Leveraging Community Partnerships

Richard Espinoza, NHACAO Post-Acute Services

Alameda Health System

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Leveraging Community Partnerships

• Is throughput an issue? • Assess where you are so you know where you’re going.• What resources are needed for your organization based

on assessment?• Who in the community can your organization collaborate

with?• Do you know who they are?• Where to start?

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Global Review of Opportunities

• Self Assessment of throughput from Acute Hospital Admission to Discharge home / Discharge to Post-Acute –identify opportunities

• Developing Partnerships SNF Partnership Home Health Health Care Services Agency – East Bay Innovations

examples Transportation – Ambulance and non-emergency

transport

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Self Assessment • Map out current workflows from Acute Admission through

discharge and identify opportunities to assist with throughput• Workflow reviewed and identified opportunities:

Earlier intervention from Rehabilitation team (PT and OT) Earlier intervention for support of potential barriers Earlier intervention of Behavioral Health Services support as

needed Earlier intervention of insurance assistance – Medi-Cal

Application This has led to earlier acceptance and placement of referrals

and a reduction in LOS SNF Partners come on site to review complex cases

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Alameda

Highland

Goal

San Leandro

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Reduction from Admission to First Referral

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Post-Acute Throughput CommitteeIdentified opportunities from workflows that included:

• PA teams developed and are providing education on levels of care (SNF, Sub-Acute, Acute Rehab, Home Health, Board and Care, Bridging programs) and their criteria

• Target audience: physicians, residents, case management, social work, rehab therapists

• Develop SNF Transfer Checklist• The development of the SNF partnership and their onsite support• Clear two-way communication and development of partnership

needs and outcomes

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SNF Partnership• Identifying partners:

Developing Criteria: CMS 5-star rating data – Quality Measures, Overall Star rating -

(CJR) Response time to acceptance in Allscripts % accepted by site – using AllScripts data

• Referral Process from CM – consistent use of SNF Transfer checklist• Monthly meetings to review data, successes and barriers – QAPI data

for sites• Hospital CM sharing pre-work for post SNF placement – collaboration –

the hope is the SNF’s feel greater support in accepting complex patients

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SNF Review for Partnership

TRANSFER CHECKLIST/SNF PACKET Ambulance Transfer Form Inter-Facility Transfer Form Face Sheet/Demographics (2) include SSN - Payor Source Insurance Information: ___________________ Authorization Number: _______________ DNR STATUS POLST FORM CLINICAL DOCUMENTATIONS: ER Report History & Physical Consultation Reports Procedure Reports N/A Nursing Notes and Progress Notes Flu Shot Pneumococcal shot Immunizations Current Medications (MAR/PRN) Oxygen N/A Wound Measurement & Treatment Plan N/A Nutrition Assessment/Notes Current Labs N/A Microbiology Results N/A Isolation Precautions N/A Radiology Reports N/A Discharge Summary D/C Orders Triplicate for Narcotics N/A Extended Care Orders PPD or Chest X-Ray DIALYSIS / RADIATION TREATMENT: Dialysis Center Treatment Schedule Transportation Contact Person N/A REHAB SERVICES: PT EVAL/ NOTES OT EVAL / NOTES ST EVAL/ NOTES RT Services N/A Including Ortho Follow-up appointments N/A CASE MANAGEMENT/SOCIAL SERVICES:CM/SS Assessment/Notes SW Notes RE: Patient’s Behavior and Psychotropic Use N/A EBI Referral / Community Discharge Plan N/A Copy of Medi-Cal Application Started Eligibility worker name ______________ N/A Follow up appointment information ___________________ N/A ANCILLARY SERVICES: Chaplain Assessment/Notes N/A Special Equipment (i.e. bariatric bed, mattress, TLSO, etc.): ______________________ N/A HT: ___________WT: _____________

RN/SW Signature: ____________________________ Phone Number: _________________

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Reduction in referral time to SNF acceptanceThree Hospitals: Focus on greatest need improvements yielding

Alameda

Highland San Leandro

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Home Health

• Safety net hospital • Under insured – uninsured• Partner to assist - right care in the right setting• From Acute or SNF setting to home

HH partner provides liaisons in the acute hospital for support Reduction in administrative days and allows for greater access to needed acute beds

CM – Physician support to review cases once patient in their home if additional support from initial authorization is needed

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Health Care Services Agency – Whole Person Care

• Health Care Services Agency• East Bay Innovations • Pilot program – Grant • Partnership for placement• Home modifications – grab bars, pots and pans – home

set up barriers, first month rent and deposit support, CM support

• Alameda County Care Connect – application process

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Transportation

• Royal Care Connect – (Royal Ambulance)• Contract with levels of care transport• Assist with transport to clinics from home

Can monitor if patients made it to their follow up appointments

Can follow up if they missed to ensure all is ok Can help assist with reducing re-hospitalization Looking at opportunities to assist in the AHS Post-Acute

settings

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Benefits of Partnerships

• Quality Care Outcomes• Continuity of Care - Right level of care at the right time• System approach to throughput• Possible reduction in LOS on the acute setting with

faster placement• Assist with Admin Day reduction in the acute • Collaboration thought the continuum of care • Partners feel supported and greater connection to acute • Reduction in re-admissions

Questions?

Raise your hand or submit a question at www.menti.com and enter code 80 39 38

Thank You

Richard Espinoza, NHAChief Administrative OfficerAlameda Health Systemraespinoza@alamedahealthsystem.org