0%18.5%21.4% All140,83935.3%25.2%19.7%19.8%

4. 4 The Team  Largest private, not-for-profit medical center in the western United States, with 923 beds  Consistently named one of America’s Best Hospitals by U.S. News & World Report  Ranked in top 2 percent in the country  In business over 33 years  Five locations throughout Southern California  Monthly census of more than 700 patients Cedars-Sinai Medical Center (CSMC) Accredited Home Health Services

5. 5 The Challenge Reduce readmissions from home health by 50 percent.

6. 6 Are you NUTS?!?!

7. 7 Enhanced Home Health Program Minimum of seven touch points within two weeks of discharge

8. 8 Results 8 Patient PopulationTime Frame Percent Readmitted (All-Cause) Cedars-Sinai discharges home with home health (any agency) July 2010–June 2011 19% Cedars-Sinai discharges home with Test of Change home health agency* July 2010–June 2011 14% Test of Change (n=59 patients) November 2011 6.8% * The agency selected for the test of change had the highest proportion of home-health referrals from Cedars-Sinai Medical Center.

9. 9 Adaptability and Spread 9 Four high-volume home health agencies tested the Enhanced Home Health program during a six-week period in February and March 2012. A total of 396 patients were enrolled. Home Health Agency BASELINE Percentage 30-day Readmissions Feb. 2011–Jan. 2012 TEST OF CHANGE Percentage 30-day Readmissions Feb. 15–Mar. 31, 2012 NUMBER OF PATIENTS enrolled in TOC Feb. 15–Mar. 31, 2012 Accredited 12.7%10.3%121 Agency II 12.1%7.8%103 Agency III 14.7%11.8%110 Agency IV 17.3%6.4%62 35% Reduction

10. 10 Lessons Learned  Increase in personnel time dedicated to the program  Communication—frequent and clear  In-patient phone call vs. visit  Patient refusal

11. 11 What You Can Do By Tuesday  Know your readmission rates. −medicare.gov  Know where your referrals are going.  Develop partnerships.  Improve communication.  Implement tuck-in phone calls.

12. 12 California Rate of Readmissions Within 30 Days per 1,000 Beneficiaries * Calendar Year (CY)

13. 13 Statewide and Regional Readmission Data Reports www.NoPlaceLikeHomeCA.com www.NoPlaceLikeHomeCA.com

14. 14 List of Hospitals Affected by HRRP http://www.kaiserhealthnews.org/Stories/2013/August/02/ readmission-penalties-medicare-hospitals-year-two.aspx

15. 15 New Resource! www.checkmypenalty.com

16. 16 New Resource! www.checkmypenalty.com (cont’d)

17. 17 Home Health Quality Improvement Campaign http://www.homehealthquality.org/Home.aspx http://www.homehealthquality.org/Home.aspx

18. 18 Thank You! Jennifer Wieckowski, MSG Program Director, Care Transitions jwieckowski@hsag.com HSAG of California 700 North Brand Blvd., Suite 370 Glendale, CA 91203 818.409.9229

19. 19 www.hsag.com This material was prepared by Health Services Advisory Group of California, Inc., 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-10SOW-8.0-091813-01 We convene providers, practitioners, and patients to build and share knowledge, spread best practices, and achieve rapid, wide-scale improvements in patient care; increases in population health; and decreases in healthcare costs for all Americans.