1

Seven Home-Health Touch Points to Prevent Avoidable

Re-hospitalizations

Jennifer Wieckowski, MSGProgram Director, Care Transitions

Health Services Advisory Group of California, Inc.(HSAG of California)

2

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

CY 2012 All-Cause 30-Day Readmission Rates

Setting Discharged To Number of Discharges

Number of Discharges Readmitted

Within 30 Days

30-Day Readmit

Rate

% of 30-Day Readmits to

Another Hospital

Home 383,017 66,102 17.3% 26.6%Skilled Nursing Facility 173,919 38,317 22.0% 27.2%

Home Health Agency 124,008 25,045 20.2% 22.0%Hospice 15,968 553 3.5% 36.9%Other 53,449 10,822 20.2% 41.6%All 750,361 140,839 18.8% 27.1%

3

Statewide Readmission ReportsMedicare FFS Data (cont’d)

CY 2012 Number of Days from Discharge to Readmission

Setting Discharged To Number ofReadmissions

1–7 Days

8–14 Days

15–21 Days

22–30 Days

Home 66,102 36.0% 24.9% 19.5% 19.6%Skilled Nursing Facility 38,317 32.5% 25.9% 20.9% 20.7%Home Health Agency 25,045 36.3% 26.1% 19.0% 18.5%Hospice 553 44.5% 26.2% 15.4% 13.9%Other 10,822 38.2% 22.0% 18.5% 21.4%All 140,839 35.3% 25.2% 19.7% 19.8%

4

The Team

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

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

Cedars-Sinai Medical Center (CSMC)

Accredited Home Health Services

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 dischargeEnhanced Home Health Program

A minimum of 7 touch points to occur within the first two weeks of discharge.

Week 1

Week 2

Home Visit the First Weekend the Patient is

Home

Additional Home

Health Visits as Needed

Tuck-in Phone Call the 1st

Friday the Patient is at

Home

Three to Four Home Visits

Including a Visit within 24–48

Hours

Pre-Discharge Introduction

Hospital Visit or Phone Call

Home Visit the 2nd Weekend

the Patient is at Home

Tuck-in Phone Call the 2nd

Friday the Patient is at

Home

Two to Three Home Visits

Enhanced Home Health Program A minimum of 7 touch points to occur within the first two weeks of discharge.

Week 1

Week 2

Home Visit the First Weekend the Patient is

Home

Additional Home

Health Visits as Needed

Tuck-in Phone Call the 1st

Friday the Patient is at

Home

Three to Four Home Visits

Including a Visit within 24–48

Hours

Pre-Discharge Introduction

Hospital Visit or Phone Call

Home Visit the 2nd Weekend

the Patient is at Home

Tuck-in Phone Call the 2nd

Friday the Patient is at

Home

Two to Three Home Visits

8

Results

8

Patient Population Time FramePercent

Readmitted(All-Cause)

Cedars-Sinai discharges home with home health

(any agency)July 2010–June 2011 19%

Cedars-Sinai discharges home with Test of Change

home health agency*July 2010–June 2011 14%

Test of Change (n=59 patients)

November 2011 6.8%

* 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

9

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.

Home Health Agency

BASELINEPercentage 30-day

ReadmissionsFeb. 2011–Jan. 2012

TEST OF CHANGEPercentage 30-day

ReadmissionsFeb. 15–Mar. 31, 2012

NUMBER OF PATIENTS

enrolled in TOCFeb. 15–Mar. 31, 2012

Accredited 12.7% 10.3% 121

Agency II 12.1% 7.8% 103

Agency III 14.7% 11.8% 110

Agency IV 17.3% 6.4% 62

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

*CY 2010 CY 2011 CY 20120

10

20

30

40

50

60

48.47 47.31 43.92

Rea

dmis

sion

s pe

r 1,

000

Ben

efic

iari

es

* Calendar Year (CY)

13

Statewide and Regional Readmission Data Reports

www.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 Campaign

http://www.homehealthquality.org/Home.aspx

18

Thank You!

Jennifer Wieckowski, MSGProgram Director, Care Transitions

jwieckowski@hsag.comHSAG of California

700 North Brand Blvd., Suite 370Glendale, CA 91203

818.409.9229

19

Closing Slide

www.hsag.comThis 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

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.