Transcript marcia-colone-updated-2-reaching-outside-the-hospital-to

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
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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
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Post-Acute Network under Development
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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
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UCLA’s Occupancy by Month
(Excluding Nursery, Psychiatry)
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SNF & HH Placements
RR & SM-Calendar Year 2012 to 2015 (as of 9/10/15)
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Bed Reservation Program
(Est. 2011)
• 2011 Site visits: Selected 2 SNFs - 6 leased beds
• 2015- 25 leased beds in two SNF facilities
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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
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Crown Jewel of the BRP
Two Nurse Practitioners
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Bed Reservation Program
2012 = 91 patients
2013 = 163 patients
2014 = 261 patients
2015 = 126 patients
2013 to 2014 = 60% increase in #
of patients placed
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New Vista Occupancy Rates
September 2014 to August 2015
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BRP Readmissions Compared to Health Services Advisory Group (HSAG)
All cause 30 day Readmissions
Q4 2013 to Q3 2014
HSAG Report
30 Day Readmit
Rate
Region
24.2%
California
20.8%
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Post SNF Funded Services
March 2015 to August 2015
Services
Total
Recuperative Care
$24,625.00
Home Health
$505.00
Medications
$217.03
DME
$2,211.00
Total Amount
$27,558.03
Avg Cost Per Patient (21 patients)
$1,312.00
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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 nonbusiness hours
• Daily identification of BRP patients
• Claims reconciliation system
• Standard reporting system
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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
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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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Improving Quality Outcomes
• Enhanced Home Health Quality Council-3 contracted
home care vendors
• Components
• 1st
•7
touchpoint in the inpatient setting (in-person or phone)
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
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Enhanced Home Health VS
30-Day All Causes HSAG Home Health Readmission Rates
EHH - November 2013 (Baseline) vs. FY 2015 Totals
Home Health Agency
Baseline
Western States
20.99%
AccentCare
22.09%
Intracare
28.49%
% Readmissions
25.07%
FY 2015 Total
18.95%
15.42%
12.68%
15.24%
Difference from Baseline
2.04%
6.67%
15.80%
9.83%
Baseline = Start of EHH Program
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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
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Thank You!
Marcia Colone
System Director, UCLA Care Coordination
310-267-9711
[email protected]
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