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Long Term Acute Care Community Study

Santa Cruz Long Term Acute Care (LTAC) Community Study

Santa Cruz County, California, has the lowest long term care hospital costs for Medicare beneficiaries in the United States.

Based on the Dartmouth Atlas of Health Care data, the Santa Cruz Hospital Referral Region (HRR) has the lowest per capita cost for Long Term Acute Care (LTAC) hospital expenditures for Medicare beneficiaries in the country-yet the reasons behind these low rates are not readily apparent.

The Santa Cruz Long Term Acute Care Community Project seeks to answer the question, "What are the conditions that contribute to lower per capita spending for LTAC services in the Santa Cruz HRR?"

The national Centers for Medicare & Medicaid Services (CMS) has asked Health Services Advisory Group of California, Inc. (HSAG-California), the state's Medicare Quality Improvement Organization, to collaborate with the Santa Cruz community on a special innovation project to explore and explain the factors that contribute to the low cost of long term acute care hospital expenditures in Santa Cruz County. The goal is to improve health while saving money by not only applying our findings to sustain the Santa Cruz effort, but also by spreading these best practices to other communities nationwide.

About Long Term Acute Care (LTAC) Hospitals

LTAC hospitals are certified as acute care hospitals that focus on patients who, on average, require an extended length of stay of more than 25 days beyond their short term acute hospitalization. LTACs consist of 24-hour inpatient comprehensive medical and rehabilitative services and provide aggressive, specialized interdisciplinary care to medically complex patients who require extended recovery time. Services may include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management.

Santa Cruz County currently does not have an LTAC hospital; the closest LTAC provider is in San Leandro.

Long Term Acute Care Community Study Leadership Team

This special innovation project brings together a broad coalition of healthcare providers and health quality stakeholders to form a Leadership Team.  The Leadership Team serves as an advisory group for several aspects of the project including engaging the broader community through the Learning and Action Network (LAN) meetings, data collection and analysis, and designing and implementing small tests of change to help improve care in the Santa Cruz community.

Eleanor Littman RN, Co-Chair


Michael Milward, Co-Chair

Hospice of Santa Cruz County

Audra Earle

Watsonville Community Hospital

Carlos Dobkin PhD

UC Santa Cruz

Janice Sanning RN

Dominican Hospital

Jo Coffaro

Hospital Council of Northern and Central California

Julio Porro MD

Central California Alliance for Health

Kelli Cole

San Francisco Bay Area LTAC - Kindred Healthcare

Lawrence deGhetaldi MD


Lois Widom


Marise Goetzl

Pacific Coast Manor

Rob Quinn MD

Dignity Health Medical Group

Sharon Tapper MD

PAMF/Dominican Hospital Palliative Care

Long Term Acute Care Community Study Events

Leadership Team Meeting - November 16, 2012

The first Leadership Team meeting served as an introductory meeting to the Santa Cruz Long Term Acute Care Community Project as well as a way for members of the Leadership Team to meet each other.  HSAG staff provided an overview of CMS Special Innovation Projects and the Santa Cruz Long Term Acute Care Community Project.  HSAG staff also discussed the initial findings of the Root Cause Analysis of quantitative data to help determine why the Santa Cruz HRR has the lowest per capita cost for LTAC hospital expenditures for Medicare beneficiaries in the country.  The Leadership Team also discussed and planned how to engage the broader community in the upcoming Learning and Action Network (LAN) meeting.

Leadership Team Meeting - December 7, 2012

During the second Leadership Team meeting, HSAG staff presented further findings of the Root Cause Analysis of quantitative data.  Staff from the Colorado Foundation for Medical Care (CFMC), a Quality Improvement Organization overseeing several similar projects in other states, presented the Appreciative Inquiry methodology for the upcoming LAN meeting.  The Leadership Team discussed plans for the LAN meeting including reviewing the format of the meeting, compiling a list of participants to invite, and developing interview and group discussion questions for the meeting. 

Learning and Action Network Meeting - January 10, 2013

Peg Behan and Rama Khalsa discussing Long Term Acute Care in Santa Cruz County at the LAN meeting.

The Learning and Action Network (LAN) meeting brought together about 50 community members representing a broad range of healthcare, community, and social service organizations.  The purpose of the LAN meeting was to hear the community perspective on how Santa Cruz has created a health care community with high quality of life, high quality of care, and relatively low costs. This meeting was the beginning of a series of activities designed to engage the community in discovering the reasons, values, and conditions for these results.

The meeting used an Appreciative Inquiry method for gathering the community perspective through one-on-one interviews and group discussion.  Appreciative Inquiry is a unique process that offers community members an opportunity to reflect on the existing strengths within the community, to discover what is important, and build a collective vision for the future. 

HSAG will use the interview and group discussion summaries to inform the qualitative portion of their Root Cause Analysis to help determine why the Santa Cruz HRR has the lowest per capita cost for LTAC hospital expenditures for Medicare beneficiaries in the country.

Leadership Team Meeting - March 22, 2013

At the third Leadership Team meeting, the Leadership Team adopted a work plan for the last six months of the project.  This work plan includes tests of change, focusing on improving the post-hospital decision planning process in the Santa Cruz County hospitals.  Also, HSAG staff presented further findings from the third Root Cause Analysis of quantitative and qualitative data.  The qualitative data consists of themes and key findings from interviews conducted at the Learning and Action Network Meeting on January 10, 2013.  The Leadership Team then discussed their key findings from the first six months of the project which included: local collaborative leadership, a supportive and resourceful community, lack of patient and provider understanding of LTAC services, and overall low hospital admissions and readmissions indicating high quality care.

Leadership Team Meeting - May 17, 2013

The fourth Leadership Team meeting focused on adopting a Consensus Statement of study findings, a report on the hospital tests of change, and planning the upcoming second Learning and Action Network (LAN) meeting.  The Consensus Statement, adopted by the Leadership Team, described two main factors that are thought to contribute to the low utilization of LTAC services in the county: substitution of services and low demand for LTAC services. The report of the test of change in the hospital revealed room for improvement in the standardizing the process of post-hospital decision making. Both hospitals have now standardized their workflow around discharge planning. Next, the Leadership Team decided to use graphic facilitation for the July LAN meeting, invite about 60 community members, and focus on The Conversation Project.

About Health Services Advisory Group, Inc. (HSAG)

Health Services Advisory Group, Inc. (HSAG) was established in 1979 by a group of medical professionals whose mutual goal was to make a difference in health care quality improvement.  Over the past three decades, HSAG has become highly skilled in designing and conducting quality of care and outcome studies; collecting, analyzing, and reporting data for quality improvement projects; conducting medical reviews; and collaborating in these efforts with state and federal agencies, managed care plans, and individual providers.  HSAG is an organization focused primarily on providing quality review services for federal and state government.

HSAG of California, Inc. (HSAG-California) is the state's Medicare Quality Improvement Organization (QIO) and one of three subsidiary corporations under Health Services Holdings, Inc. (HSH), the holding company. 

HSAG-California aligns its strategy with the National Quality Strategy Triple Aim to achieve goals of better health care, better health for people and communities, and affordable care. The strategy also articulates six priorities:

  • Making care safer
  • Promoting effective coordination of care
  • Assuring care is person- and family-centered
  • Promoting the best possible prevention and treatment of the leading causes of mortality, starting with cardiovascular disease
  • Helping communities support better health
  • Making care more affordable for individuals, families, employers, and governments by reducing the costs of care through continual improvement.

HSAG-California promotes the quality of services by securing commitments and by being conveners, organizers, motivators, and change agents, and providing a call to action through outreach, education, and social marketing; serving as a trusted partner with beneficiaries, health care providers, practitioners, and stakeholders; achieving measurable quality improvement results through data collection, analysis, education, and monitoring for improvement; facilitating information exchange within the healthcare system; and dissemination and spread of best practices.