1. Coordinating Care to Improve Healthcare in Kern County Jennifer Wieckowski, MSG State Program Director Health Services Advisory Group (HSAG) May 2015

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. 2

3. HSAG’s QIN-QIO Responsibility 3 HSAG is the Medicare QIN-QIO for California, Arizona, Florida, Ohio, and the U.S. Virgin Islands. Nearly 25 percent of the nation’s Medicare beneficiaries

4. Centers for Medicare & Medicaid Services (CMS) Care Coordination Community Expectations 4 Sustainable Community Engage community partners Develop coalition charter Develop leadership structure Refresh root cause analyses Select interventions Evaluate interventions

5. Kern County Medicare Fee-for-Service Hospital Readmission Rates HospitalReadmission Rate Q2 2013 to Q1 2014 A 27.70% B 21.40% C 21.10% D 20.40% E F 19.90% G 19.70% H 18.30% I 17.10% J 11.10% 5 The ASAT data file representing Q2 2013 to Q1 2014 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.

6. Kern County Medicare Fee-for-Service Hospital Readmission Rates (cont.) Calendar YearReadmission Rate 201022.3% 201121.3% 201220.7% 201320.8% July 2013 to June 2014 20.1% 6 9.9% relative improvement rate The ASAT data file representing calendar year 2010 to Q2 2014 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.

7. Kern County’s Progress: All-Cause, 30-Day Readmission Rate 7 California Nation Kern County

8. 30-Day Readmission Rate by Setting After Inpatient Hospitalization for All Causes: Q3 2013–Q2 2014 Setting Discharged To 30-Day Readmit Rate Nursing Home22.1% Home with Home Health20.6% Home19.3% Total20.1% 8

9. Kern County Providers Connected by a Minimum of 30 Transitions 9

10. Kern County Workgroups Focused on Medication Safety Hospital to Nursing Home Hospital to Home/Home Health Nursing Home to Home/Home Health 10

11. HCAHPS® Measures of Interest 16. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? 17. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand? 25. When I left the hospital, I clearly understood the purpose for taking each of my medications. 11 HCAHPS=Hospital Consumer Assessment of Healthcare Providers and Systems

12. 12 Patients Who Reported That Staff "Always" Explained About Medicines Before Giving it to Them

13. While Great Strides Have Been Accomplished… 13 Further Progress on Behalf of Our Patients Is Essential. Creative Commons/Flicker. BXP135677. Tableatny, August 5, 2013. https://www.flickr.com/photos/53370644@N06/4976497160/

14. Thank you! Health Services Advisory Group quality@hsag.com 818.409.9229

15. 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.3—05292015-01