1. Community Collaboration Webinar September 2, 2015 Lindsay Holland, MHA, BS Bruce Spurlock, MD Pat Teske, RN, MHA Carrie Wong, MSW, MPH, LCSW

2. The Panelists Bruce Spurlock, MD Cynosure Health Solutions Executive Director Pat Teske, MHA RN Cynosure Health Solutions Implementation Officer Improvement Advisor Lindsay Holland, MHA, BS Health Services Advisory Group (HSAG) Clinical Project Manager Carrie Wong, MSW, MPH, LCSW Department of Aging and Adult Services Director of Long Term Care Operations

3. Objectives At the conclusion of this presentation, the participant shall: – Identify approaches used by Community-based Care Transitions Programs to reduce hospital readmissions. – Describe the role of a transitional care specialist – Explain the types of services and resources that are important in various high risk populations.

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12. Contact Hours Provider approved by the California Board of Registered Nursing, Provider Number: CEP 15958, for 1 contact hour Eligibility: – Remain on the webinar for 50 minutes – Complete program evaluation after the webinar – Provide RN license #

13. Agenda Carrie Wong, Transitional Care Efforts and CCTP Demonstration Project Lindsay Holland, Together We’re Better: Community Collaboration to Reduce Readmissions Pat Teske, ARC

14. San Francisco: Transitional Care Efforts and CCTP Demonstration Project Carrie Wong, MSW, MPH, LCSW Director of Long-Term Care Operations San Francisco Department of Aging and Adult Services

15. Agenda CCTP Background San Francisco Transitional Care Program Challenges Successes Life after CCTP contract 15

16. Created by Section 3026 of the Affordable Care Act Launched in 2011 Goal: to test models for improving care transitions from the hospital to other settings and reducing readmissions for high- risk Medicare beneficiaries. Also a part of the Partnership for Patients which is a nationwide public-private partnership that aimsPartnership for Patients to reduce preventative errors in hospitals by 40% and reduce hospital readmissions by 20% The Community-based Care Transitions Program (CCTP) 16

17. CCTP Participants  72 participants nationwide (originally 102)  California has 6 CCTP Teams (originally 11)  Northern California  San Francisco  Sonoma  Marin  Southern California  Anaheim  Glendale  Los Angeles  Reseda  San Diego  San Fernando  Ventura 17

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19. San Francisco Transitional Care Program CCTP Contract from Nov 2012 to May 2015 8 hospitals, 8 CBOs, City & County of San Francisco Transitional Care Services using a hybrid coaching and care coordination model Hospital visit 24 hours prior to discharge, home visit within 3 days after discharge, and follow up calls Additional Service Packages Home delivered meals Transportation to/from medical appts Home care hours 19

20. Hospital Liaison Assist staff/units with information and referrals Connect with patients for initial hospital visit Collectively covers all 7 hospital campuses every weekday Transitional Care Specialist Provide transitional care services in the 5 focus areas Complete home visits and appropriate follow up Arrange for service packages (transportation, meals, or homecare) Stabilize and refer to long term resources Complete Patient Activation Survey Two Roles 20

21.  Set a recovery goal  Understand one's health issues and role of medications  Recognize symptoms and have a plan of action if they occur  Develop “My Wellness Plan” – a tool to organize health information  Secure/prepare for the first PCP appointment including questions and concerns  Establish services and resources with emphasis on nutrition, transportation, care at home Client Areas of Focus 21

22. Challenges Ramp up period needed to achieve contract goals Start up money for staffing, database, etc. Hire and train transitional care staff Legal issues to cover transitional care work Contracts such as BAAs, MOUs and data sharing agreements Logistics: employee orientations, background checks, vaccinations Sufficient footprint to impact readmission rates (align with CMS goals) Add the role of hospital liaison mid-contract Expand eligibility to include clients discharged from SNFs Exclude eligibility to those served less than 180 days Ongoing collaboration & the role of “champions” 22

23. Successes Centralized intakes & one stop access for SF Department of Aging and Adult Services Programs including: Information & Referral Line Home-Delivered Meals In-Home Supportive Services Adult Protective Services Community Living Fund and other county programs Private, non-profit, and government partnership Data sharing and active communication about discharge plan Warm hand off from acute to community settings Decreased Readmission Rates 23

24. How about you? 24

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26. 273 Prevented Readmissions! (FY 13/14) 26

27. CCTP Contract Ended. Now what? 27

28. 28

29. Benefits of IHSS Care Transitions Program Integrating transitional care services in existing programs Focus on the Medicaid population instead of Medicare FFS only Kept the momentum from the CCTP contract Continued private, non-profit and government collaboration Continued quality indicators for client outcomes and readmission rates Creative planning for local funds around the service packages for meals, home care and transportation Freedom to focus on broader city-wide priorities and bridging gaps rather than contract goals 29

30. Questions? Carrie Wong, MSW, MPH, LCSW Director of Long-Term Care Operations San Francisco Department of Aging and Adult Services Carrie.Wong@sfgov.org 1 (415) 355-6748 30

31. Together We’re Better: Community Collaboration to Reduce Readmissions Lindsay Holland, MHA Clinical Project Manager, Care Coordination Health Services Advisory Group (HSAG) September 2, 2015

32. 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. 32

33. Why Care Coordination Matters 33

34. Putting It All Together Creative Commons/Pixabay. http://pixabay.com/en/connect-connection-cooperation-316638/ 34

35. California’s Progress: All-Cause, 30-Day Readmission Rate for Patients Discharged From a Hospital 35 The ASAT data file representing calendar years (CYs) 2010–2013 and Q1–Q2 2014 were 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 fee-for-service beneficiaries. California Nation

36. National Success in Reducing Readmissions in Communities Recognized by QIOs 36

37. Strategies to Reduce Readmissions 1.Improve processes within settings. 2.Improve processes between settings.

38. How about you? 38

39. Building Community Coalitions 39

40. CMS Community Expectations 40 Sustainable Community Engage community partners Create leadership structure Develop coalition charter Conduct root cause analysis Select interventions Evaluate interventions

41. Importance of Tracking Measures Select interventions to solve problems, identify measures of success, collect data, and report results. Track measures to discover whether interventions are working and why or why not. – Strengthen effective activities. – Eliminate or revise ineffective activities. – Where did improvement occur? – How did improvement occur? Share results at meetings. 41

42. Community Success Story 42

43. While Great Strides Have Been Accomplished… 43 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/

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

45. 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—08262015-03

46. ARC’s Community Guide

47. Who we visited Congregational Health Network Washington County Coalition

48. What we learned

49. More learnings

50. Even more learnings

51. Other ideas we heard Dare to be a leader! Be Transparent Talk Less Act More Talk Less Act More Identify strong champions CelebrateCelebrate

52. How about you?

54. Looks for the GUIDE soon @ www.avoidereadmissions.comwww.avoidereadmissions.com For more information please contact Pat Teske @ pteske@cynosurehealth.org

55. Contact Hours Provider approved by the California Board of Registered Nursing, Provider Number: CEP 15958, for 1 contact hour Eligibility: – Remain on the webinar for 50 minutes – Complete program evaluation after the webinar – Provide RN license #

56. Thank you! Bruce Spurlock, MD cynosure@cynosurehealth.org