California Health Care Improvement Projects (CHIPs)

Implementing CalAIM Community Supports to Create a System of Safe Discharge Options for Challenging Patients from Acute Care Facilities to Decrease Administrative and Denied Days

Medicaid patients remain in acute care settings (acute hospitals, long term acute care hospitals, skilled nursing facilities) because there are no safe, clinically appropriate discharge options. This results in an increased number of administrative or denied days because the patients are no longer clinically acute and are just awaiting placement. Patients who could be in an inpatient bed or in a skilled nursing facility are instead stuck boarding in the emergency department or an inpatient bed. This leads to crowding both in the emergency department and the inpatient setting, which is both bad for the patient and costly for the health care system.

Enhanced Care Management (ECM) and Community Supports (CS), as offered through California Advancing and Innovating Medicaid (CalAIM), can address this problem by increasing the number of safe, clinically appropriate discharge options. The challenge is weaving the discrete benefits and funding streams offered under CalAIM into a system of care that augments the existing discharge options.

This project focuses on the implementation of CalAIM Community Supports by translating CalAIM’s vision into a concrete approach through nontraditional partnerships. The project expands the capacity of existing service providers (personal care services providers, shelters, recuperative care/medical respite, transitional housing, sober living environments, board and cares, assisted living facilities, residential care facilities for the elderly (RCFEs), etc.) through using CalAIM CS to pay for these services and makes them directly accessible to acute care facilities as Medicaid funded discharge options.

Inpatient University: Empowering seamlessly

Often, education of our hospitalized patients occurs in the last few hours of their stay. And there are no standards for how to perform this critical work. This project was inspired by my Spanish-speaking patient, Jose. Jose was re-admitted to our hospital with cirrhosis and volume overload, a new diagnosis that was made just a few months prior to when I cared for him. In exploring what happened, he barely recognized the term “cirrhosis” let alone Lasix and the other medications that were prescribed to control his symptoms. Lots of evidenced-based practices exist for management interventions and clinical care decisions (e.g., goal directed therapy for heart failure or sepsis), but few standards are reinforced around the key education a patient should receive about their clinical diagnoses before they are sent home from the hospital. This project is titled “Inpatient University” as it aims to standardize a patient-centered curriculum to guide the empowerment of our patients. And it aims to make this education and communication as easy and seamless as possible for hospital staff.

There are three key aims for the “Inpatient University” project:
• Standardized education to be delivered to our patients throughout the course of their hospitalization,
• Simple written instructions given to patients at time of discharge, and
• Assurance that instructions on pill bottle labels dispensed from our Discharge Pharmacy are always translated into a patient’s preferred language.

Team Based Care to Reduce Burnout

Clinicians at Keck Medicine of USC are burned out due to the COVID 19 pandemic, competing demands on their time and insufficient support to achieve work life balance. This project was designed to establish a team-based care program at Keck Medicine of USC to reduce clinician and staff burnout in the Family Medicine Department. Burnout affects over 50% of physicians and nurses and leads to reduced access to care due to sick calls, reduced patient safety and lower quality of care. Clinicians are more likely to leave practice due to burnout and depersonalize patients which leads to poor interactions. Keck Medicine was facing a high turnover rate for clinicians and nurses (close to 20%). The goal was to create a team-based care program by December 2022 to reduce clinician burnout and improve engagement. In our health system clinicians spend an inordinate amount of “pajama time” doing charts, paperwork and answering messages. Charts are late, patient messages are unanswered, and prescriptions are not refilled in a timely manner due to burnout. Patient complaints have gone up and patient satisfaction scores decreased. To achieve Team Based care at Keck Medicine the goals were identify the steps, get leadership buy in, launch a prototype. Develop a plan to build the necessary infrastructure, learn the roles of the team members and train to work at the top of the skill sets, understand the barriers to overcome them.