Caring Wisely FY 2025 Project Contest

Expedited Post-Discharge Enrollment into Care at Home: Reducing Length of Stay and Preventable Readmissions for Medically Complex Homebound Older Adults

Submitted by Robert Zimbroff on March 1, 2024 - 12:21pm Last revised by Robert Zimbroff on March 29, 2024 - 4:38pm.

Proposal Status:

Selected for 2nd Round

PROJECT LEADS

Robbie Zimbroff, MD - Assistant Professor, Division of Geriatrics; Assistant Medical Director, Care at Home (Outpatient Lead)
Todd James, MD - Professor, Division of Geriatrics; Co-Lead, Age-Friendly Emergency Department (Inpatient Lead)
Melody Luo, MPH - Age-Friendly Health Systems QI Specialist (Admin and QI lead)

EXECUTIVE SPONSORS

Cynthia Barginere, DNP, RN, FACHE - President of Adult Services, UCSF Health; Senior Vice President, UCSF Health
Gina Intinarelli, RN, MS, PhD - Vice President and Chief Population Health Officer, UCSF Health; Associate Dean for Clinical Affairs, UCSF School of Nursing; Associate Chief Nursing Officer, Institute for Nursing Excellence

ABSTRACT

Home-based primary care (HBPC) provides longitudinal, interdisciplinary care for medically complex, vulnerable patients in their place of residence. Homebound patients often have high Emergency Department (ED) and inpatient utilization rates because they cannot access appropriate primary, urgent, and palliative care due to physical, cognitive, and social complexities. Nationally, HBPC consistently reduces inpatient hospitalization and ED utilization for homebound older adults.^1-10 Since 2017, UCSF’s HBPC practice, Care at Home (CAH), has reduced inpatient hospitalization by 27% and ED visits by 18% in the twelve months following enrollment. Geriatricians staffing four inpatient services at UCSF Parnassus Hospital currently identify vulnerable admitted patients who are appropriate for CAH referral, but to date, the standard referral and admission workflows have not enabled seamless and expedited enrollment essential for immediate post-discharge continuity of care. While CAH does accept referrals from the inpatient setting, enrollment takes weeks before a provider’s first home visit. In this Caring Wisely submission, we propose an expedited enrollment pathway to admit eligible Parnassus inpatients directly into CAH upon discharge. Our primary outcome is reducing index admission length of stay (LOS) for patients enrolling into CAH on discharge. Our secondary outcomes are reducing hospital readmissions and ED visits and preventing primary care-sensitive admissions. The aims of this proposal align squarely with four objectives of Caring Wisely: improving hospital throughput and reducing excess inpatient bed days, reducing hospital readmissions, preventing unnecessary admissions, and improving clinical access.

TEAM

Robbie Zimbroff, MD - Assistant Professor, Division of Geriatrics; Assistant Medical Director, Care at Home
Todd James, MD - Professor, Division of Geriatrics; Co-Lead, Age-Friendly Emergency Department
Melody Luo, MPH - Age-Friendly Health Systems QI Specialist
Rebecca Conant, MD - Professor, Division of Geriatrics; Medical Director, Care at Home
Stephanie Rogers, MD - Associate Professor and Associate Chief, Division of Geriatrics; Medical Director, Inpatient Geriatrics at UCSF Parnassus; Director, Age-Friendly Health Systems at UCSF
Michael Helle, NRP/CCP, FP-C, MHA, MBA - Director, Clinical Programs, Office of Population Health
Irina Kaplan, RN, BSN - Practice Manager, UCSF Care at Home
Megan Rathfon, NP - Provider, Acute Care for the Elders (ACE) Unit

PROBLEM

Homebound older adults have limited-to-no access to primary care, whether due to disabilities or medical and social conditions that make it difficult or impossible to leave their homes. As a result, homebound individuals often rely on ED and inpatient care for treatment of preventable sequelae of chronic conditions. Homebound individuals are twice as likely as matched, non-homebound counterparts to be hospitalized for any reason and three times as likely to be admitted for a potentially preventable diagnosis. ED utilization is 65% higher for homebound individuals.¹¹

San Francisco is home to tens of thousands of adults who meet the Center for Medicare & Medicaid Services (CMS) definition of homebound status. Over 29,000 San Franciscans receive In-Home Supportive Services (IHSS), a Medi-Cal program for persons requiring assistance with Activities of Daily Living (eating, bathing, dressing, grooming, toileting, transferring, ambulating).¹²^,¹³ Over 50,000 community-dwelling San Franciscans ≥ 65 years old report a disability.¹⁴ And while 18.3% of San Franciscans are ≥ 65 years old, this population represents 46% of all UCSF inpatient discharges.

At UCSF, homebound older adults not enrolled in HBPC have high ED and inpatient utilization rates with extended lengths of stay. In the twelve months prior to enrollment in CAH, homebound patients admitted to Parnassus utilized the Parnassus ED an average of 2.4 times and were admitted to Parnassus wards an average of 1.7 times. The average LOS for each admission was 18 days.

One means of addressing prolonged LOS, unnecessary readmissions and ED utilization, and potentially avoidable admissions is to enroll medically complex, homebound older adults into UCSF’s CAH program. CAH has demonstrated success in reducing inpatient utilization: hospitalization reduced by 27%, ED visits reduced by 18%, and average pre-enrollment LOS of 18 days reduced to 6.5 days post-enrollment. However, the average time between referral placement and first provider visit is six weeks. Inpatient providers are often left with less-than-ideal discharge planning options for homebound patients at high risk of re-hospitalization. Expedited enrollment into CAH on the day of discharge (versus 6 weeks later) may provide a better transition into outpatient primary care.

TARGETS

Target 1: Reduce index admission LOS by an average of 2 days for homebound patients admitted to Parnassus through expedited enrollment into Care at Home.
Target 2: Reduce hospitalizations by 27% within 12 months of expedited enrollment from Parnassus into Care at Home.

Below we highlight the future state the targets of this proposal aim to achieve:

	Current State	Future State
Average LOS, Index Admission	18 days	At least 2 days shorter, on average
Referral to CAH	Ad hoc patient identification and referral to CAH from the inpatient providers	CAH referral is integrated into normal multidisciplinary rounds and discharge planning workflow
Discharge planning	Inpatient provider has difficulty with safe discharge planning given a lack of options to manage complex medical and social needs at home. CAH provider relies on chart review for post-acute follow-up needs.	Inpatient provider can plan safe discharges to CAH knowing patients will have close follow-up by phone and in person. Standardized handoff process to readily identify post-acute needs for CAH providers on index home visit.
Post-Acute Follow-up	6-week interval between referral placement and first provider home visit	Managed by phone from the day of discharge, seen by CAH provider within 5 business days
Patient Scheduling	Scheduling limited by provider availability in patient’s home zip code	No delays scheduling new patients within 5 days of hospital discharge
Primary Care Access	Homebound patient has limited primary care access due to mobility and/or medical limitations	Homebound patient receives longitudinal primary and urgent care at home starting the day of discharge from Parnassus
ED / Inpatient utilization	Homebound patient has high ED and inpatient utilization due to poor primary care access	CAH provides primary care access, leading to 18% lower ED utilization and 27% lower hospitalization rate
Average LOS per subsequent admission	18 days (per chart review of CAH patients prior to CAH enrollment)	6.5 days (actual observed Parnassus LOS for CAH patients in FY23)

GAPS

The gap this proposal seeks to address is CAH’s six-week delay from referral to first provider visit. This gap leaves inpatient providers caring for medically complex, homebound patients admitted to Parnassus (i.e., potential CAH patients) without good options for close post-discharge follow-up. Discharge is often delayed by the lack of available post-discharge care options, care which CAH could provide but for its extended intake process. The delay between referral and the first provider visit likely contributes to the longer lengths of stay (average 18 days) for these patients and risks potentially preventable readmissions in the post-discharge period before the first CAH provider visit.

We identify three components of CAH’s current practice that contribute to the gap described above:

At present, CAH has no workflow for expedited enrollment. The CAH intake process involves in-depth eligibility, home safety, medical appropriateness, and insurance screenings that are time-intensive workflows for CAH patient coordinators and care managers prior to an initial provider home visit.
Scheduling new patients has always been geographically determined, not time-from-discharge-based. CAH providers collectively cover all zip codes in San Francisco, but individual providers only see patients within a subset of geographically clustered zip codes. New patient scheduling has historically been determined by provider availability in the zip code where a patient resides.
Post-discharge management is time- and resource-intensive. CAH patient coordinators and medical providers make significant efforts to ensure smooth transitions of care.

With support from the Caring Wisely program, we believe these 3 gaps can be closed with human-centered design of the above workflows without increasing CAH staff FTE.

INTERVENTION

We outline below each step of our proposed intervention. We include the responsible stakeholder and setting for each step (in parentheses). We also outline potential barriers to implementation as well as potential countermeasures to these barriers. If selected, we anticipate significant opportunities to hone these potential countermeasures further through PDSA cycles and with the support of implementation science coaching from the Caring Wisely team.

Following the table, we discuss our plans to measure and close equity gaps. We are eager to work with Caring Wisely implementation science coaches and benefit from technical assistance to help realize this intervention and attain a sustainable direct enrollment pathway for vulnerable patients.

Step	Potential Barriers	Proposed Countermeasure
Admitted patient identified as potentially eligible for CAH (inpatient provider during index admission)	Manual provider screening could add time to existing provider workload.	Create an ApeX report that identifies admitted patients potentially eligible for CAH, including: age ≥75 with ≥3 Parnassus admissions in prior 12 months and lives in San Francisco, age ≥75 with dementia-related admission and lives in San Francisco, age ≥75 with documented activity of daily living (ADL) impairment, no PCP, and lives in San Francisco.
Patient or caregiver is asked if they are interested in CAH (inpatient provider during index admission)	Explaining program details of CAH and transition of primary care could add time to provider workload or rounding time.	Design informational materials (e.g., patient brochure) to overview the CAH program in easy to understand language.
Basic eligibility screening performed (hospital-based Age-Friendly Health Systems QI Specialist)	QI specialist will need to speak to the patient, which could lead to patient confusion about QI specialist’s role on the inpatient treatment team.	Standardize language for QI specialist to introduce themselves, include eligibility criteria in patient informational materials.
Referral placed to CAH (inpatient provider during index admission)	QI specialist performing eligibility screening would have to confirm with provider prior to order placement, which could delay subsequent steps.	Systematize communication during MDR rounds to review all interested / eligible patients for provider referral to CAH.
Insurance review (CAH Patient Coordinators after referral is placed)	Somewhat specialized, lengthy task performed by CAH Patient Coordinators would need to be completed before inpatient discharge (i.e., when CAH assumes care)	Referring provider marks ApeX referrals for expedited enrollment as “urgent” to help CAH Patient Coordinators triage insurance review priority.
Transitional care hand-off prior to discharge (inpatient provider, CAH Care Manager [RN], by telephone)	Coordinating telephone availability for hand-off may be difficult and add to existing provider workloads. Unclear what documentation is needed / burdensome for this step.	Iterate peer-to-peer dot phrases to communicate essential information, utilize information gathered from Geriatrics/ACE Unit Consult Notes, familiarize CAH Care Managers with Voalte.
Care manager contacts patient within two business days of discharge (CAH Care Manager, by telephone)	Patient may have limited telephone access, sensory impairment limiting phone use. Patient may not remember or understand role of CAH post-discharge.	Confirm communication preferences prior to discharge (part of current state referral process).
Provider sees patient within five business days (CAH Provider, at patient’s residence)	Index visit workflow may vary from usual admission visit based on post-acute needs. Patient may not remember or understand role of CAH post-discharge.	Iterate New Patient note as needed for expedited enrollment patients, have CAH Case Manager confirm visit prior to provider arrival.
Longitudinal HBPC (CAH team, at patient’s residence)	Patient may choose not to continue with CAH. Patient may need a higher level of care (e.g., SNF).	Review patients who go through the expedited enrollment pathway bi-weekly, understand root causes of those choosing not to continue with CAH or at inappropriate level of care.

Measuring and closing equity gaps: Providing equitable care is a core value of CAH’s practice. CAH routinely tracks equitable care provision in its internal “Monthly Scorecard” via several measures, which include the following metrics: race and ethnicity of empaneled patients, enrollment wait time (days) by zip code, enrollment wait time (days) race and ethnicity, enrollment (total) by zip code. CAH has successfully reduced its enrollment wait time, including in underserved zip codes, due to new provider availability (median of 284 days in June 2023 as compared to median of 46 days today). We would continue to track and improve equitable care provision via the existing Monthly Scorecard and in weekly team meetings. We will report these metrics to the Caring Wisely team. Our most recent scorecard is in the supplementary materials for reference.

PROPOSED EHR MODIFICATIONS

CAH has several existing EHR tools in place to manage referrals and track the quality of care that are directly applicable to this proposal. These include an active referral order (Ambulatory Referral to Care at Home) and a Work Queue list of active CAH referrals. A Monthly Scorecard is also generated using EHR data, which includes information on monthly admissions, readmissions, and equity measures. We do not anticipate any major EHR modification needs in implementing this proposal (other than some communication dot phrases we will use to communicate between the inpatient and outpatient Geriatrics teams). We will need to update our Monthly Scorecard (which pulls data from the EHR) to specifically identify and track patients admitted to CAH through the proposed expedited enrollment pathway.

RETURN ON INVESTMENT (ROI)

We estimate this proposal's total ROI to be $733,920. Our estimate includes $264,000 in direct cost savings by reducing LOS of the index admission at Parnassus (analysis based on real-time chart review of actual patients).^dWe also estimate the contribution margin of 160 bed days made available to treat additional patients at Parnassus to be $469,920. The contribution margin was calculated using UCSF Finance data and with guidance from UCSF Health Value Improvement and is felt to be a conservative estimate. Finally, we also estimate the downstream effect of patients enrolling into CAH by reducing readmissions, ED visits, and LOS of subsequent hospitalizations (based on actual CAH data from 2017 to the present).^h

Direct Cost Savings from Reduced LOS (80 Patients Enrolled in Year 1)

	Expected LOS	Observed (Avg) LOS	Projected Patients	Expected LOS Reduction	Cost/Day	Potential ROI
Age ≥75 with ≥3 Parnassus Admissions^a	8.4^c	7.5^c	40	2 days^d	$1,650^e	$132,000
Age ≥75 with Dementia-Related Admission^b	8.3^c	17.7^c	40	2 days^d	$1,650^e	$132,000
Total			80			$264,000

Contribution Margin of Acute Bed Day Backfill (160 Bed Days for 80 Patients Enrolled in Year 1)

	Projected Patients	Expected LOS Reduction	Bed Days Saved	Contribution Margin per Bed Day	Potential ROI
Age ≥75 with ≥3 Parnassus Admissions^a	40	2 days^d	80	$2,937^f	$234,960
Age ≥75 with Dementia-Related Admission^b	40	2 days^d	80	$2,937^f	$234,960
Total	80		160		$469,920

Readmissions Reduction: 80 Patient Enrolled in Year 1

	12 months pre-CAH (encounters)	12 months post-CAH utilization reduction (%)	12 months post-CAH (encounters)	Admits saved (encounters)
Parnassus ED utilization	192^g	0.18^h	157.4	34.6
Parnassus hospitalizations	136^g	0.27^h	99.3	36.7

Observed/Expected LOS

	Expected LOS	Observed (Avg) LOS
Age ≥75 with ≥3 Parnassus Admissions	8.4^c	7.5^c
Age ≥75 with Dementia-Related Admission	8.3^c	17.7^c
CAH patients enrolled in FY23	8.1^c	6.5^c

^a We describe two comparator populations whose characteristics, as described, may indicate appropriateness for CAH. The first population consists of all individuals age ≥75 admitted to Parnassus ≥3 times in FY 2023. Patients were included if admitted to Hospital Medicine and excluded if they were admitted to other services (e.g., Heme/Onc, Neurosurgery, Kidney Transplant, etc.). n = 419 patients.

^b The second comparator population chosen were individuals age ≥75 admitted to Parnassus for a dementia-related diagnosis in FY2023. n=100 patients. (Currently, approximately 40% of CAH patients have a diagnosis of dementia).

^c Observed and expected LOS were calculated by the Caring Wisely team using data from tag.bio. CAH observed vs expected LOS was calculated for patients enrolled in CAH during FY 2023 using tag.bio data.

^d Expected LOS Reduction was calculated by chart review of patients identified by inpatient Geriatrics providers as potentially CAH-eligible from 2/19/24-2/23/24. In one week, providers identified 13 potentially CAH-eligible patients; 8 discharged to home (all with home health services) and 5 discharged to SNF. Two providers reviewed the admissions of the 8 patients discharged home and found 16 opportunity days (average 2 opportunity days/admission) based on case management notes, inpatient provider disposition estimation, and clinical documentation.

^e Direct variable cost per day of an acute bed was provided by the Caring Wisely team.

^f Financial analysis conducted by UCSF Finance for an awarded Caring Wisely FY23 proposal: “Revitalizing Transfers: Creating an EHR-based admission and lateral transfer decision support tool to identify patients for transfer to non-Parnassus sites.” This proposal calculated an ROI based on increasing Parnassus bed availability (through lateral transfers to other hospitals). We similarly propose increasing Parnassus bed availability (through expediting discharges for homebound patients with difficult, often delayed, dispositions). This analysis calculated an average LOS for Medicine patients of 8.3 days and an average contribution margin of $56,189 per case for tertiary and quaternary (T/Q) cases and $24,380 for all cases (including T/Q and non-T/Q cases). We have estimated contribution margin conservatively using T/Q and non-T/Q cases, and is thus calculated to be ($24,380/case)/(8.3 days/case) = $2,937/day.

^g These estimates are obtained by multiplying the average ED and inpatient utilization for actual CAH patients admitted to Parnassus in the 12 months prior to enrollment (2.4 Parnassus ED presentations, 1.7 Parnassus admissions) by our anticipated 80 patients enrolled in Year 1.

^h Twelve months following actual CAH enrollment, patients have 18% lower ED utilization and 27% lower inpatient utilization (data from 2017-present).

SUSTAINABILITY

This Caring Wisely proposal would help support the initial implementation and iteration of a sustainable CAH referral and enrollment pathway. In addition to relatively high patient turnover (approximately 30% annually), CAH has recruited several new providers, increasing our enrollment capacity. In FY23, CAH had 8 providers (4.425 FTE). Provider availability limited new enrollment. In FY24, CAH added two new physicians (1.25 FTE), and in FY25, we anticipate adding up to four additional physicians (2.7 FTE). This expected growth increases our practice FTE by 90% and practice capacity by 136% (the discrepancy is due to larger panels held by MDs than NP providers). This growth is one of the largest growth rates in primary care across the UCSF system, which we hope to leverage to implement and sustain this expedited enrollment program.

Our proposal includes a conservative ramp-up plan for monthly enrollment via this expedited enrollment pathway. We budget for enrolling one patient weekly for FY25 Q1, 1.5 patients weekly for FY25 Q2, and two patients weekly for FY25 Q3 and Q4.

BUDGET

Item	Cost
Salary support for project CAH lead (0.1 FTE)	$29,000
Salary support for project Inpatient co-lead (0.05 FTE)	$17,000
Educational materials (handouts, advertisements, etc.)	$2,000
Inpatient-outpatient team education and PDSA events supplies	$2,000
Total	$50,000

Supporting Documents:

CAH Monthly Scorecard - February 2024

CAH Caring Wisely References

Comments

As an adult geriatrtic

Ashley Johnson - March 1, 2024 - 3:19pm

As an adult geriatrtic primary care nurse practitioner working in dementia care, I find the care at home program an integral part of care for our aging population. Since most of my work involves calling patients in the comfort of their homes, supporting the care at home program will help to increase access. My patients have expressed appreciation of being cared for in their homes.

Our patient population is

Carolyn Welty - March 1, 2024 - 3:43pm

Our patient population is getting older and with more disability and need more medical care at home to prevent rehospitalization

We see many older adults in

Anna Hines - March 1, 2024 - 4:24pm

We see many older adults in the emergency department (AFED) who are unable to leave their homes independently. Getting to a PCP appoinment is extremly challenging and can require signficant effort and resources leading to insufficient engagement with primary care. Patients often share they are unable to safely get up and down stairs, have transportation constraints, and lack of caregiver support. Investing in the Care at Home program not only supports compassionate and age-friendly care, it will help reduce barriers and inequities for our community's most vulnerable older adults.

Amazing! This is much needed

Qiao Yu Kuang - March 1, 2024 - 4:27pm

Amazing! This is much needed for our growing older adult population with complex medical and social needs. Meeting patients where they're at is absolutely necessary for improving access to care.

I just spent a month on the

Ryan Mcmahan - March 1, 2024 - 6:43pm

I just spent a month on the care at home rotation for my geriatrics fellowship and finding ways to streamline referrals would be an excellent way to expand this vital program for our most vulnerable elders. This is a great idea!

This is such an important

Louise Walter - March 1, 2024 - 6:50pm

This is such an important proposal that will help hospitalized older adults return to their homes sooner and avoid hospital readmissions. Fantastic idea!

This is such an important

Leah Witt - March 1, 2024 - 7:04pm

This is such an important project!

This proposal is integral to

Michelle Delk - March 2, 2024 - 12:07pm

This proposal is integral to the work that needs to be done here as part of providing complete care to our patients that are medically complex. Support for this program is vital!

This is an extremey well

James Harrison - March 3, 2024 - 4:06pm

This is an extremey well designed proposal supporting Age Friendly care transitions for a vulnerable and high need population. This proposed program would have significant impact for patients, clinicians and the health system.

The Care at Home program is

Armond Esmaili - March 3, 2024 - 5:07pm

The Care at Home program is an incredibly impactful clinical service to its patients -- this proposal is extremely thoughtful. I'm curious if there might be an opportunity to leverage our EHR to automatically identify (via certain patient criteria like age, diagnoses, and frequency of hospital admissions) patients who might be eligible for CAH enrollment (instead of relying upon manual provider screening for eligible patients).

As a provider and clinical

Mitchel Erickson - March 3, 2024 - 10:18pm

As a provider and clinical lead on the Age-friendly ED Consult Service patient access to the most appropriate modality of post-ED or post-hospitalization care is a significant challenge. The lack of access impedes timely discharge or results in admission when an ED discharge plan is not acceptable without timely follow-up care. Family and caregivers are challenged with transporting patients to appointments when they are essentially homebound. San Francisco is a city of topographical challenges for older adults with frailty. Access to home-based care would improve the patient/family/caregiver experience, enable timely discharge planning from all clinical settings when primary care is absent or inaccessible, and potentially reduce skilled nursing home transitions. This proposal supports the mission/vision/values of UCSF Health.

Highly significant proposal

Ashwin Kotwal - March 4, 2024 - 8:40am

Highly significant proposal and impressive preliminary data suggesting feasibility and likelihood of improving patient-related outcomes for older adults with complex medical needs. Thanks for doing this work!!

This is a very important

Gina Intinarelli - March 4, 2024 - 9:00am

This is a very important performance improvement initiative that takes advanatge of exisiting infrastcruture on the Care at Home team, thus allwoing for ongoing sustainability.

What a great proposal. I

Misti Meador - March 4, 2024 - 12:41pm

What a great proposal. I agree this would have a significant impact on LOS. Many of our high-risk homebound clients have a difficult time accessing services because they cannot leave their home for appointments and struggle with technology needed for Telehealth visits.

Such a meaningful and

Olivia Bernal - March 4, 2024 - 2:13pm

Such a meaningful and impactful proposal to expand access to care for older adults! So important!

Not only will this

Candace Kim - March 6, 2024 - 4:49pm

Not only will this intervention likely affect patient related outcomes for our frail and functionally dependent community individuals, it will also be a huge resource for the caregivers who will be looking after them when they return home from the hospital. This is a tremendously thoughtful proposal.

Fantastic proposal to address

Stacy Han - March 7, 2024 - 8:15am

Fantastic proposal to address a significant gap in care for vulnerable older adults. This intervention would have such meaningful impacts on transitions of care, long-term healthcare access, and prevention of re-hospitalization for homebound older adults.

This will proposal will help

Krista Harrison - March 8, 2024 - 4:04pm

This will proposal will help meet demand for home-based services for homebound older adults. Great proposal, outstanding team, likely to have high ROI.

Thank you for submitting this

Catherine Lau - March 11, 2024 - 1:30pm

Thank you for submitting this excellent proposal that harnesses the planned, budgeted increases in staffing of the Care at Home program with making the overall enrollment of patients into the program more streamlined and efficient. A few points of feedback to address in the 2nd round:

1) I appreciate you outlining each of the steps of your intervention and some of the potential barriers. I would encourage you to think about how you might address each of these barriers -- for instance creating a "proposed countermeasures to barriers" column in the table. For instance, relying on manual provider screening and/or having the rounding provider approach the patient about Care at Home could add a lot of time/energy to already busy inpatient providers. Could their be other alternatives that are explored?

2) Would advise you use the number of $1650 for direct variable costs per day of an acute care bed for your ROI calculation instead of dividing the total direct costs by the overall LOS. This is because the direct costs of the hospital stay tend to be more frontloaded (more tests, imaging, procedures done) and the costs aren't evenly distributed across the hospitalization. This will make your ROI more conservative and realistic to the Caring Wisely Executive Committee.

Thanks so much for this

Robert Zimbroff - March 29, 2024 - 12:58pm

Thanks so much for this feedback! We address each of the comments below:

1) We have updated our "Steps / Potential Barriers" table to include a third column, “Proposed Countermeasures.” If selected, we anticipate many opportunities to hone these potential countermeasures further through PDSA cycles and with the support of implementation science coaching from the Caring Wisely team. We are eager to work with the Caring Wisely team to develop and implement countermeasures that will maximize the likelihood of success of this proposed expedited enrollment pathway.

2) We appreciate the guidance regarding the direct variable cost per day of an acute care bed at Parnassus and reflect this change in our updated ROI calculation. We have also updated our Expected LOS reduction estimate based on additional information since our initial submission.

In our initial proposal, we described calculating the Expected LOS Reduction via chart review of patients admitted to Parnassus from 2/19/24-2/23/24 identified by inpatient Geriatrics providers as potentially CAH-eligible. Inpatient Geriatrics providers identified 13 potentially CAH-eligible patients. At the time of our initial submission, 7 discharged to home (all with home health), 4 discharged to SNF, and 2 were still admitted. Both patients who were admitted at the time of our initial submission have now been discharged. One of these patients discharged to SNF, and the other discharged to home (again with home health). We identify at least 3 opportunity days in this latter admission.

Our Expected LOS Reduction estimate now reflects this additional information. Our proposal now reads as follows (Direct Cost Savings table, footnote D): "Two providers reviewed the admissions of the 8 patients discharged home and found 16 opportunity days (average 2 opportunity days/admission) based on case management notes, inpatient provider disposition estimation, and clinical documentation."

Finally, in addition to calclulating direct cost savings savings (as above), we have also estimated the contribution margin of 160 bed days made available to treat additional patients at Parnassus. The contribution margin was calculated using UCSF Finance data and with guidance from UCSF Health Value Improvement. This analysis is described in footnote F of the Contribution Margin of Acute Bed Day Backfill table.

This is such an important and

Angelin Cheng - March 13, 2024 - 11:28pm

This is such an important and thoughtful proposal that would help reduce many of the barriers that homebound older adults and their families/caregivers face in accessing medical care after a hospitalization.