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 PlacementsRR & 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

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2012 = 91 patients 2013 = 163 patients 2014 = 261 patients

2013 to 2014 = 60% increase in # of patients placed

2015 = 126 patients

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New Vista Occupancy RatesSeptember 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%

Post SNF Funded ServicesMarch 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 non-

business 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 touchpoint in the inpatient setting (in-person or phone)

• 7 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 FY 2015 Total Difference from Baseline

Western States 20.99% 18.95% 2.04%

AccentCare 22.09% 15.42% 6.67%

Intracare 28.49% 12.68% 15.80%

% Readmissions 25.07% 15.24% 9.83%

Baseline = Start of EHH Program

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

mcolone@mednet.ucla.edu

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