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Community Collaboration WebinarSeptember 2, 2015
Lindsay Holland, MHA, BSBruce Spurlock, MDPat Teske, RN, MHA
Carrie Wong, MSW, MPH, LCSW
The Panelists
Bruce Spurlock, MDCynosure Health Solutions
Executive Director
Pat Teske, MHA RNCynosure Health Solutions
Implementation OfficerImprovement Advisor
Lindsay Holland, MHA, BSHealth Services Advisory Group (HSAG)
Clinical Project Manager
Carrie Wong, MSW, MPH, LCSWDepartment of Aging and Adult ServicesDirector of Long Term Care Operations
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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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 #
Agenda
Carrie Wong, Transitional Care Efforts and CCTP Demonstration Project
Lindsay Holland, Together We’re Better: Community Collaboration to Reduce Readmissions
Pat Teske, ARC
San Francisco:Transitional Care Efforts and CCTP Demonstration Project
Carrie Wong, MSW, MPH, LCSWDirector of Long-Term Care Operations San Francisco Department of Aging and Adult Services
Agenda
• CCTP Background• San Francisco Transitional Care Program• Challenges• Successes• Life after CCTP contract
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• 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 aims • to reduce preventative errors in hospitals by 40% and • reduce hospital readmissions by 20%
The Community-based Care Transitions Program (CCTP)
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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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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
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• 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
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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
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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
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
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How about you?
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273 Prevented Readmissions! (FY 13/14)
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CCTP Contract Ended. Now what?
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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
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Questions?
Carrie Wong, MSW, MPH, LCSWDirector of Long-Term Care Operations San Francisco Department of Aging and Adult ServicesCarrie.Wong@sfgov.org1 (415) 355-6748
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Together We’re Better: Community Collaboration to Reduce Readmissions
Lindsay Holland, MHAClinical Project Manager, Care Coordination
Health Services Advisory Group (HSAG)September 2, 2015
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.
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Why Care Coordination Matters
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Putting It All Together
Creative Commons/Pixabay. http://pixabay.com/en/connect-connection-cooperation-316638/34
California’s Progress: All-Cause, 30-Day Readmission Rate for Patients Discharged From a Hospital
35The 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.
CaliforniaNation
National Success in Reducing Readmissions in Communities Recognized by QIOs
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Strategies to Reduce Readmissions
1. Improve processes within settings.
2. Improve processes between settings.
How about you?
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Building Community Coalitions
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CMS Community Expectations
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SustainableCommunity
Engage community
partners
Create leadership structure
Develop coalition charter
Conduct root cause
analysis
Select interventions
Evaluate interventions
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.
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Community Success Story
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While Great Strides Have Been Accomplished…
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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/
Thank you!Health Services Advisory Group
quality@hsag.com818.409.9229
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
ARC’s Community Guide
Who we visited
Congregational Health Network
Washington County Coalition
What we learned
More learnings
Even more learnings
Other ideas we heard
Dare to be a
leader!
Be Transparent
Talk LessAct More
Identify strong
champions Celebrate
How about you?
Looks for the GUIDE soon @ www.avoidereadmissions.comFor more information please contact Pat Teske @
pteske@cynosurehealth.org
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 #
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