Seven Home-Health Touch Points to Prevent Avoidable Re-hospitalizations

1. Seven Home-Health Touch Pointsto Prevent Avoidable Re-hospitalizations Jennifer Wieckowski, MSG Program Director, Care Transitions Health Services Advisory Group of California, Inc. (HSAG of California)

2. Statewide Readmission ReportsMedicare Fee-For-Service (FFS) Data

3. Statewide Readmission ReportsMedicare FFS Data (cont’d)

4. The Team Cedars-Sinai Medical Center (CSMC) • Largest private, not-for-profit medical center in the western United States, with 923 beds • Consistently named one of America’s Best Hospitals by U.S. News & World Report Accredited Home Health Services • Ranked in top 2 percent in the country • In business over 33 years • Five locations throughout Southern California • Monthly census of more than 700 patients

5. The Challenge Reduce readmissions from home health by 50 percent.

6. Are you NUTS?!?!

7. Enhanced Home Health ProgramMinimum of seven touch points within two weeks of discharge

8. Results * The agency selected for the test of change had the highest proportion of home-health referrals from Cedars-Sinai Medical Center .

9. Adaptability and Spread Four high-volume home health agencies tested the Enhanced Home Health program during a six-week period in February and March 2012. A total of 396 patients were enrolled. 35% Reduction

10. Lessons Learned • Increase in personnel time dedicated to the program • Communication—frequent and clear • In-patient phone call vs. visit • Patient refusal

11. What You Can Do By Tuesday • Know your readmission rates. • medicare.gov • Know where your referrals are going. • Develop partnerships. • Improve communication. • Implement tuck-in phone calls.

12. California Rate of Readmissions Within 30 Days per 1,000 Beneficiaries * Calendar Year (CY)

13. Statewide and Regional Readmission Data Reportswww.NoPlaceLikeHomeCA.com

14. List of Hospitals Affected by HRRPhttp://www.kaiserhealthnews.org/Stories/2013/August/02/ readmission-penalties-medicare-hospitals-year-two.aspx

15. New Resource!www.checkmypenalty.com

16. New Resource! www.checkmypenalty.com (cont’d)

17. Home Health Quality Improvement Campaignhttp://www.homehealthquality.org/Home.aspx

18. Thank You! Jennifer Wieckowski, MSG Program Director, Care Transitions jwieckowski@hsag.com HSAG of California 700 North Brand Blvd., Suite 370 Glendale, CA 91203 818.409.9229

19. Closing Slide We convene providers, practitioners, and patients to build and share knowledge, spread best practices, and achieve rapid, wide-scale improvements in patient care; increases in population health; and decreases in healthcare costs for all Americans. www.hsag.com This material was prepared by Health Services Advisory Group of California, Inc., 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-10SOW-8.0-091813-01