Santa Clara Care Coordination Collaborative Meeting. Debra Nixon, PhD, MSHA, BSN Corporate Advisor Health Services Advisory Group (HSAG) June 8, 2018

Transcription

1 Santa Clara Care Coordination Collaborative Meeting Debra Nixon, PhD, MSHA, BSN Corporate Advisor Health Services Advisory Group (HSAG) June 8, 2018

2 You Are Here! Improving care coordination together with your peer providers Enriched with new learning Empowered with new resources Improving quality of care for our patients! 2

3 Santa Clara Care Coordination Collaborative 2018 Community Quarterly Meeting Schedule WHEN WHERE REGISTRATION REQUIRED Friday June 8, :30 a.m. 12 noon Silicon Valley Community Foundation 2440 West El Camino Real, Mountain View, CA Friday August 3, :30 a.m. 12 noon TBD Save the Date. Registration Coming Soon! Friday October 5, :30 a.m. 12 noon TBD Save the Date. Registration Coming Soon! 3

4 Community Introductions Who Is In The Room? 4

5 Today s Agenda Welcome and introductions Santa Clara readmission and high-risk medication (HRM) data update Community initiatives Sepsis Collaborative INTERACT Collaborative Nursing Home Reducing Readmission Preparation Program 7-day readmission focus and group activity Meeting summary, evaluation, and next steps 5

6 6 Thank you to our partners

7 Your Meeting Feedback Is Important! Please help us exceed the 85 percent target! 7

8 Santa Clara Community Readmission Data Updates

9 Spikes 9

10 Santa Clara Readmissions Relative Improvement Rate (RIR) 7.0% Santa Clara Readmissions RIR Goal: 6% RIR by Sept 30, % 5.0% 4.0% 3.0% 3.14% 3.76% 2.82% RIR 2.0% 1.0% 0.62% 0.04% 0.0% -0.90% -1.0% -1.71% -1.54% -2.0% -3.0% Q Q1 Q Q2 Q Q3 Q Q4 Q Q1 Q Q2 Q Q3 Q Q4 Q Q1 Q Q2 Q Q The number of beneficiaries for each community and the percentage of beneficiaries within the cohort are displayed next to the Santa Clara Coalition community name. 0.62% The data 3.14% source for the 3.76% beneficiary counts 2.82% is the NCC 0.04% Scorecard % -1.71% -1.54% (144,275; 14.3%) Goal Readmissions 2% 2% 2% 2% 6% 6% 10

11 How Far Is This Collaborative From Reaching the CMS 1 Readmission Improvement Target? Target RIR = 6% RIR Goal is to reach or exceed this target by September 2018 Avert 485 readmissions Centers for Medicare and Medicaid Services=CMS

12 How Do We Achieve a 6 Percent RIR? Avert 485 Readmissions in 4 months Avert 121 Readmissions per month Avert 30 Readmissions per week 12

13 Santa Clara All-Cause Readmission Rates by Setting Q Q Community Setting Discharged To 30-Day Readmission Rate Readmissions 30-Day Volume Discharges Santa Clara County Home 14.8% 1,727 11,670 Nursing Home 20.3% 1,438 7,077 Home Health 18.1% 923 5,086 Region Total 16.9% 5,616 33, Data files provided to Health Services Advisory Group (HSAG) by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries.

14 Santa Clara Readmission Rate by Condition Q Q Community Condition 30-Day Readmission Rate Readmissions 30-Day Volume Discharges AMI % HF % 376 1,536 Santa Clara County PNE % 300 1,713 COPD % CABG % THA/TKA 6 3.3% 39 1, Acute Myocardial Infarction=AMI 2. Heart Failure=HF 3. Pneumonia=PNE 4. Chronic Obstructive Pulmonary Disease=COPD 5. Coronary Artery Bypass Graft=CABG 6. Total Hip/Total Knee Arthroplasty=THA/TKA 14 Data files provided to Health Services Advisory Group (HSAG) by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries.

15 Santa Clara: All-Cause Readmissions to a Different Hospital January December 2017 WARNING: Average is 23.3% How does this impact your internally tracked readmission rates? What impact might be seen in the patient s experience and the cost and quality of care? 15 Source: Data files provided to Health Services Advisory Group (HSAG) by the Centers of Medicare and Medicaid Services (CMS) and include Part-A claims for Medicare Fee-For-Service beneficiaries.

16 Santa Clara HRMs: Readmission Rates

17 Engaging With Hospitals to Create and Implement Interventions to Reduce ADEs 1 Data reveal that some Santa Clara hospitals rank above the state average for high-risk readmission rates related to one or more of the three HRM classes: anticoagulants diabetic agents opioids Adverse drug events (ADEs)

18 Let s Talk About 7 Day Readmissions 18

19 Santa Clara All-Cause 7-Day Readmission Rate by Setting Q Q Community Setting Discharged To 30-Day Readmission Rate 7-Day Readmission Rate Santa Clara County Home 14.8% 35.1% Nursing Home 20.3% 33.9% Home Health 18.1% 38.9% Region Total 16.9% 37.2% 19 Data files provided to Health Services Advisory Group (HSAG) by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries.

20 Santa Clara: Readmission Rates by Condition Q Q Condition Santa Clara 30-Day Readmission Rate Santa Clara 7-Day Readmission Rate AMI 19.3% 41.2% HF 24.5% 27.7% PNE 17.5% 35.6% COPD 20.6% 33.4% CABG 14.3% 38.9% THA/TKA 3.3% 43.6% All-Cause 16.9% 36.1% 20 Data files provided to Health Services Advisory Group (HSAG) by the Centers of Medicare and Medicaid Services (CMS) and include Part-A claims for Medicare Fee-For-Service beneficiaries.

21 Why Are 7-Day Readmissions Happening? Potential Gaps 1. Poor patient self-management skills 2. Low health literacy 3. Neglecting chronic comorbid conditions 4. Inaccurate medication history/medication reconciliation 5. Unrecognized social determinants of health 6. Higher patient acuity management in the post-acute setting 7. Lack of timely follow-up calls and appointments after discharge 8. Lack of standardized discharge processes 21

22 Polling Question What is the reason for unnecessary readmissions? A. Poor patient self-management skills B. Low health literacy 18% C. Neglecting chronic comorbid 16% conditions 14% D. Inaccurate medication 12% history/medication reconciliation 10% 10% 8% E. Unrecognized social determinants of 6% health 4% 4% F. Higher patient acuity management in the post-acute setting G. Lack of timely follow-up calls and appointments after discharge H. Lack of standardized discharge processes I. Physician communication J. Patient/Family Expectations 22 Poor patient self-mana... Neglecting chronic como... Unrecognized social dete... Lack of timely follow-up c... Physician communication

23 Table Top Activity Identify the 4 5 top reasons for readmissions. Develop solutions for that challenge. Be specific and identify 4 5 tactics to implement that solution. Identify spokes person to report out results to the group. 23

24 Words to Remember Doing things the same way will NOT reduce readmissions. 24

25 Meeting Summary and Evaluations

26 Polling Question What Time of the Day is Best to Meet? A. 8 a.m. noon B. 9 a.m. 1 p.m. 37% 37% C. 10 a.m. 2 p.m. D. 1 4 p.m. 9% 15% E. 1 5 p.m. 8 a.m. noon 9 a.m. 1 p.m. 10 a.m. 2 p.m. 1 4 p.m. 2% 1 5 p.m. 26

27 Polling Question What Day of the Week is Best to Meet? A. Monday 65% B. Tuesday C. Wednesday D. Thursday 2% 7% 13% 13% E. Friday Monday Tuesday Wednesday Thursday Friday 27

28 Meeting Summary Connecting all the moving pieces 28

29 Your Meeting Feedback Is Important! Please help us exceed the 85 percent target! 29

30 Questions? 30

31 Thank You! Debra Nixon HSAG

32 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