TRANSITIONS OF CARE SANTA CLARA VALLEY MEDICAL CENTER. Better Health for All

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1 TRANSITIONS OF CARE SANTA CLARA VALLEY MEDICAL CENTER

2 SANTA CLARA COUNTY MEDICAL CENTER SCVMC is a tertiary teaching medical facility with 574 beds. Santa Clara Valley Medical Center services include: adult level one trauma center, pediatric level one trauma center, a federally designated spinal cord injury center/ traumatic brain injury Rehabilitation Trauma center, and numerous critical care units including the highest level neonatal intensive care unit. The medical center also is licensed for cardiovascular surgery, cardiac catheterization, it is designated a primary stroke treatment center, and it operates onsite outpatient federal qualified healthcare clinics & satellite clinics Santa Clara Valley Health & Hospital System

3 SCVMC (CONT.) SCVMC has a little over 25,000 discharges per year. The Care Management department consists of case managers, utilization review nurses, medical social workers, data analysis manager, and support staff. Our staff provides utilization review, care coordination, and discharge planning to the patient population we serve. There are inpatient and outpatient case managers and medical social workers. We work very closely with the patients and their families, the insurance plans and community services/resources to provide our patient with a safe discharge Santa Clara Valley Health & Hospital System

4 THE 24-HOUR CARE UNIT The 24-Hour unit is a centralized authorization unit for placement of individuals into all county contracted residential programs such as IMD s, Skilled Nursing Facilities (SNF), State Hospitals and Supplemental Services (Board & Care Homes) The team facilitates appropriate transitions and placements for individual returning into the community from acute services or other locked facilities The team serves as a liaison by providing consultation, coordination and collaboration for discharge and placement of individuals in and out of acute hospitals Santa Clara Valley Health & Hospital System

5 BARRIERS TO DISCHARGE FROM THE HOSPITAL & COMMUNITY TB resistant drug therapy, undocumented, & Homeless-DOT Conservatorship Process: 3-4 Months or longer People with Cognitive & Behavioral Issues requiring Long Term Placement People meeting minimal requirements for Custodial Level of Care, & may have no stable home environment for a safe discharge Santa Clara Valley Health & Hospital System

6 BARRIERS (CONT.) Medical Respite candidate & needs to ambulate 450 Ft or be totally independent in a wheelchair, do their own ADLs, will not be able to discharge to Medical Respite at discharge from SNF Bariatric, New Tracheostomies, Ventilator Dependent, Patients Undergoing Chemotherapy & Radiation People on parole, homeless Managed Plans do not have contracts with Long Term Acute Hospitals (LTACs) & limited Subacute SNF contracts Santa Clara Valley Health & Hospital System

7 BARRIERS (CONT.) Limited SNFs, RCFEs, & IMDs that take people with Mental Illness Issues & Substance Abuse Goals of Care & Advance Directives, Hospice House(s) Payment to SNFs & Home Health-challenges with insurance payment Custodial Level of Care Residents, Homeless, with only SSI/SSP income to pay for RCFE-all RCFEs that would take that payment closed because of the cost of housing in Santa Clara County Challenges obtaining Home Health for MediCAL beneficiaries Santa Clara Valley Health & Hospital System

8 MULTIDISCIPLINARY ROUNDS STOP LIGHT Santa Clara Valley Health & Hospital System

9 Total patient days by month SANTA CLARA VALLEY MEDICAL CENTER NON-ACUTE VS. ACUTE DAYS JULY 2014 JULY % % 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0 July Aug Sept Oct Nov Dec Jan Feb Mar April May June PD-FY15* PD-FY16* PD-FY17* 6510 FY15 - % of Non-acute Days** 4.64% 9.62% 9.81% 11.21% 10.15% 8.49% 10.26% 14.62% 16.94% 15.68% 14.23% 11.27% FY16 - % of Non-acute Days 8.92% 9.08% 10.13% 9.75% 10.86% 12.39% 14.22% 13.84% 13.86% 12.66% 8.51% 9.65% FY17 - % Non-Acute Days 11.87% FY17 Goal (25% reduction of FY15 rate) 3.48% 7.21% 7.36% 8.41% 7.61% 6.37% 7.69% 10.96% 12.70% 11.76% 10.67% 8.45% 0.00% Santa Clara Valley Health & Hospital System

10 Total BAP Patient Days by Month SCVMC BARBARA ARONS PAVILION 2016 INPATIENT PSYCHIATRIC SERVICES Jan Feb Mar Apr May Jun Jul Admin Days Acute Days Denied Days Santa Clara Valley Health & Hospital System

11 % of Requests for Transfer Accepted Average Daily Census by Month SANTA CLARA VALLEY MEDICAL CENTER REPATRIATION RATE JULY 2014 JULY % % 70% 60% % % % 20% 10% % 300 Repatriation Rate Average Daily Census Linear (Repatriation Rate) Santa Clara Valley Health & Hospital System

12 Challenges With The Homeless & Coordinated Efforts At SCVMC Reminders: Cal MediConnect Demonstration Project County: Santa Clara Family Health Plan & Blue Cross Anthem of the Medicare/MediCAL clients, & On Lok Santa Clara County Has Been Granted A MediCAL Waiver Program which supplements funding for people on SSI/SSP to transition to RCFEs from SNFs & the community. HHS SCVMC is partnering with the Institute On Aging In VMC ED placing people directly in to Skilled Nursing Facilities if they do not require acute care Santa Clara Valley Health & Hospital System

13 CARE TRANSITIONS PROGRAMS Re-entry program along with the jail-obtaining insurance & securing housing & medical care Repatriation from prisons & other countries Medical Respite with future consideration shelter beds on floor for transition, lay-in beds Heart Failure & COPD Care Transition Teams Transitions of Care Pharmacy program that reduces the risk for readmission by providing discharge counseling to high-risk patients & streamlining inpatient hospital discharge process with outpatient medication plan SCVMC have case managers & SWs in the ambulatory clinics Santa Clara Valley Health & Hospital System

14 CARE TRANSITIONS PROGRAMS (C0NT.) 2 Transformation Teams: #1 started with SCVMC looking at reducing risk for readmission by focusing on high risk people with a follow-up with a Public Health Nurse. These people are referred by the inpatient team & the PHN connects the person to the appropriate community services, does medication reconciliation, & makes sure that the person keeps their follow up MD appointments Santa Clara Valley Health & Hospital System

15 CARE TRANSITIONS PROGRAMS (C0NT.) #2 Care Coordination & Transitions Program (CCTP) focus on people with dual diagnosis of chronic behavioral health & chronic medical condition(s) who are high utilizers & fall through the system cracks due to their complex medical needs through better team care coordination horizontally & stabilize people to function on their own. The ultimate goal of this program is to connect these people to the long-term, community-based services needed to optimize their health & well-being, as well as having a more logical utilization pattern with improved service Santa Clara Valley Health & Hospital System

16 LONG TERM SUPPORT SERVICES Our county has teams from HHS SCVMC & the Health Trust, along with other CBOs working on assessing care management & caregiver support throughout the county, discharge planning, & housing through the Long Term Support Services serving the disabled & people 65 years & older. VMC has hired a consultant to assess facilities needs over the next 10 years with the changing healthcare needs of SCC population as part of the facility assessment Caregiver Policy just launched 1/16 & Discharge Planning Policy proposed by CMS Santa Clara Valley Health & Hospital System

17 PAY FOR SUCCESS PROGRAMS #1 serving chronically homeless high utilizers of SCVHHS services to help people gain a greater understanding of where they can get support for their health & housing needs. This project is addressing the costliest chronically homeless individuals, working on increasing the stability of permanent supportive housing, & improving their health & wellbeing Santa Clara Valley Health & Hospital System

18 PAY FOR SUCCESS PROGRAMS (C0NT.) #2 new pay for success program Partners in Wellness has started to serve high-utilizers in SCC using EPS, inpatient behavioral health system, and acute inpatient services. The services will include: intensive case management, comprehensive behavioral health treatment, substance use treatment, and housing support. This will stabilize some of our most challenging clients in the community, reducing utilization in acute care settings, and reducing or avoiding costs to the HHS Later this year Behavioral Health is starting a mobile mental health crisis van, and crisis residential beds SCVMC works closely with Behavioral Health Case Coordinators because many of our people have dual diagnosis & have extremely complex CM needs Santa Clara Valley Health & Hospital System

19 24 HOUR CARE WORKFLOW WITH VMC CARE MANAGEMENT Santa Clara Valley Health & Hospital System

20 REACHING OUT TO THE COMMUNITY Director of Medical Social Work & I have made site visits to several Community Health Clinics, local skilled nursing facilities, & continue to visit more Hospital to Home-working with CBOs Institute on Aging implemented the Community Living Connection (CLC) program, in partnership with SCC s Dept of Aging & Adult Services, Santa Clara Family Health Plan, & SCVMC. CLC is an intensive CM model geared toward supporting our County s highest risk & poorest older adults & adults with disabilities so that they can live independently in the community Santa Clara Valley Health & Hospital System

21 REACHING OUT TO THE COMMUNITY (CONT.) Site visits to 18 SNFs including subacutes & psych facilities. We also have partnered with our local SNFs (13+) using the Interact 4 program to prevent readmissions & plan to expand this partnership with home health, hospice, & assisted livings in the county plus invite the other hospitals in our county participate in our work group. Dr. Albert Lam from the Palo Alto Medical Foundation has received a CALTCM s Interact grant to help support the SNFs on the Interact journey both at the facility level & also telephonically for the SNFs caring for the SCFHP Cal MediConnect residents and others Santa Clara Valley Health & Hospital System

22 REACHING OUT TO THE COMMUNITY (CONT.) SCVMC has been working with the insurance companies & the SNFs to promote smooth transitions of care, especially around authorizations for SNF LOC, patient s needs in the SNF, & at discharge from SNF to obtain home health & DME needed for residents to transition back into the community SCVMC has purchased beds with Skyline Health Care Center for our uninsured patients who require short term rehab, & board & care beds at Mag s Rest Home in Newark, CA, also working on a contract for Home Health services for the uninsured Santa Clara Valley Health & Hospital System

23 REACHING OUT TO THE COMMUNITY (CONT.) Alzheimer s Friendly Community Working with Dr. Steinke at Skyline to have a hospitalist/resident make site visits to better understand SNFs & good handoffs Housing, dementia care, & mental health/substance abuse are some of our biggest challenges in Santa Clara County. I mention dementia separate from psychiatric illness because dementia is a medical diagnosis treated by medical doctors rather than psychiatrist. Dementia is growing in our population & we don t have enough services for the future to support that population Santa Clara Valley Health & Hospital System

24 Thank you for inviting us! Questions? Santa Clara Valley Health & Hospital System

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