Chronic Disease Transitional Care Northridge Hospital Medical Center Health Services Advisory Group 102017 Dr Jeremy Grosser Medical Director Transitional amp Palliative Care 2 I have no financial relationships with commercial interests ID: 770929
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Chronic Disease Transitional CareNorthridge Hospital Medical Center Health Services Advisory Group 10/20/17 Dr. Jeremy Grosser Medical Director Transitional & Palliative Care
2 I have no financial relationships with commercial interests Disclosure
Social Determinants of Health Source: Institute for Clinical Systems Improvement, Going Beyond Clinical Walls: Solving Complex Problems (October 2014)
Transitional Care Department Palliative Care Frail Elderly Pain Management CHF COPD CVA ESRD CANCER CJR 65 and older Build Trust Communicate Educate Chronic Diseases Diabetes Management Mitigate
5 Patient safety Safe transition home by improving patient and family preparation for discharge Ensure follow up with Physicians after discharge Improve flow of information between hospital, providers, patient, and families Increase safety by improving the transition for discharge, and mitigating risk for adverse advents Home Visit- conducting home safety check Follow up phone calls to ensure access & continuity of care Why Care Coordination?
6 Clinical Team is composed of: Nurse Practitioners (7.5) Social Workers (2) Clinical Pharmacists (2) Physicians – Provides clinical oversight for NP’s (2.0) and pain management staff Diabetes NP (1.0) Registered Nurse (1.0) – Program Coordinator for Discharge Planning The Transitional Care Team works collaboratively with patients/care partners, medical staff, nursing, case management, pharmacy, ancillary services, SNF’s & Home health agencies towards safe patient discharge : The NP educates the patient and family about their chronic disease & red flags of their illness & provides clinical oversight and problem resolution for 30-90 days post discharge. The Pharmacist conducts Medication reconciliation & education. The NP conducts home & SNF visits ensuring a safe discharge and that required supplies and equipment are in place. The Social Worker provides psychosocial support, makes referrals for support groups, community services, spiritual services, hospice support. Chronic Disease /Transitional Care Dept.
Pharmacy Medication reconciliation for all chronic disease & pain management patients enrolled in program Physicians Automatic consultation for all 30 day readmits ED icon for readmission potential, notification of cardiologist & surgeon Cardiology Co-management auto consult orders Neurology auto consult orders for Stroke patients Family Medicine/Foundation MD’s: RN Coordinator ensuring access to medications & follow up appointments Nursing Units Daily ICU rounds & Palliative Care consultation Glycemic Management FY 18 Goals Pharmacy review of Pain Management Regimens Case Management Collaboration between Case Management &Transitional Care for discharge Planning Specialized populations: Medications in hand at discharge & appointments with PCP within 7 days of discharge Internal Collaboratives: 7
8 Pharmacist Medication Mitigation Categories August 2016 – July 2017
Skilled nursing facilities (SNFs) Must maintain Star rating at 3+ Narrowed network of 8 facilities Weekly NP driven patient rounds at the SNF’s Weekly clinical calls with Medical Director & NP’s Monthly collaborative meetings Review of SNF readmission outcomes Identify best performers Adjustments to narrowed network as needed Home health Narrowed network of 8 vendors NP’s coordinate care with HHA Weekly clinical calls with Medical Director & NP’s Monthly collaborative meetings External Collaboratives 9
10 SNF Readmission Rates from CDTC
Northridge Hospital: Readmission RIR* Q1 2014–Q1 2017 Source: Medicare Fee for Service Claims Data. Baseline period: CY 2014. *The formula for Relative Improvement Rate (RIR) is (Baseline-Current)/Baseline. Desired Direction RIR: Target: 12% RIR by Q3 2018
Readmission Data Q2 2016–Q1 2017 Patients Discharged Home With Home Health Patients Discharged Home Without Home Health 12 Location 30-Day Readmission Rate Readmissions within 0–7 Days Northridge Hospital (n=106) 16.4% (n=36) 34.0%Los Angeles 21.1%36.1%California 19.3%36.0% Location 30-Day Readmission Rate Readmissions within 0–7 Days Northridge Hospital (n=315) 19.2% (n=122) 38.7% Los Angeles 20.6% 38.7% California 17.4% 37.6%
Readmission Data Q2 2016–Q1 2017Patients Discharged to Nursing Homes Location 30-Day Readmission Rate Readmissions within 0–7 Days Northridge Hospital (n=237) 22.5% (n=83) 35.0% Los Angeles 24.9% 33.1% California 21.6% 32.9% 13
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