To improve care for patients with complex needs, such as homelessness, substance use disorder, and mental illness, Santa Clara Valley Medical Center developed the Post-Acute Care Transitions (PACT) initiative, which focuses on patients who are medically stable, but who do not yet have a safe discharge plan after hospitalization. Using a multidisciplinary approach, PACT coordinates a seamless transition for patients from the hospital to a contracted nursing home where patients can access resources related to mental health, homeless medicine, substance use, wound care, housing programs, and palliative services. Once the patient is ready for discharge from the nursing home, a team-based assessment informs a care coordination plan for patient integration back into the community. Since the program’s start in 2018, hospital length of stay for non-acute patients decreased by 50% from 70 to 35 days and hospital bed capacity increased by more than 5,000 hospital bed days – the program overall resulted in potential cost avoidance of over $11M. In addition, PACT patients had a low 30-day readmission rate of 5.5% and improved access to follow-up care.
Performance Excellence - San Joaquin General Hospital
The prevalence of Heart Failure (HF) is increasing both nationally and in San Joaquin County. To better care for patients with HF and prevent HF-related admissions and emergency department visits, San Joaquin General Hospital implemented a team-based care model consisting of an internist, pharmacists, nurse care manager, registered dietician, and health coaches. The new HF clinic, co-located within primary care to improve collaboration and communication, was designed to improve access, provide multilingual and multicultural care, engage and empower patients to support lifestyle changes and self-management, ensure transitions from inpatient care into the HF program, and address social needs. Patients were also provided with one-one-one coaching, transportation to and from the clinic and pharmacy, and nursing support services by phone. On average, patients with at least one visit to the HF clinic experienced a 35% reduction in emergency department visits, a 67% reduction in admissions, and a 68% reduction in length of stay, resulting in a cost decrease of approximately $365,000 over the first year.
Data-Driven Organizations - Riverside University Health System
Riverside University Health System (RUHS) data shows that approximately 90% of the time, patients have unidentified non-physical health needs that may be more pressing than their physical health needs. Although tools exist to screen patients for social needs, few, if any, integrate social and physical needs into the same assessment or provide an actionable score that can easily guide care teams to prioritize needs. To address this gap, RUHS created the Whole Person Health Score, a six-letter score that quantifies an individual’s Physical Health, Emotional Health, Resource Utilization, Socioeconomics, Ownership/Activation, and Nutrition/Lifestyle (PERSON). Initially piloted at the RUHS Medical Center, results from the Whole Person Health Score showed that 50% of patients had emotional health needs, 61% had resource utilization needs, 80% had socio-economic needs, 77% had ownership/activation needs, and 89% had nutrition/lifestyle needs. These findings led to an increase in social needs referrals, including a 34% increase in nutrition visits. Patient experience also improved with increased ratings in provider communication (73% to 92%) and time spent with patient (63% to 85%), even though visit duration remained unchanged, demonstrating that providers are more focused on what’s most meaningful to patients. Use of the tool, which is now available within their electronic health record, has spread to nine community health center locations, and numerous trainings have been held across RUHS and with local community programs. RUHS will continue to leverage the information gathered by the PERSON score to improve care, engage patients on what matters most to them, and make connections to community-based services that make a difference in patients’ lives.
To address the opioid epidemic, LAC+USC Medical Center Adult Primary Care implemented a series of interventions to safely reduce opioid prescribing for patients experiencing chronic, non-cancer pain. Their model, launched at a large training clinic site with residents, included changes at the local clinic level, collaborative partnerships with other hospital departments and community partners, and alignment with larger Los Angeles County Department of Health Services initiatives. Key components included improving patient-provider continuity by shifting care supervision of patients receiving opioids to core faculty, increasing the visit frequency for these patients, and empowering pharmacy oversight to monitor prescribing practices. The program also included the treatment of opioid addiction when necessary, integration of social work and psychiatry services into the clinic, rolling out universal screening for depression and anxiety, which are known to increase the perception of pain, and increasing referrals to The Wellness Center where patients can access alternative pain management options, such as yoga and acupuncture. Over the two-year period, there was a 74.3% reduction in total quantity of opioids prescribed and a 66.5% reduction in morphine milligram equivalents prescribed per patient – the program overall reduced the risk of overdose for the average patient by a factor of four.
QIP PY4Reporting Manual User Agreement AMAPQA CMS v20210125
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