Coordinating Care to Improve Healthcare in Kern County

Jennifer Wieckowski, MSGState Program Director

Health Services Advisory Group (HSAG)May 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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HSAG’s QIN-QIO Responsibility

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HSAG is the Medicare QIN-QIO for California, Arizona, Florida, Ohio, and the U.S. Virgin Islands.

Nearly 25 percent of the nation’s Medicare beneficiaries

Centers for Medicare & Medicaid Services (CMS) Care Coordination Community Expectations

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SustainableCommunity

Engage community

partners

Develop coalition charter

Develop leadership structure

Refresh root cause analyses

Select interventions

Evaluate interventions

Kern County Medicare Fee-for-Service Hospital Readmission Rates

Hospital Readmission RateQ2 2013 to Q1 2014

A 27.70%B 21.40%C 21.10%D 20.40%E 20.40%F 19.90%G 19.70%H 18.30%I 17.10%J 11.10%

5The ASAT data file representing Q2 2013 to Q1 2014 was used for the analyses in this report. The ASAT data file is provided to Health Services Advisory Group (HSAG) by the Centers for Medicare & Medicaid Services (CMS). The ASAT data file includes Part-A claims for Fee-for-Service beneficiaries.

Kern County Medicare Fee-for-Service Hospital Readmission Rates (cont.)

Calendar Year Readmission Rate

2010 22.3%

2011 21.3%

2012 20.7%

2013 20.8%July 2013 to

June 2014 20.1%

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9.9% relative improvement rate

The ASAT data file representing calendar year 2010 to Q2 2014 was used for the analyses in this report. The ASAT data file is provided to Health Services Advisory Group (HSAG) by the Centers for Medicare & Medicaid Services (CMS). The ASAT data file includes Part-A claims for Fee-for-Service beneficiaries.

Kern County’s Progress: All-Cause, 30-Day Readmission Rate

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California NationKern County

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30-Day Readmission Rate by Setting After Inpatient Hospitalization for All Causes: Q3 2013–Q2 2014

Setting Discharged To

30-Day Readmit Rate

Nursing Home 22.1%Home with Home Health 20.6%Home 19.3%Total 20.1%

Kern County Providers Connected by a Minimum of 30 Transitions

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Kern County Workgroups Focused on Medication Safety

• Hospital to Nursing Home• Hospital to Home/Home Health• Nursing Home to Home/Home Health

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HCAHPS® Measures of Interest

16. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?

17. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?

25. When I left the hospital, I clearly understood the purpose for taking each of my medications.

11 HCAHPS=Hospital Consumer Assessment of Healthcare Providers and Systems

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Bakersfield M

emorial H

ospita

l

Good Samaritan Hosp

ital

Mercy Hosp

ital

Kern M

edical C

enter

San Joaquin Community

Hospita

l

Delano Regional Medica

l Center

Bakersfield Heart

Hospita

l

Tehachapi H

ospita

l 0

10

20

30

40

50

60

70 63 6660

54 57 5459

66

Patients Who Reported That Staff "Always" Explained About Medicines Before Giving it to Them

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While Great Strides Have Been Accomplished…

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—05292015-01