Coordination of Care Community Scorecard

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Coordination of Care Community Scorecard July 01, 2014 through June 30, 2018 West Metro Community Report Date: 01/10/2019 This material was prepared by the Lake Superior Quality Innovation Network - Quality Improvement Organization (QIN-QIO) 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. 11SOW

Table of Contents Section Introduction West Metro Community Map Page 1 2 Quarterly admissions and readmissions Figure 1.1: Observed admissions per 1,000 3 Figure 1.2: Observed readmissions per 1,000 4 Table 1.1: Quarterly Admissions and Readmissions for West Metro 5 Table 1.2: Quarterly Admissions and Readmissions for State 6 Table 1.3: Quarterly Admissions and Readmissions for Nation 7 Quarterly Emergency Department, Observation Stays, and Inpatient Admissions Figure 2.1: Emergency Department visits per 1,000 8 Figure 2.2: Observation stays per 1,000 9 Figure 2.3: Combined ED visits, observation stays, and inpatient visits for West Metro 10 Table 2.1: Quarterly Emergency Department, Observation Stays, and Inpatient Admissions for West Metro 11 Table 2.2: Quarterly Emergency Department, Observation Stays, and Inpatient Admissions for State 12 Table 2.3: Quarterly Emergency Department, Observation Stays, and Inpatient Admissions for Nation 13 Other Community Measures Figure 3.1: Days Spent by Fee For Service (FFS) Beneficiaries in Institutional Settings 14

Readmission Rate Page 1 Introduction The Coordination of Care Community Scorecard is a report designed to help communities monitor and evaluate their progress in reducing admissions and readmissions, and improving quality of care. The Scorecard is based on the most recent available community data from CMS and quality measures data from communities. This report has been prepared by the Lake Superior Quality Innovation Network's analytical team. Metrics in the Scorecard The Scorecard is divided into different sections displaying trends in admissions and readmissions metrics. It also includes emergency department visit and observation stay metrics, and admission and readmission metrics pertaining to post-acute care settings. All metrics are reported for quarterly time periods from the most recent available data from CMS. Graphs The graphs in the Scorecard display observed metrics and trends (unless otherwise noted) for the following cohort designations: National: All Medicare fee-for-service (FFS) residing in any valid zip code in the 50 states, District of Columbia, Puerto Rico, and the United States (U.S.) Virgin Islands State: All Medicare FFS residing in any valid zip code in Minnesota Community: All Medicare FFS residing in the zip codes associated with the West Metro Community Community Readmission Rate Comparison (year ending 6/30/2017 vs 6/30/2018) 25.0% 20.0% 15.0% 10.0% 7/1/2016-6/30/2017 7/1/2017-6/30/2018 5.0% 0.0% Central MN Cuyuna/ Riverwood/ Mille Lacs Area East Metro Fargo/ NW MN Area Mora Area North Central MN North East MN Ridgeview Area South Central MN West Metro State Nation

Page 2

Q3 2014 Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 2015 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 Q3 2017 Q4 2017 Q1 2018 Q2 2018 Page 3 Figure 1.1: Observed admissions per 1,000 Number of hospitalizations among eligible Medicare FFS per 1,000 eligible Medicare FFS residing in the zip codes associated with the designated cohort. Figure 1.1 displays a graph of admissions per 1,000, by quarter, for the Medicare FFS residing in the zip codes associated with the designated cohort. The time periods are denoted by quarter number and year (e.g., Q1 2010). 80.00 Quarterly observed admissions per 1,000 Medicare FFS 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00 Community admissions per 1,000 National admissions per 1,000 State admissions per 1,000 Linear (Community admissions per 1,000 )

Q3 2014 Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 2015 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 Q3 2017 Q4 2017 Q1 2018 Q2 2018 Page 4 Figure 1.2: Observed readmissions per 1,000 Number of readmissions within 30 days of hospital discharge among eligible Medicare FFS per 1,000 eligible Medicare FFS residing in the zip codes associated with the designated cohort. Figure 1.2 displays a graph of readmissions per 1,000, by quarter, for the Medicare FFS residing in the zip codes associated with the designated cohort. The time periods are denoted by quarter number and year (e.g., Q1 2010). 16.00 Quarterly observed readmissions per 1,000 Medicare FFS 14.00 12.00 10.00 8.00 6.00 4.00 2.00 0.00 Community readmissions per 1,000 National readmissions per 1,000 State readmissions per 1,000 Linear (Community readmissions per 1,000 )

Page 5 Coordination of Care Table 1.1: Quarterly Admissions and Readmissions for West Metro Number of hospitalizations and readmissions among eligible Medicare FFS per 1,000 eligible Medicare FFS residing in the zip codes associated with the designated community. Overall timeframe included: Q3 2014 - Q2 2018 Quarter Admissions Readmissions Eligible Community admissions per 1,000 Observed Community readmissions per 1,000 Observed Readmission percent (Observed readmissions / Discharges) Q3 2014 7,883 1,414 115,477 68.26 12.24 18.4% Q4 2014 7,818 1,432 115,982 67.41 12.35 18.9% Q1 2015 7,992 1,417 114,431 69.84 12.38 18.3% Q2 2015 7,822 1,468 114,881 68.09 12.78 19.3% Q3 2015 7,554 1,423 115,388 65.47 12.33 19.4% Q4 2015 7,626 1,383 115,791 65.86 11.94 18.6% Q1 2016 7,871 1,512 114,226 68.15 13.09 19.8% Q2 2016 7,631 1,426 114,904 66.41 12.41 19.2% Q3 2016 7,485 1,461 115,468 64.82 12.65 20.0% Q4 2016 7,731 1,468 115,827 66.75 12.67 19.5% Q1 2017 7,964 1,540 113,086 70.42 13.62 19.9% Q2 2017 7,518 1,404 113,363 66.32 12.38 19.2% Q3 2017 7,359 1,429 113,917 64.60 12.54 19.9% Q4 2017 7,433 1,385 114,528 64.90 12.09 19.2% Q1 2018 7,714 1,415 113,200 68.14 12.50 18.9% Q2 2018 7,477 1,396 113,924 65.63 12.25 19.1%

Page 6 Coordination of Care Table 1.2: Quarterly Admissions and Readmissions for State Number of hospitalizations and readmissions among eligible Medicare FFS per 1,000 eligible Medicare FFS residing in the state. Overall timeframe included: Q3 2014 - Q2 2018 Quarter Admissions Readmissions Eligible State admissions per 1,000 Observed State readmissions per 1,000 Observed Readmission percent (Observed readmissions / Discharges) Q3 2014 27,363 4,610 427,852 63.95 10.77 17.3% Q4 2014 27,705 4,675 428,769 64.62 10.90 17.4% Q1 2015 28,257 4,825 419,746 67.32 11.50 17.6% Q2 2015 27,153 4,675 420,661 64.55 11.11 17.8% Q3 2015 26,341 4,621 421,804 62.45 10.96 18.1% Q4 2015 26,503 4,501 422,505 62.73 10.65 17.6% Q1 2016 26,922 4,656 414,961 64.17 11.10 17.9% Q2 2016 26,383 4,562 416,950 63.28 10.94 17.8% Q3 2016 25,570 4,493 418,019 61.17 10.75 18.1% Q4 2016 26,479 4,485 418,784 63.23 10.71 17.5% Q1 2017 27,672 4,799 410,585 67.40 11.69 17.9% Q2 2017 26,186 4,435 410,981 63.72 10.79 17.4% Q3 2017 25,471 4,518 412,409 61.76 10.96 18.2% Q4 2017 26,098 4,528 413,777 63.07 10.94 17.9% Q1 2018 27,538 4,706 409,870 67.19 11.48 17.7% Q2 2018 25,734 4,360 412,373 62.40 10.57 17.4%

Page 7 Coordination of Care Table 1.3: Quarterly Admissions and Readmissions for Nation Number of hospitalizations and readmissions among eligible Medicare FFS per 1,000 eligible Medicare FFS nationwide. Overall timeframe included: Q3 2014 - Q2 2018 Quarter Admissions Readmissions Eligible National admissions per 1,000 Observed National readmissions per 1,000 Observed Readmission percent (Observed readmissions / Discharges) Q3 2014 2,532,716 460,753 37,315,969 67.87 12.35 18.8% Q4 2014 2,593,871 468,559 37,483,659 69.20 12.50 18.7% Q1 2015 2,701,838 483,125 37,223,128 72.58 12.98 18.5% Q2 2015 2,594,653 467,920 37,374,982 69.42 12.52 18.6% Q3 2015 2,508,158 454,294 37,564,649 66.77 12.09 18.7% Q4 2015 2,533,664 453,528 37,775,085 67.07 12.01 18.5% Q1 2016 2,653,807 475,040 37,767,574 69.49 12.44 18.5% Q2 2016 2,565,399 457,880 37,980,288 67.55 12.06 18.4% Q3 2016 2,504,185 454,720 38,196,258 65.56 11.90 18.7% Q4 2016 2,550,751 458,113 38,400,933 66.42 11.93 18.6% Q1 2017 2,695,102 483,460 37,867,500 71.17 12.77 18.6% Q2 2017 2,550,270 459,223 38,034,986 67.05 12.07 18.6% Q3 2017 2,468,052 448,083 38,249,423 64.53 11.71 18.7% Q4 2017 2,529,743 456,432 38,441,428 65.81 11.87 18.6% Q1 2018 2,628,556 468,818 37,823,677 69.49 12.39 18.5% Q2 2018 2,434,960 429,025 37,901,103 64.25 11.32 18.1%

Q3 2014 Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 2015 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 Q3 2017 Q4 2017 Q1 2018 Q2 2018 Page 8 Figure 2.1: Emergency Department visits per 1,000 Number of ED visits among eligible Medicare FFS residing in the zip codes associated with the designated cohort Figure 2.1 displays a graph of Emergency Department (ED), by quarter, for the Medicare FFS residing in the zip codes associated with the designated cohort. The time periods are denoted by quarter number and year (e.g., Q1 2010). 120.00 Quarterly emergency department visits per 1,000 Medicare FFS 100.00 80.00 60.00 40.00 20.00 0.00 Community State National Linear (Community)

Q3 2014 Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 2015 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 Q3 2017 Q4 2017 Q1 2018 Q2 2018 Page 9 Figure 2.2: Observation stays per 1,000 Number of observation stays among eligible Medicare FFS residing in the zip codes associated with the designated cohort. Figure 2.2 displays a graph of Emergency Department (ED), by quarter, for the Medicare FFS residing in the zip codes associated with the designated cohort. The time periods are denoted by quarter number and year (e.g., Q1 2010). 18.00 Quarterly observation stays per 1,000 Medicare FFS 16.00 14.00 12.00 10.00 8.00 6.00 4.00 2.00 0.00 Community State National Linear (Community)

Q3 2014 Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 2015 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 Q3 2017 Q4 2017 Q1 2018 Q2 2018 Encounters per 1,000 Page 10 Figure 2.3: Combined ED visits, observation stays, and inpatient visits for West Metro Number of Emergency Department (ED) visits, observation stays, and inpatient visits among eligible Medicare FFS residing in the zip codes associated with the community. Figure 2.3 displays a graph of ED, Observation stays, and Inpatient visits, by quarter, for the Medicare FFS residing in the zip codes associated with the designated community. The time periods are denoted by quarter number and year (e.g., Q1 2010). 120.00 Quarterly Emergency Department, Observation Stays, and Inpatient Admissions for community 100.00 80.00 60.00 40.00 20.00 0.00 Emergency Department Observation Inpatient Linear (Emergency Department)

Page 11 Coordination of Care Table 2.1: Quarterly Emergency Department, Observation Stays, and Inpatient Admissions for West Metro Number of ED visits, observation stays, and inpatient visits among eligible Medicare FFS residing in the zip codes associated with the designated community. Overall timeframe: Q3 2014 - Q2 2018 Emergency Department Observation Inpatient Quarter Eligible Q3 2014 115,477 12,086 104.66 1,713 14.83 7,883 68.26 Q4 2014 115,982 11,405 98.33 1,730 14.92 7,818 67.41 Q1 2015 114,431 10,849 94.81 1,847 16.14 7,992 69.84 Q2 2015 114,881 11,306 98.41 1,852 16.12 7,822 68.09 Q3 2015 115,388 12,248 106.15 1,892 16.40 7,554 65.47 Q4 2015 115,791 11,479 99.14 1,796 15.51 7,626 65.86 Q1 2016 114,226 11,331 98.11 1,851 16.03 7,871 68.15 Q2 2016 114,904 11,566 100.66 1,844 16.05 7,631 66.41 Q3 2016 115,468 12,551 108.70 1,737 15.04 7,485 64.82 Q4 2016 115,827 11,438 98.75 1,720 14.85 7,731 66.75 Q1 2017 113,086 11,299 99.92 1,758 15.55 7,964 70.42 Q2 2017 113,363 11,454 101.04 1,649 14.55 7,518 66.32 Q3 2017 113,917 11,929 104.72 1,664 14.61 7,359 64.60 Q4 2017 114,528 10,915 95.30 1,635 14.28 7,433 64.90 Q1 2018 113,200 10,679 94.34 1,621 14.32 7,714 68.14 Q2 2018 113,924 10,760 94.45 1,502 13.18 7,477 65.63 Community

Page 12 Coordination of Care Table 2.2: Quarterly Emergency Department, Observation Stays, and Inpatient Admissions for State Number of ED visits, observation stays, and inpatient visits among eligible Medicare FFS residing in the state. Overall timeframe: Q3 2014 - Q2 2018 Emergency Department Observation Inpatient Quarter Eligible Q3 2014 427,852 47,347 110.66 5,697 13.32 27,363 63.95 Q4 2014 428,769 44,633 104.10 5,727 13.36 27,705 64.62 Q1 2015 419,746 42,920 102.25 5,871 13.99 28,257 67.32 Q2 2015 420,661 45,111 107.24 5,823 13.84 27,153 64.55 Q3 2015 421,804 47,333 112.22 6,056 14.36 26,341 62.45 Q4 2015 422,505 43,807 103.68 5,854 13.86 26,503 62.73 Q1 2016 414,961 43,845 104.50 5,977 14.25 26,922 64.17 Q2 2016 416,950 45,537 109.21 5,924 14.21 26,383 63.28 Q3 2016 418,019 47,734 114.19 5,618 13.44 25,570 61.17 Q4 2016 418,784 43,996 105.06 5,358 12.79 26,479 63.23 Q1 2017 410,585 43,766 106.59 5,628 13.71 27,672 67.40 Q2 2017 410,981 44,427 108.10 5,317 12.94 26,186 63.72 Q3 2017 412,409 45,386 110.05 5,265 12.77 25,471 61.76 Q4 2017 413,777 42,675 103.14 5,277 12.75 26,098 63.07 Q1 2018 409,870 42,375 103.39 5,098 12.44 27,538 67.19 Q2 2018 412,373 42,505 103.07 4,984 12.09 25,734 62.40 State

Page 13 Coordination of Care Table 2.3: Quarterly Emergency Department, Observation Stays, and Inpatient Admissions for Nation Number of ED visits, observation stays, and inpatient visits among all eligible Medicare FFS nationwide. Overall timeframe: Q3 2014 - Q2 2018 Emergency Department Observation Inpatient Quarter Eligible Q3 2014 37,315,969 3,786,247 101.46 517,487 13.87 2,532,716 67.87 Q4 2014 37,483,659 3,652,106 97.43 510,208 13.61 2,593,871 69.20 Q1 2015 37,223,128 3,594,786 96.57 500,644 13.45 2,701,838 72.58 Q2 2015 37,374,982 3,777,882 101.08 522,141 13.97 2,594,653 69.42 Q3 2015 37,564,649 3,865,795 102.91 533,707 14.21 2,508,158 66.77 Q4 2015 37,775,085 3,684,805 97.55 520,266 13.77 2,533,664 67.07 Q1 2016 37,767,574 3,704,371 97.01 537,551 14.08 2,653,807 69.49 Q2 2016 37,980,288 3,818,346 100.53 545,133 14.35 2,565,399 67.55 Q3 2016 38,196,258 3,898,442 102.06 540,245 14.14 2,504,185 65.56 Q4 2016 38,400,933 3,743,448 97.48 532,145 13.86 2,550,751 66.42 Q1 2017 37,867,500 3,731,970 98.55 534,051 14.10 2,695,102 71.17 Q2 2017 38,034,986 3,788,117 99.60 530,690 13.95 2,550,270 67.05 Q3 2017 38,249,423 3,856,992 100.84 530,862 13.88 2,468,052 64.53 Q4 2017 38,441,428 3,716,781 96.69 524,724 13.65 2,529,743 65.81 Q1 2018 37,823,677 3,614,573 95.56 511,045 13.51 2,628,556 69.49 Q2 2018 37,901,103 3,573,758 94.29 509,133 13.43 2,434,960 64.25 National

Average Days per Beneficiary Days Spent by Fee For Service (FFS) Beneficiaries in Institutional Settings (07/01/17-06/30/18) 30.00 25.00 Community Tenure (higher is better): Nation: 93.35% MN: 94.05% West Metro: 94.18% 20.00 15.00 10.00 5.00 0.00 Short-Term Hospital LTACHs Psych Units & Hospitals Rehab Units & Hospitals SNFs & Swing Beds Total Institutional Days Nation 7.39 0.40 0.82 0.66 15.02 24.28 State 6.96 0.18 0.79 0.21 13.56 21.70 West Metro 7.16 0.26 1.05 0.20 12.60 21.25

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