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Reaching Outside the Hospital to Create Community Partnerships

This presentation discusses UCLA Health's efforts to reach outside the hospital and create partnerships with community organizations to improve patient care and reduce readmissions. Topics include the development of a post-acute network, the Bed Reservation Program, and the Enhanced Home Health Program. Lessons learned and opportunities for improvement are also highlighted.

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Reaching Outside the Hospital to Create Community Partnerships

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  1. Reaching Outside the Hospital to Create Community Partnerships Marcia Colone, Ph.D., MS, LCSW, ACM System Director, UCLA Health, Los Angeles, CA Patient Flow Summit Tuesday, October 13, 2015 San Francisco, CA

  2. UCLA Health • Hospitals located in Los Angeles and Santa Monica, CA • Comprised of Ronald Reagan UCLA Health: Ronald Reagan- 520 Beds, Santa Monica-266 beds, Resnick Neuropsychiatric Hospital- 74 beds, Mattel Children's Hospital-131 beds, and the UCLA Medical Group with its wide-reaching system of primary-care and specialty-care offices throughout the region. • Ronald Reagan-Level 1 Trauma Center • 25,000 admissions and over 45,000 ED visits

  3. Post-Acute Network under Development

  4. UCLA’s Mandate to Build a PAC • Too few beds • Occupancy rates consistently exceed 95% • LOS increasing • Queueing in ED • High patient acuity and complex discharges • Over 50% of discharges occur after 4:00pm • Significant homeless population • Discharge barriers

  5. UCLA’s Occupancy by Month(Excluding Nursery, Psychiatry)

  6. SNF & HH PlacementsRR & SM-Calendar Year 2012 to 2015 (as of 9/10/15)

  7. Bed Reservation Program (Est. 2011) • 2011 Site visits: Selected 2 SNFs - 6 leased beds • 2015- 25 leased beds in two SNF facilities

  8. Bed Reservation Program (BRP): 2011 • Established daily bed lease rate to hold bed- based on acuity to facilitate discharges for unfunded/underfunded patients • Funded care includes board/care, medications, PT/OT • Established concept of “Backfill” to reduce daily bed lease costs • SNF can deny patient admission if criteria is not met • Started funding post SNF transitions in 2012

  9. Crown Jewel of the BRP Two Nurse Practitioners

  10. Bed Reservation Program 2013 = 163 patients 2012 = 91 patients 2014 = 261 patients 2015 = 126 patients 2013 to 2014 = 60% increase in # of patients placed

  11. New Vista Occupancy RatesSeptember 2014 to August 2015

  12. BRP Readmissions Compared to Health Services Advisory Group (HSAG)All cause 30 day Readmissions Q4 2013 to Q3 2014

  13. Post SNF Funded ServicesMarch 2015 to August 2015

  14. Lessons Learned from BRP Program • Invest in relationships & training over the long term • Build a training program for SNF staff & visit quarterly • NPs are essential for clinical quality • Develop a process to review metrics, address referral and refusal patterns and readmissions • Constantly review referral process/handoffs, especially during non-business hours • Daily identification of BRP patients • Claims reconciliation system • Standard reporting system

  15. Home Health Enhanced Program-November 2013 Develop a strategy to ensure the delivery of reliable and consistent home health services across the continuum of UCLA Health (inpatient and ambulatory) and identify actionable steps for quality improvement and readmission reductions

  16. Opportunities • Communication: external/internal providers • To/from PMD • Inpatient teams • Lack of accountability infrastructure • High number of patient refusals at time of service • Differences in referral processes from inpatient and outpatient setting • Absence of electronic home health orders

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  18. Improving Quality Outcomes • Enhanced Home Health Quality Council-3 contracted home care vendors • Components • 1st touchpoint in the inpatient setting (in-person or phone) • 7 touchpoints in first 2 weeks post hospital discharge • Measurement • 30-day all-cause readmission • % of patients who refuse home health services • % of patients who were unable to be located post-discharge • % of patients who had a delayed start of care

  19. Enhanced Home Health VS 30-Day All Causes HSAG Home Health Readmission Rates Baseline = Start of EHH Program

  20. Lessons Learned in HH Enhanced Program • Invest in the relationships over the long term • Establish quality standards • Develop a process to review metrics, address issues (denials, refusals, etc) and readmissions • Establish a quality review process to review real-time failures • Establish a claim reconciliation system for funded patients • Constantly improve referral processes/handoffs, especially for referrals that occur during non-business hours

  21. Thank You! Marcia Colone System Director, UCLA Care Coordination 310-267-9711 mcolone@mednet.ucla.edu

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