5/10/13 HEALTH CARE REFORM LONGITUDINAL CARE COORDINATION HEALTH CARE REFORM WHY = VALUE WHY WHAT HOW WHEN WHO WHY WHAT HOW WHEN WHO

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1 TRANSITION CARE TRANSITION CARE WHY WHAT HOW WHEN WHO HEALTH CARE REFORM HEALTH CARE REFORM WHY = VALUE WHY WHAT HOW WHEN WHO Cost/Quality equation Higher cost care has not/does not equate with higher quality care Higher quality care does equate with lower cost care VALUE is created by improving Quality with coincident decrease in Cost Improve Quality by increasing COORDINATION of care = COORDINATED CARE is higher quality care COORDINATION LONGITUDINAL CARE LONGITUDINAL CARE = improving patient healthiness TRANSITIONS OF CARE = GAP CONTROL Coordination BEGINS before illness warrants hospitalization, CONTINUES in hospital, MOVES patient seamlessly back into community GAP CONTROL is the critical measure of COORDINATION and QUALITY across continuum of care 1

2 TRANSITION CARE TRANSITIONS = HANDOFFS Vulnerable exchange points that contribute to unnecessarily high rates of health service use and spending Expose chronically ill people to lapses in quality and safety Associated with increased rates of Potentially Preventable Readmissions (PPR) (Naylor et al Health Affairs, 2011) TRANSITIONAL CARE DEFINITION TRANSITIONAL CARE FEATURES time-limited services designed to ensure health care continuity, avoid preventable poor outcomes among at risk populations, and promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another. GOAL ensure health care continuity and avoid preventable poor outcomes TARGET POPULATION highly vulnerable chronically ill SETTING Health care exchange points DURATION time-limited FORMAL DISCHARGE yes ( Care Continuum Alliance -2011) TRANSITION CARE WHY 19.6% of Medicare discharges are rehospitalized within 30 days, 34% in 90 days Striking regional variations MedPAC estimates that 75% of these are avoidable = $12 Billion annually Rates not budging (last epoch ) Accountable Care Act targets this for direct financial penalties to hospitals beginning 10/01/12 2

3 ISSUES Define Preventable Readmission (PPR) ID factors that lead to PPR ID interventions that favorably impact PPR rates Factors that Lead to Readmission Pt illness level Communication with patients and families Medication Reconciliation Coordination and timely f/u with community physician/provider Longitudinal post-discharge care Local pattern of hospital utilization ( Dartmouth Atlas Project -2011) Current Improvement Efforts HOW 1) Better measurement of the problem 2) Better D/C planning and care coordination 3) Change financial incentives to reward/ penalize hospitals based on readmission rates Parker et al Health Tech Assess 2002 Hansen et al AIM 2011 Naylor et al Health Affairs 2011 Accountable Care Act MGMC/ McFarland

4 Hansen et al Categories 12 intervention categories 3 Temporal categories 1) PREDISCHARGE INTERVENTION Patient Education, Discharge planning, Med reconciliation, appt scheduled before D/C 2) POSTDISCHARGE INTERVENTION timely f/u, timely PCP communication, f/u telephone call, pt hotline, Home Visit 3) BRIDGING INTERVENTION transition coach, pt-centered D/C instructions, provider continuity CONCLUSIONS Hansen et al Naylor et al Summary screened 4013 studies 43 met criteria for inclusion did not ID a discrete intervention or bundle of interventions that appear to reliably reduce rehospitalization Avoid critical voltage drop between D/C and f/u appt = facilitate knowledge at transfer and engage the patient = process WITH a pt not TO a pt Continue to study as more are involved in creating processes Comprehensive D/C planning and follow-up Disease or Case Management CONCLUSIONS Naylor et al Accountable Care Act 21 randomized trials robust body of evidence substantiating the benefits of transitional care Successful programs relied on nurse managers comprehensive d/c planning that incorporate pt and caregiver goal setting, individualized care planning, educational and behavioral strategies and clinical management; and telehealth Post discharge follow-up Comprehensive assessments, Care planning Interaction with post acute OP providers Coordination/referrals for community resources, supports Self-management support Comprehensive medication review, mgmt Use of EMR 4

5 MGMC REVIEW Transition Care Steering Committee Local initiatives Resources Processes Experience Interpretation of available literature and recommendations Quality Management First Nurse Respiratory Therapy HOMEWARD MGMC Administration McFarland Clinic Medical Director MGMC COMPONENTS Patient Identification and Tracking Patient Identification and Tracking Daily Care Conferences Patient Education (across continuum) Follow-up Home Care Visit Follow-up Provider Visit First Nurse Tracking Identify from Admitting Problem List, added diagnosis during hospitalization Four Diagnoses COPD, PNEUMONIA, CHF, AMI Label Transition Patient Epic FYI and Best Practice Alerts Add patient to Transition Registry Daily Care Conferences Patient Education (across continuum) Identify, label, and track new Transition Care patients during Care Conference Review List Dx, clinical status update, D/C destination, process update, (nursing unit) List to Unit Secretary Arrange for Materials to be delivered to patient room (clipboard by White Board with Checklist and Diagnosis specific Stoplight) Consistent teaching materials for each diagnoses Booklets, stoplight, videos, Education checklist, Teach Back validation questions, D/C instructions All care sites have the same materials (hospital, HOMEWARD, clinics) 5

6 Inpatient Care Checklist clipboard next to White Board in pt room Letter introducing Transition Care Standardized Disease Specific Education booklet and video Staff validate pt understanding Schedule post- discharge f/u care Take Home Stoplight Action Plan and Discharge Instructions Post Discharge Follow-up Home Care Visit Transition Care Home Visit within hours of discharge Appointment with PCP within 3-5 days of discharge First Nurse Review Stoplight Action Plan, f/ u phone calls every three days for 30 days Visits made within hours of discharge Include patients with AMI, pneumonia, COPD, CHF within HOMEWARD service area ( 50 miles) Referral made by Transition Homecare RN/ Case Managers by contacting HOMEWARD referral line, Transition RN visits patient while in hospital and educates about the Transitional Care visit including teach-back 6

7 Follow-up PCP Visit First Nurse after HOMEWARD PCP visit within 3-5 days of discharge Follow-up visit with Specialist Appointment made by patient s nurse or unit secretary Registry updated after PCP visit First Nurse Follow-up patient calls and support for 4 diagnoses Available 24/7 to triage patient needs Update registry after each encounter Trained staff in patient teaching materials Registry Tracking Track Transition Care patient s and outcomes Registry document for each diagnosis PROCESS MEASURES OUTCOME MEASURES PROCESS MEASURES OUTCOME MEASURES % with Transition Care Visit by HOMEWARD NURSE within hours % with PCP appointment within 3-5 days # of Medication Reconciliation discrepancies from Hospital to Home Readmission rates - CHF, COPD, Pneumonia, and AMI Readmission rates All Cause Patient Satisfaction related to Discharge Planning (HCAHPS scores) During this hospital stay, did someone on the hospital staff explain what to do if problems or symptoms continued, got worse or came back? 7

8 TO BE CONTINUED Transition Patients not on 2 South Patient declining process Enhancing Provider engagement Primary v. non-primary diagnosis Discharge to Nursing Home Reevaluate Education resources Questions? 8

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