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Community Collaboration Webinar

Join this webinar to learn about the approaches used by Community-based Care Transitions Programs to reduce hospital readmissions, the role of transitional care specialists, and the types of services and resources that are important in various high-risk populations.

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Community Collaboration Webinar

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  1. Community Collaboration Webinar September 2, 2015 Lindsay Holland, MHA, BS Bruce Spurlock, MD Pat Teske, RN, MHA Carrie Wong, MSW, MPH, LCSW

  2. The Panelists Lindsay Holland, MHA, BS Health Services Advisory Group (HSAG) Clinical Project Manager Bruce Spurlock, MD Cynosure Health Solutions Executive Director Pat Teske, MHA RN Cynosure Health Solutions Implementation Officer Improvement Advisor Carrie Wong, MSW, MPH, LCSW Department of Aging and Adult Services Director of Long Term Care Operations

  3. 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.

  4. Helpful Webinar TipsWebEx Eventsconvergencehealthevents.webex.com

  5. Please don’t put us on hold

  6. After you login to the webinar, to open the chat box, please make sure you turn on (it will toggle on/off) the chat icon in the top right corner of the webinar. 6

  7. After the webinar begins, you will see the chat box in the bottom right section of your screen. Please send your comments to “All Participants”. 7

  8. Raise your hand and chat Let’s try it

  9. After the webinar begins, you can save the presentation being shown by clicking on File, Save As, Document… 9

  10. The easiest format to save as: is Portable Document Format (.pdf). The default is Universal Communicate Format (.ucf) which is specific to WebEx and does not save properly when in this format. 10

  11. You can also download from our websitewww.cynosurehealth.org under Tools & Resources (find the webinar with the slides you want and click View/Download): 11

  12. 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 #

  13. Agenda Carrie Wong, Transitional Care Efforts and CCTP Demonstration Project Lindsay Holland, Together We’re Better: Community Collaboration to Reduce Readmissions Pat Teske, ARC

  14. San Francisco:Transitional Care Efforts and CCTP Demonstration Project Carrie Wong, MSW, MPH, LCSW Director of Long-Term Care Operations San Francisco Department of Aging and Adult Services

  15. Agenda • CCTP Background • San Francisco Transitional Care Program • Challenges • Successes • Life after CCTP contract

  16. The Community-based Care Transitions Program (CCTP) • 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%

  17. 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

  18. 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

  19. Two Roles • 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

  20. Client Areas of Focus • 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

  21. 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

  23. How about you?

  24. 273 Prevented Readmissions! (FY 13/14)

  25. CCTP Contract Ended. Now what?

  26. 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

  27. Questions? Carrie Wong, MSW, MPH, LCSW Director of Long-Term Care Operations San Francisco Department of Aging and Adult Services Carrie.Wong@sfgov.org 1 (415) 355-6748

  28. Together We’re Better: Community Collaboration to Reduce Readmissions Lindsay Holland, MHA Clinical Project Manager, Care Coordination Health Services Advisory Group (HSAG) September 2, 2015

  29. 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.

  30. Why Care Coordination Matters

  31. Putting It All Together Creative Commons/Pixabay. http://pixabay.com/en/connect-connection-cooperation-316638/

  32. California’s Progress: All-Cause, 30-Day Readmission Rate for Patients Discharged From a Hospital California Nation The 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.

  33. National Success in Reducing Readmissions in Communities Recognized by QIOs

  34. Strategies to Reduce Readmissions Improve processes within settings. Improve processes betweensettings.

  35. How about you?

  36. Building Community Coalitions

  37. CMS Community Expectations

  38. 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.

  39. Community Success Story

  40. 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/

  41. Thank you! Health Services Advisory Group quality@hsag.com 818.409.9229

  42. 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

  43. ARC’s Community Guide

  44. Who we visited Washington County Coalition Congregational Health Network

  45. What we learned

  46. More learnings

  47. Even more learnings

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