Enhanced Home Health Program

Cedars-Sinai Health System

April 23, 2015

Los Angeles market for Home Health Agencies

2

There are over 700 Home Health Agencies that

operate within Cedars-Sinai’s Primary Service

Area.

Root Causes for Home Health Readmissions

3

• Patients & families often turn away Home Health agencies after hospital discharge

• Inconsistency in frequency of home visits post-discharge

• 45% of readmissions occurred on a Saturday or Sunday

• Patient/Family not communicating Red Flags to Home Health agency

• Medication Management/Reconciliation

• Physicians not responsive when Home Health Agencies have questions/concerns

A chart review of 45 Home Health patients revealed recurring factors that likely contributed to preventable readmission within 30 days.

The Problem

4

Home with Home Health

Cedars-Sinai 15.8%

All UHC Hospitals(Average) 16.2%

All-Cause 30-Day Readmission RateMarch 2013 – March 2014

The Cedars-Sinai 30-day all-cause readmissions rate for Home Health patients was about even as the average for all UHC hospitals.

The Enhanced Home Health Program

5

Focus Home Health Patients

Metric30-day all-cause

readmissions to CSMC

Target 10% readmission rate

By When March 2015

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Agency Selection Process

125• Agencies submitted RFPs

25

• Selected based on Home Health Compare Data

• Complete self-assessment

13• Interviewed in person

5• Selected to participate in Enhanced Home

Health

The Enhanced Home Health Program

7

7 Touch Points

On-site Liaison

MD Interface

CS-Link access

24/7 On-Call Clinical Support

Building Awareness

Data Collection & Documentation

EHH is a collaboration with 5 home health agencies to ensure high quality patient-

centered care transitions from hospital to home.

Enhanced Home Health Protocol Touch points to occur within the first two weeks of discharge

24 – 48 Hours prior

to dischargeDay after

discharge

1st weekend patient

is at home

Pre-Discharge

Hospital Visit

with Home

Health Liaison

Home visit• Med rec

• Safety check

• Assessment &

education

• Identify other

disciplines that

may be needed

Home visit (2-3 in first week)

• Med

compliance

• Vitals

assessment

• Schedule next

home visit

Tuck-in Phone

call • Identify red flags

• Schedule next

home visit

• MD Follow up

appointment?

2nd weekend that

patient is at home

1st Friday patient is

at home

Home visit• Med compliance

• Vitals

• Well-being

assessment

Monday-Thursday

Minimum of 1 home

visit

Home visit• Med compliance

• Vitals

• Well-being

assessment

Tuck-in Phone

call• Address questions

• Schedule next home

visit

Week 1

Week 2-4

2nd Friday patient is

at home

Tuck-in Phone

call• Address questions

• Schedule next home

visit

Weekly 15-30 days

post discharge

Intro Phone

Call• Identify red flags

• Address

questions/anxiet

y

Evening of

Discharge

8

9

On-Site Liaison

How can your Agency benefit from having an On-Site Liaison?

Increase your agency acceptance rate

Gain in Medical Staff engagement and buy-in

No surprises for you or your patient

Ability to pull all necessary patient information prior to discharge

Ensure that the patient has all the necessary equipment

Inpatient RN is present to answer any additional questions

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Proposed Pre-discharge visit: Home Health Liaison

Home Health Liaison complete the following on site, prior to discharge:

• Patient contact information

• Caregiver contact information

• MRN and ACCT ID Number

Verify the following in CS-Link

• EHH fact sheet

• When to call 9-11

Review Cedars-Branded Patient Education Materials with patient and family

• Preferred language

• Preferred time of day

• Presence of a caregiver (if applicable)

Identify patient preferences

• Speak with Attending Physician and identify the MD who will be following the patient in the post-discharge setting

• Call identified MD and ensure they are on board with post-discharge plan

Identify post-discharge MD follow-up

• Survey Monkey Tool

• CS-Link (long-term)

Documentation and Data Collection

11

EHH Patient Flow

Notification of new patient referral to one of the “Enhanced Home Health” (EHH) Agencies.

Visit patient prior to discharge to inform patient about HH agency and EHH program

Track all EHH discharges and referring agency to facilitate communication with the HH agencies and track all patients

Communicate regularly with the HH agencies to confirm all discharges to the agencies and track EHH touch-points

Follow-up with patients to ensure that the Home Health agencies are providing Enhanced Home Health

EHH Data

The EHH Population

13

Medicine35%

Surgery65%

Type of Hospital Encounter

2.8

2.4

2.2

2.3

2.4

2.5

2.6

2.7

2.8

2.9

EHH Non-EHH

EHH vs. Non-EHHCMI

March 2014-January 2015

EHH

Non-EHH

*Data Source: ROM, CMI and Hospital Encounter for patients discharged to EHH agencies, Date Range: March-14 to Jan-15

EHH vs. Non-EHH Readmission

14

17%

14.7%

11.4%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Baseline - All HomeHealth

Non-EHH EHH

Re

adm

issi

on

Rat

e

Patient Home Health Discharges

Baseline - AllHome Health

Non-EHH

EHH

April 2013 – February 2014 March 2014 – January 2015

*Data Source: ROM, Readmission rate for patients discharged to EHH agencies, Date Range: April-13 to Jan-15

EHH Process Improvements

Continued Performance and Process Improvements

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CS-Link (Epic EMR) Access

Agency liaisons in the ED

Home health agency and Attending Physician communications

Alignment of patient education materials

Real time feedback using patient interviews

Agency clinical huddles

Agency check-in meetings

Organizational engagement through Grand Rounds

Epic Home Health build

Empathy Interviews

Patient’s trigger point

• Pain

• Afraid

Key findings

• Strong patient/nurse relationship

• Compassionate care

Opportunities

• Accessibility to contacts

• Consistent patient education

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Looking Forward

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• Year One Celebration and Raising Awareness • Grand Rounds on the EHH test of change

• Learning opportunity for physicians • Main target: Hospitalists

• Year Two Forecast• Potential partnership with vendor to pilot wearable technology that

could improve patient care• CS-Link Integration (home health module)• Continue empathy interviews and other performance improvement

initiatives

Thank you!

Any Questions?