1. The Role of Hospice and Palliative Care in Reducing Readmissions Jennifer Wieckowski, MS, Health Services Advisory Group April Bolles, Palliative Care Alliance Michael Demoratz, PhD., CCM., LCSW, AMADA Senior Care October 16, 2014

2. Moderator: Jennifer Wieckowski, MSG State Program Director Health Services Advisory Group 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). Committed to improving quality of healthcare for more than 35 years

3. California’s Progress All-cause, 30-day readmission rate for Californians discharged from a hospital The ASAT data file representing calendar years (CYs) 2010–2013 was used for the analyses in this report. The ASAT data file is provided to HSAG by CMS. The ASAT data file includes Part-A claims for FFS beneficiaries.

4. April Bolles, BSW, CEO Palliative Care Alliance (PCA) 17 years healthcare and leadership experience specializing in end-of-life care. Responsible for spearheading several healthcare company start-ups, the subsequent management of the daily operations and growth of each. 2005, received national recognition from an American Business Award she won for Best Office Manager. January 2014, founded PCA in Arizona. In 2015, PCA will be launching in CA, TX, NV and NM.

5. The Elements of Community Based Palliative Care Palliative Care Alliance (PCA) is a community-based palliative care company that offers clinical services at home for patients with chronic and/or serious illness. Palliative care team consists of physicians, nurses and social workers. PCA is a free-standing palliative care service and is not owned by a hospice or home health company. “Filling the gap” by offering a proven resource to patients who often fall through the cracks that addresses both palliative and transitional care needs.

6. PCA – A Transitional Model That Works PCA lead a transitional care pilot program for a large health system, Dignity Health, in Arizona and lowered the readmission rate by over 15%. By partnering with the in- patient palliative care program we were able to achieve these results. Hospital Re-admission Rates CMS 30 Day Readmission Threshold 2.5% 24.8%

7. Cost Savings Benefits and High Quality Care This is a unique palliative model because it offers exceptional patient care and great cost savings to both hospitals and health plans: 1.PCA provides transitional care to hospitals looking to reduce their Medicare readmission penalties while delivering palliative care services to the patients who discharge from the hospital needing additional support at home. 2.Similarly, health insurance plans can increase cost savings significantly by utilizing PCA for the members who are at a high risk for hospitalization or re-hospitalization by having an assigned home palliative care team.

8. Michael J Demoratz, LCSW, CCM, PhD Director of Business Development AMADA Senior Care Nationally recognized subject matter expert with 35 years experience in end-of-life and senior care. Published numerous articles and a book Dying 101: A Short Course on Living for the Terminally Ill. Former Board Member, National Case Management Society of America 2001, Distinguished National Case Manager of the Year Board Member, Coalition for Compassionate Care of California Commissioner on Board of Commission for Case Manager Certification Director of Business Development for Amada Senior Care Creates new business opportunities to improve care for seniors Provides case management clinical support & guidance on national level to local franchise offices and assists them in management of higher complexity clients.

9. Southern California Readmissions Summit – 10/16/2014 Readmission penalties have the attention of hospitals (2,610 hospitals in the U.S. will see their Medicare payments docked in fiscal 2015) Medicare Case Management Departments are saddled with the responsibility of managing high risk patients for readmission without the ability to control the actual process after the patient is discharged. In the post-acute environment - we know who these patients are. NRPC So Cal Readmissions Update October 16, 2014

10. Northern California Readmissions Summit – 9/12/2014 Typically, they are patients who could benefit from palliative care services and are typically those at highest risk for readmission. We have the awareness that symptom management is at the core of managing these clients in the home from a palliative perspective. These are the most vulnerable due to age, socioeconomic status, education level, culture, medical literacy, language and of course condition NRPC So Cal Readmissions Update October 16, 2014

11. Northern California Readmissions Summit – 9/12/2014 Hospitals are not islands. Know your providers. Knowing the limits & abilities of post-acute providers is key – no longer acceptable to just give a list to families Home Care Providers like AMADA are stepping up to deliver - high quality programs to address the readmission issue. 3 Pronged approach to care delivery. High Touch – High Tech and Relocation Services NRPC So Cal Readmissions Update October 16, 2014

12. Josh Luke, Ph.D., FACHE Founder, The National Readmission Prevention Collaborative Contact: joshluke@nationalreadmissionprevention.com NRPC So Cal Readmissions Update October 16, 2014