August 2, 2018 NOTICE

August 2, 2018 NOTICE The Board of Directors of the Kaweah Delta Health Care District will meet in an open Quality Council Committee meeting at 7:00AM on Thursday August 9, 2018, in the Kaweah Delta Medical Center Acequia Wing Executive Office Conference Room {400 W. Mineral King, Visalia}. The Board of Directors of the Kaweah Delta Health Care District will meet in a Closed Quality Council Committee meeting immediately following the 7:00AM Open Quality Council Committee meeting on Thursday August 9, 2018, in the Kaweah Delta Medical Center Acequia Wing Executive Office Conference Room {400 W. Mineral King, Visalia} pursuant to Health and Safety Code 32155 & 1461. All Kaweah Delta Health Care District regular board meeting and committee meeting notices and agendas are posted 72 hours prior to meetings in the Kaweah Delta Medical Center, Mineral King Wing entry corridor between the Mineral King lobby and the Emergency Department waiting room. The disclosable public records related to agendas are available for public inspection at the Kaweah Delta Medical Center Acequia Wing, Executive Offices (Administration Department) {1st floor}, 400 West Mineral King Avenue, Visalia, CA and on the Kaweah Delta Health Care District web page http://www.kaweahdelta.org. KAWEAH DELTA HEALTH CARE DISTRICT Nevin House, Secretary/Treasurer Cindy Moccio Board Clerk, Executive Assistant to CEO DISTRIBUTION: Governing Board Legal Counsel Executive Team Chief of Staff http://www.kaweahdelta.org/ 400 West Mineral King Avenue Visalia, CA (559) 624 2000 www.kaweahdelta.org

KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS QUALITY COUNCIL Thursday, August 9, 2018 Kaweah Delta Medical Center Acequia Wing 400 W. Mineral King Avenue, Visalia, CA Executive Conference Room ATTENDING: Herb Hawkins Committee Chair, Board Member; Nevin House, Board Member; Gary Herbst, CEO; Regina Sawyer, RN, VP & CNO; Edward Hirsch, MD, CMO/CQO; Harry Lively, MD, Chief of Staff; Byron Mendenhall, MD, Professional Staff Quality Committee Chair; Monica Manga, MD, Secretary/Treasurer; Dan Boken, MD, Past Chief of Staff; Lori Winston, MD, DIO; Tom Gray, MD, Quality and Patient Safety Medical Director; Sandy Volchko, Director of Quality and Patient Safety; Evelyn McEntire, Director of Risk Management; Ben Cripps, Compliance Officer, Rose Newsom, Director of Nursing Practice; and Heather Goyer, Recording OPEN MEETING 7:00AM Call to order Herb Hawkins, Committee Chair & Board Member Public / Medical Staff participation Members of the public wishing to address the Committee concerning items not on the agenda and within the subject matter jurisdiction of the Committee may step forward and are requested to identify themselves at this time. Members of the public or the medical staff may comment on agenda items after the item has been discussed by the Committee but before a Committee recommendation is decided. In either case, each speaker will be allowed five minutes. 1. Readmissions and Transitions of Care A report of current Kaweah Delta initiatives focused on reducing readmissions through improved transitions of care - Ryan Gates, PharmD, Director of Population Health. 2. Fiscal Year 2018 Health Outcome Goals - Status Update of Kaweah Delta performance on clinical quality goals - Sandy Volchko, RN, Director of Quality and Patient Safety 3. Approval of Quality Council Closed Meeting Agenda Kaweah Delta Medical Center Executive Conference Room immediately following the open Quality Council meeting o Quality Assurance pursuant to Health and Safety Code 32155 and 1461, report of Professional Staff Quality Committee (Pro-Staff) Byron Mendenhall, MD, and Professional Staff Quality Committee Chair; o Quality Assurance pursuant to Health and Safety Code 32155 and 1461, report of Professional Staff Quality Committee (Pro-Staff) Evelyn McEntire, Director of Risk Management. Adjourn Open Meeting Herb Hawkins, Committee Chair & Board Member Thursday, August 9, 2018 Quality Council Page 1 of 2 Herb Hawkins Zone I Lynn Havard Mirviss Zone II John Hipskind, MD Zone III David Francis Zone IV Nevin House Zone V Board Member President Vice President Board Member Secretary/Treasurer

CLOSED MEETING Immediately following the 7:00AM open meeting Call to order Herb Hawkins, Committee Chair & Board Member 1. Quality Assurance pursuant to Health and Safety Code 32155 and 1461, report of Professional Staff Quality Committee (Pro-Staff) Byron Mendenhall, MD, and Professional Staff Quality Committee Chair 2. Quality Assurance pursuant to Health and Safety Code 32155 and 1461, report of Professional Staff Quality Committee (Pro-Staff) Evelyn McEntire, Director of Risk Management. Adjourn Herb Hawkins, Committee Chair & Board Member In compliance with the Americans with Disabilities Act, if you need special assistance to participate at this meeting, please contact the Board Clerk (559) 624-2330. Notification 48 hours prior to the meeting will enable the District to make reasonable arrangements to ensure accessibility to the Kaweah Delta Health Care District Board of Directors committee meeting. Thursday, August 9, 2018 Quality Council Page 2 of 2 Herb Hawkins Zone I Lynn Havard Mirviss Zone II John Hipskind, MD Zone III David Francis Zone IV Nevin House Zone V Board Member President Vice President Board Member Secretary/Treasurer

READMISSIONS: PRIME Project 2.2 - Transitions of Care, CMS Readmission Reduction Program & Human Medicare and the Virtual Care Team Ryan Gates, PharmD, CDE, Director of Population Health Management Kaweah Delta VP of Clinical Integration Sequoia Integrated Health Keri Noeske, DNP Director of Care Management Kaweah Delta Pro Staff Committee June 21, 2018

PRIME Project: Impact of Readmissions Public hospital Redesign and Incentives in Medicaid 7 Projects: 2.2 Transitions of Care = focus of today 42 Metrics $80,000,000 over 5 years (FY15-20) Pay for Performance (FY 18-20) 30-Day Readmissions and PQI#90 Admissions = 4 metrics $1.4 Million/Year = $7 million over life of PRIME Project

Overview of Inpatient TOC Process PRIME Pt Admitted to KD - DC Adv: Performs Risk-Assessment via modified LACE in MIDAS - Clinical Pharmacy Team: Flag patient as High-Risk High-Risk Humana Medicare Patient - DC Adv: Notifies VCT via MIDAS alert and removes patient from their workflow - Inpatient Pharmacist: Performs medication reconciliation - Outpatient Pharmacy: Meds-to-Beds Delivery attempted - See separate workflow Patient has PCP High-Risk Patient - Inpatient Pharmacist: Performs medication reconciliation - Outpatient Pharmacy: Meds-to-Beds Delivery attempted - DC Adv: Educates patient at the bedside of Hospital-2-Home program No established PCP FHCN - DC Adv: Call FHCN carecoordinator and schedule patient with PCP - Offer CDMC if apt > 5 days - Refer only if FHCN agrees Post-Discharge - DC Adv: Calls patient at ~ days 3/7/10 - Refer to CDMC if: - If no-show to PCP - If signs/symptoms of decompensation or exacerbation - DC Adv: schedules apt with PCP for NAD - If apt < 5 days = no CDMC referral - If apt > 6 days - Notify PCP pt will be followed by H2H until established with PCP - Refer to CDMC via CPOE - DC Adv: Reinforces Hospita-2-Home service - Pt to expect calls at ~ days 3/7/10 - If referred, pt to expect call from CDMC CDMC Referral (PCP apt > 5 days) No CDMC Referral (PCP apt > 6 days) - DC Adv: Refer to CDMC via CPOE - DC Adv: Reinforces Hospita-2-Home service - Pt to expect calls at ~ days 3/7/10 - Pt to expect call from CDMC CDMC Apt Kept CDMC No-Show CDMC Apt Kept - CDMC: Ensure safe transition to PCP CDMC No-Show - CDMC: Notify CHW for home-visit - CDMC: - Establish with PCP - Manage until established with PCP - CDMC: Notify CHW for home-visit

CMS Readmission Reduction Program (RRP) CMS RRP Program: Penalties started 2013 6 DRGs: o HF, AMI, CABG, PNA, COPD, TKA/THA 30-Day Readmission Benchmark set for each DRG o Each DRG 30-Day Readmission Rate contributes to Hospital Penalty RRP Penalty applied to hospital s Inpatient Prospective Payment System rate for ALL CMS Part A charges

All-Cause 30-Day Readmissions by Region Q1-Q4 2017 Kaweah Delta 17.7%

CMS Readmission Penalties of Central Valley Hospitals FY13 through FY 17 1.2 CMS Penalty (% of Medicare Charges) 1 0.8 0.6 0.4 0.2 0 0.18 0.12 0.08 0.02 0 FY13 FY14 FY15 FY16 FY17 Kaweah Delta CRMC Adv. Hanford Sierra View Tulare Kaiser - Fresno St. Agnes Kern Medical

CMS Readmission Penalties Incurred by Kaweah Delta KD Gross Medicare Part- A Charges CMS % Penalty CMS $ Penalty Total Possible CMS Penalty (3%) FY13 $62,386,440-0.02% $10,305 $1,871,593 FY14 $69,318,267-0.18% $96,874 $2,079,548 FY15 $72,966,597 0.00% $27,874 $2,188,998 FY16 $82,008,166-0.08% $50,635 $2,460,245 FY17 $81,230,900-0.12% $73,604 $2,436,927 YTD $259,292 $11,037,311

30-Day All-Cause Readmission Rates Q1 2017 Q4 2017 19.5 All-Cause 30-Day Readmission Rate 19 19 Readmission Rate (%) 18.5 18 17.5 17 16.5 16 17.9 17.7 16.7 17.8 17.8 17.5 18.3 17.9 17.9 17.6 17.5 18.4 18 17.7 16.6 Kaweah Delta Region 10 California Nation 15.5 15 Baseline CY 2013 Q1 2017 Q2 2017 Q3 2017 Q4 2017

CMS Readmission Penalties Incurred by Kaweah Delta by Condition FY17 Condition Eligible Discharges Estimated Impact % of Impact Acute Myocardial Infarction (AMI) 531 $0 0.00% Heart Failure (HF) 783 $0 0.00% Pneumonia (PN) 1,298 $0 0.00% Total Hip/Total Knee Arthroplasty (THA/TKA) 493 $12,012 16.32% Chronic Obstructive Pulmonary Disease (COPD) 500 $61,592 83.68% Coronary Artery Bypass Graft (CABG) 168 $0 0.00%

30-Day Readmission Rates by Condition Q2 2015 Q4 2017

30-Day Readmission Rates by Condition Q2 2015 Q4 2017

Discharge Distribution after Inpatient Hospitalization for All-Causes Q1 2017 Q4 2017

Top 10 Readmission DRGs for Kaweah Delta Q1 2017 Q4 2017

Humana Medicare VCT Impact on Readmissions Pro Staff Committee August 1, 2018 Ryan Gates, PharmD, CDE, Director of Population Health Management Kaweah Delta VP of Clinical Integration Sequoia Integrated Health Keri Noeske, DNP Director of Care Management Kaweah Delta

Sequoia Integrated Health & Humana CMS Humana Sequoia Integrated Health Part A Kaweah Delta Part D Shared Risk Part B Key Medical Group

Virtual Care Team Clinical Department Staff: Key Medical Group Team Members Medical Director Registered Nurse Case Managers Social Workers (MSW s) Health Coaches Inpatient Case-Managers Department Assistants KDHCD Team Members Clinical Pharmacists Pharmacy Technicians What the VCT assists with: Care Coordination Referrals/Authorizations Medical needs Pharmaceutical needs Social needs (transportation, meals, shelter)

Virtual Care Team Inpatient and Outpatient Activities Inpatient VCT Daily team rounds (Mon-Friday) All admitted patients reviewed by dedicated Team Physician Clinical Pharmacists Case-Management Social-Worker Facilitate care, discharge and transitions Member and family interaction Coordination with PCP and Hospitalist Outpatient VCT Weekly team rounds Case-discussions of high-risk patients Whole Person Care: Medical, social, behavior, mental, access issues resolved Health Coaches and Social workers report on member interactions and concerns Daily HF Scale Monitoring/Outreach Pharmacists address Rx issues Coordination with PCP 17

Humana Medicare Readmission Rates 20.00% 15.00% 10.00% 5.00% 18.38% 30 Day Readmission Rate Total Readmissions Kaweah Delta 17.7% 16.09% 14.57% 0.00% 2015 Annual 2016 Annual 2017 Annual Total 30 Day Readmission Rate Linear (Total 30 Day Readmission Rate) 20.00% 18.00% 16.00% 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% Gold Readmission Rate 17.37% 14.10% 13.42% 2015 Annual 2016 Annual 2017 Annual 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% D-SNP 30 Day Readmissions 29.85% 27.93% 20.00% 2015 Annual 2016 Annual 2017 Annual D-SNP 30 Day Readmissions Gold Readmission Rate Linear (Gold Readmission Rate) Linear (D-SNP 30 Day Readmissions)

Humana Medicare PQI#90 Potentially Avoidable Admissions 12.0 10.0 Admits per 1000 8.0 6.0 4.0 COPD Diabetes Heart Failure UTI Dehydration Bacterial Pneumonia Hypertension 2.0 0.0 2016 2017 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

FY 2018 Kaweah Care Goals July 11, 2018

Kaweah Delta Health Care District For the Three Months Ended 3/1/18 Health Outcomes CAUTI Clostridium Diff. SSI Colon 7/1/2017 12/31/2017 1/1/2018 3/31/2018 7/1/17-3/31/18 Goal Target Hospital Acquired Infections (1) 0.945 0.331 0.733 <=0.517 (30.0%) 1.021 0.679 0.887 <=0.924 50 th P 0.89 0 (no SIR) 0.779 <=0.438 (30.0%) SSI Hysterectomy 1 Case (No SIR ) 0 (no SIR) 1 Case (No SIR ) <=0.762 50 th P Terms: CAUTI Catheter Associated Urinary Tract Infection SSI Surgical Site Infection SIR Standardized Infection Ratio