Orange County Care Transitions Collaborative - hsag.com · Road Map to Action. ... –Lack of...

Orange County Care Transitions Collaborative

Health Services Advisory GroupJuly 11, 2018

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Ettie Lande, BSN, MS, ACM-RNHealth Services Advisory Group (HSAG)

July 11, 2018

Thank You!

For hosting today’s meetingSaddleback Memorial Medical Center

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Thank You!

For sponsoring today’s breakfast24Hr Home Care and Blake Naudin

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If you can sponsor breakfast at a future

meeting, contact [email protected]

or 818.265.4660

Community Introductions—Who Is At Your Table?

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Today’s Agenda

Welcome and Introductions

Findings From the Field

Community Readmission Performance

Immunizations and Avoidable Readmissions

Resources for Success: You and Your Patients

Meeting Summary

Evaluation Feedback

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Your Meeting Feedback Is Important!

Please help us exceed the 85% target!

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73%

55%

85% 85% 85% 85%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jan. 2018 Apr. 2018 Jul. 2018 Oct. 2018

2018 Orange County CollaborativeEvaluation Completion Rate



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Road Map to Action

Note the important takeaways from today’s

meeting on this Roadmap to Action to

share with staff members and

colleagues when you return to work.

“Findings from the Field”

A Solutions-Based Talk Show

Hosted by Ettie Lande

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How Can We Fix These Transition Gaps?

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Guests on Today’s Show

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• Laura GarciaFountain Valley Regional Hospital

• Lisa ForsytheMemorial Care Saddleback Medical Center

• Claudia SkinnerSt. Jude Medical Center

• Sally GasparSt. Joseph Health

• John MastrocolaGenerations Healthcare, Southern Region



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What We Will Learn From Each Guest Today

1. What gap opportunity related to caretransitions was identified by yourorganization?

2. What was the biggest challenge youexperienced in moving the strategy along toits next steps?

3. What advice would you give to someonetrying to implement this strategy in theirown organization?

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Network and Break: 15 Minutes

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http://www.online-stopwatch.com/eggtimer-countdown/full-screen

http://www.online-stopwatch.com/eggtimer-countdown/full-screen



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Orange County Community Performance:

Readmission Reduction

Orange County Community

• 240,893 Medicare Fee-for-Service (FFS) Beneficiaries

• 23 Acute-Care Hospitals

• 69 Skilled Nursing Facility (SNFs)

• 57 Home Health Agency (HHAs)

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Orange County Community

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How far is this collaborative from reaching the CMS1 readmission improvement target?

• Target RIR2 = 8% RIR

• Goal is to reach orexceed this target bySeptember 2018

1. Centers for Medicare & Medicaid Services (CMS)2. Relative Improvement Rate (RIR)

Orange County CommunityRIR July 2015–December 2017

Jul 2015 - Jun2016

Oct 2015 - Sep2016

Jan 2016 - Dec2016

Apr2016 - Mar2017

Jul 2016 - Jun2017

Oct 2016 - Sep2017

Jan2017- Dec2017

Target RIR 8.0% 8.0% 8.0% 8.0% 8.0% 8.0% 8.0%

Actual RIR 2.05% 2.78% 2.49% 1.83% 0.05% 2.18% 1.71%

2.05%2.78% 2.49%

1.83%

0.05%

2.18%1.71%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

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Desired Direction:Goal: 8.0% RIR by Sept 30, 2018

Source: Medicare FFS Claims Data for beneficiaries residing within the ZIP codes of this community. The number of beneficiaries for this is 240,893.*The RIR is calculated based on the readmission rates per 1,000 beneficiaries and this formula: (Baseline–Current)/Baseline.



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90-Day Sprint to the Finish!

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Turn in Your Meeting Evaluation and Receive a Copy of Your Community’s Report

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Data Source for this Report:

Medicare FFSClaims Data for

beneficiaries residing within the ZIP codes of this community



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Using Teach-Back to Improve Immunizations and Readmissions in HHAs

Maria Gallegos Project Coordinator, HSAG

So Let’s Start With Readmission Rates

Methodology:

– Derived from FFS, Part-A hospital claims.

– The rates represent readmissions from January 1, 2017–December 30, 2017 (mature data).

– Excludes planned readmissions.

– Excludes any beneficiary who dies in the hospital or is transferred to another hospital on the same day.

– Inclusive of all Medicare beneficiaries, regardless of age.

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All-Cause 30-Day Readmission Rates and Volume by Hospital Discharge Setting Q1 2017–Q4 2017

Setting Hospital Discharged To

Hospital Discharge Volume

30-DayReadmission

Rate

30-DayReadmission

Volume

Orange County

Community

Home 19,665 15.1% 2,961

SNF 12,828 20.8% 2,664

HHA 12,811 17.3% 2,215

Hospice 1,446 2.9% 42

Other* 3,562 19.1% 682

Total 50,312 17.0% 8,564

*Other: based on hospital discharge disposition codes and include, for example, include psychiatric hospital, long-term acute care hospital, acute rehab, intermediate-care, left against medical advice, and correctional facility.

Data files provided to 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 FFS beneficiaries. 21

All-Cause 0–7-Day Readmission Rates and Volume by Hospital Discharge Setting Q1 2017–Q4 2017

Setting Discharged To0-7 Day

Readmission Volumes

0-7 DaysReadmission Rates

Orange County

Community

Home 1,143 38.6%

SNF 855 32.1%

HHA 797 36.0%

Hospice 18 42.9%

Other* 291 42.7%

Total 3,104 36.2%

*Other: psychiatric hospital, long-term acute care hospital, acute rehab, intermediate-care, left against medical advise, based on hospital discharge disposition codes.

Source: Data files provided to 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 FFS beneficiaries. 22



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Why Teach-Back?

• Numerous studies haveshown that patientsremember as little as 50%of what they are told bytheir doctors.1

• Common causes for readmission

– Lack of patient/family involvement andaccountability in their own healthcare

– Patients/families do not fully understand how tocare for themselves at home

231. A. Boutwell and S. Hwu, Effective Interventions to Reduce Rehospitalizations: A Survey of the Published Evidence (Cambridge, Mass.: Institute for Healthcare Improvement, 2009), p. 14. And, S, Silow-Carroll, J. Edwards, and A. Lashbrook, Reducing Hospital Readmissions: Lessons from Top-Performing Hospitals (Commonwealth Fund Synthesis Report, April 2011) p. 8-9.

50%

30-Day and 7-Day Readmission Rates and Volume from HHA by Condition: Changes the Priority

Condition

30-DayReadmission

Volume

30-DayReadmission

Rate

0-7 DayReadmission

Rate

Orange County

Community

AMI 52 21.9% 48.1%

HF 180 22.4% 38.3%

PNE 172 21.0% 40.7%

COPD 78 17.6% 28.2%

CABG 15 12.0% 53.3 %

THA/TKA 41 2.3% 46.3%Data files provided to HSAG by the CMS were used for analysis in this report. The data files include Part-A claims for Medicare FFS beneficiaries.

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1. Acute Myocardial Infarction=AMI 2. Heart Failure=HF3. Pneumonia=PNE 4. Chronic Obstructive Pulmonary Disease=COPD5. Coronary Artery Bypass Graft=CABG 6. Total Hip/Total Knee Arthroplasty=THA/TKA



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The 2017–2018 Flu Season in California

CA Alameda, Contra Costa, and San Francisco Counties

The seasonal baseline was calculated using a regression model applied to data from the previous five years. Two standard deviations above the seasonal baseline is the point at which the observed percentage of ILI is significantly higher than would be expected at that time of year.

25https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/Week2017-1820_FINALReport.pdf

Older Adults Are Hit Harder by the Flu

Incidence of Influenza Hospitalizations in California Emerging Infections Program (CEIP) Counties, 2015–2018

https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/Week2017-1820_FINALReport.pdf26

https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH Document Library/Immunization/Week2017-1820_FINALReport.pdf

https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH Document Library/Immunization/Week2017-1820_FINALReport.pdf



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Heart Attack Risk and the Flu

The NEW ENGLAND January 25, 2018JOURNAL of MEDICINE

Acute Myocardial Infarction after Laboratory-Confirmed

Influenza InfectionJeffrey C. Kwong, MD., Kevin L. Schwartz, MD, Michael A. Campitelli, MPH, et. al.

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Risk of heart attack is six times greater than normal while people are ill with the flu.

https://www.nejm.org/doi/full/10.1056/NEJMoa1702090

Pneumonia Risk for Older Adults

16,000 adults 65 years and older die annually due to pneumococcal disease

https://www.cdc.gov/features/adult-pneumococcal/index.html28

https://www.nejm.org/doi/full/10.1056/NEJMoa1702090

https://www.cdc.gov/features/adult-pneumococcal/index.html



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One Possible Issue: Low Immunization Rates

Type Total White Black Hispanic Asian

Seasonal Flu (> 18 years) 1 42.2% 45.4% 35.6% 33.1% 43.6%

Season Flu (Medicare Claims) 2 53.5% 71.7% 55.3% 33.9% 56.1%

Pneumococcal (> 65 years) 3 59.9% 64.0% 46.1% 43.4% 41.3%

1. Centers for Disease Control and Prevention. (2014). Flu vaccination coverage United States, 2013-14 influenza season. Retrieved from http://www.cdc.gov/flu/fluvaxview/coverage-1314estimates.htm#by-race-adults

2. Centers for Disease Control and Prevention. (2014). Interactive mapping tool: Live-tracking flu vaccinations of Medicare beneficiaries. Retrieved from http://www.hhs.gov/nvpo/flu-vaccination-map/index.html

3. Williams, W. W., Lu, P-J., O’Halloran, A., Bridges, C. B., Pilishvili, T., Hales, C. M., & Markowitz, L. E. (2014). Noninfluenza vaccination coverage among adults – United States, 2012. Morbidity and Mortality Weekly Report, 63(5), 95-102.

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Goal: Increase Immunizations Rates

Current HSAG Progress

Time Period Flu Rate PNE Rate

Oct. 17–Jan. 18 74.81% 81.26%

Source: CMS Claims Data30

http://www.hhs.gov/nvpo/flu-vaccination-map/index.html



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Our Strategy: Teach-Back

• Health literacy is the cognitive and social skills whichdetermine the motivation and ability of individuals togain access to, understand, and use information inways that promote and maintain good health.

• Teach-back is a way to confirm that you have explainedto the patient what they need to know in a mannerthat the patient understands.

• Motivational interviewing is a scientific, patient-centered approach for fostering motivation andassisting patients to resolve ambivalenceabout change.

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Our Strategy: Teach-Back (cont.)

• Teach-back is asking patients to repeat—intheir own words—what they need to knowor do.

• It is not a test of the patient, but of how wellyou explained the concept.

• It is a chance to check for understanding and,if necessary, re-teach the information.

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10% of what

they read

20% of what they hear

30% of what they see

50% of what they hear and see

70% of what they say or write

90% of what they do

Sources: Dale, Edgar. Cone of Experience. 1946. Treichler, DG. Film and Audio-Visual Communications. 1967. Glaser, R. (1983, June). Education and Thinking: The Role of Knowledge. Technical Report No. PDS-6. Pittsburgh, PA: University of Pittsburgh, Learning and Development Center. Thalheimer, Will. Will at Work Learning. May 1, 2016 .http://www.willatworklearning.com/2006/05/people_remember.html


• Engage those that have the highest impact in each community based on volume and return to hospital rates.

• Schedule and provide teach-back trainings to HHA nurses and other staff members.

• Goal: Improve patient understanding of immunizations to help prevent avoidable hospital readmissions.

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Thank you!

Maria Gallegos

[email protected]

Resources for Success: HSAG Website and YouTube Channel

Ettie Lande



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Where Can You Find Resources and Tools on HSAG’s Website?

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You will always start with the path below:

• For Medicare Providers > California > Care Coordination > California Tools & Worksheets

Tools and Resources for California

38 https://www.hsag.com/care-coord-ca-tools

https://www.hsag.com/care-coord-ca-tools



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ADEs and HRMs Tabs

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Tools/resources include: • Quick tips for prescribers• HRM resources

‒ Anticoagulants ‒ Opioids‒ Diabetic agents

• ADE tools• And more….

www.hsag.com/care-coord-ca-tools

Provider Tools: Organization and Patient Assessment Resources Tab

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Tools/Resources include: • Organizational Assessment

Summary • 7-day Readmission Checklist• Strategy Tree • Admission Observation Tool• Discharge Observation Tool• And more….



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Behavioral Health Resources Tab

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• Alcohol Misuse Screening Tools

• Depression Screening Tools• Reference Guide for Medicare

Preventive Services• Patient Education • Treatment• Quality Payment Program

• Behavioral Health Readmission Audit Tool

• Top Ten Intervention Series–practices critical to reducing readmissions

• Webinars—NEXT Changing the Stigma and Images of ECT (Electroconvulsive Therapy)

What Influences Readmissions? Jane’s Experience is Now on HSAG’s YouTube Channel

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• Pre-Hospital/Pre-Admissionhttps://youtu.be/pz1_7ssdXZU

• Inpatient

• Post-Discharge/Community

https://youtu.be/CRfANRvzJwU

https://youtu.be/urvR4Tdzf6E

https://youtu.be/pz1_7ssdXZU

https://youtu.be/CRfANRvzJwU

https://youtu.be/urvR4Tdzf6E



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Patient Tools Tab

Red Flag Zone Tools: • English/Spanish

• Asthma• COPD• Diabetes• Heart Disease• Heart Failure• Medications• Mood and Health• Urinary System

Teach-Back and Health Literacy Tab

Tools/Resources include:

• Teach-back Starter Sentences

– Generic

– For Heart Failure

• Plain Language

– Generic

– For Heart Failure

• Health Literacy Tool Kit

• And more….

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Nursing Home Reducing Readmissions Preparation Program

Why You Should Join:

• Improve your staff members knowledge on readmission interventions

• Create and strengthen your internal readmission prevention program

• Help you to become, and stay, a preferred provider to your local hospitals

• Improve your readmission rates to receive maximum reimbursement

45 www.hsag.com/ca-rrpp

Reducing Readmissions Preparation Program 2018 Webinar Series

4646

Fourth Wednesday

of every month,

11 a.m. PT

July 25Listening to Your Residents: Teach

Back and Motivational Interviewinghttps://goo.gl/a4FyXu

August 22Chronic Obstructive Pulmonary

Disease (COPD)https://goo.gl/9WrgyV

September 26Ready, Set, Go! Sharing Success Stories

https://goo.gl/GF2a9v

Past event slides and recordings available

www.hsag.com/events



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Home Health Best Practice Intervention Package (BPIP)

• Customize many of these materials with your organization’s logo or make changes to meet your individual needs.

• There are no copyrights on any of the HHQI Campaign’s original material.

• Resources are no cost, but you have to sign up for the HHQI Campaign to access them.

• www.homehealthquality.org

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• Cardiovascular Health (Part 1– revised 2017 and Part 2)

• Blood Pressure Control and Smoking Cessation

• Cross Settings I, II, and III• Depression Management

(revised 2017)• Disease Management: Part 1 and 2• Disease Management: Diabetes• Disease Management: Heart Failure

• Fall Prevention• Fundamentals of Reducing

Hospitalizations• Immunization/Infection

Control (revised 2017)• Improving Management of

Oral Medications• Medication Management• Patient Self-Management• Underserved Populations • New! Wound Management

BPIP Topics

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http://www.homehealthquality.org/



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Home Health Services—What a Patient Should Know

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Now on HSAG’s YouTube Channel

Video link: https://youtu.be/jh1jOnZ28Ds

Meeting Summary: What Will You Share When You Get

Back to Work?

https://youtu.be/jh1jOnZ28Ds



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Your Meeting Evaluation Feedback Is Needed

• Target: At least 85% of you will complete a meeting evaluation form.

• Please complete the evaluation before you leave today (fold in half and leave on the center of the table).

• Your feedback is very important to us and highly valued.

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Questions?

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Thank You All for Your Participation Today!

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Thank You!

Ettie Lande

[email protected]



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DisclaimerThis 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.3-07132018-01

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