Transitional Care at Mount Sinai The PACT Program

Transcription

1 Transitional Care at Mount Sinai The PACT Program Maria Basso Lipani, LCSW Program Director, PACT Mount Sinai Hospital

2 Mount Sinai Medical Center Founded in ,171-bed tertiary-care teaching and research Hospital 183 Hospital based practices 3,500 Physicians, residents, and fellows 2000 Nurses 200 Social Workers 58,000 Discharges 95,000 ED visits One million ambulatory visits in hospital clinics and Family Practice Associates

3 Mount Sinai Medical Center Transition/Readmission Initiatives Objective: Reduce 30-Day Readmissions of All Adult Patients IMPROVED TRANSITION PROCESSES For All Patients Enhanced RN Discharge Phone Calls Discharge Instructions with Medication Reconciliation IT Real-time In-Hospital Alert for High-Risk Patients Primary Care Provider Coffey Practice FPA IMA IMA PACT CLINIC MSMC Voluntary Physician Non-MSMC Physician SNF /Hospice Transplant Visiting Doctors INTENSIFIED TRANSITION CARE For Patients at Risk of Readmission Improved Processes for 7-10 day Post-Discharge Appointment- VNSNY Heart Program, VNSNY NP Program, ArchCare PACE, IMA Heart POST-DISCHARGE INTERVENTION For Patients at Highest Risk of Readmission (2 admissions/6mo or 1 in 30 days ) PACT In-Hospital Identification & Assessment 5-Week Post-Discharge Care Coordination Identification of PACT Patients with Fragmented Primary Care and Linkage to IMA PACT Clinic 3

4 Transitional Care: PACT Model Identification of PACT Patients Daily High Risk Report (HCC score + MSH admissions history) Nursing Assessment Questions (Readmission history outside of MSH) Direct provider referrals Pre-assessment consultation with PCP/Attending/ NP/Resident re prognosis Inpatient Effort Comprehensive psychosocial bedside assessment (with patient/family) to identify: Drivers of readmission Patient s current understanding of illness, prognosis and selfmanagement strategies Patient s degree of motivation to change behavior and to collaborate with PACT Collaboration with unit staff, primary care provider, and family Five-Week Post- Discharge Care Coordination Activation of patient: (VERY HIGH INTERVENTION) 16 phone calls + 2 accompaniments (HIGH INTERVENTION) 7 phone calls + 1 accompaniment (if needed) to address unique drivers of readmission Reinforce or establish continuity of care with referral to FPA, Coffey, Visiting Doctors, IMA, IMA PACT Clinic, IFH and/or other medical providers Facilitate communication between patient and PCP/specialists around new symptoms and changes in plan of care Primary Care IMA PACT Clinic Enhanced medical home Not a transition clinic: patients are seen regularly until Visiting Doctors or hospice becomes appropriate or until patient expires Same providers at each visit On-going assessment & intervention around new psychosocial barriers to self-management of illness Open access model No restrictions at time of appointment or first visit Enhanced telephone communication model Call center priority - notification to NP/SW for all calls Rapid response to patient phone calls Same day appointments as needed Home visits as needed Collaborate with ACO; GEDIWISE; HEALTH HOME to avoid duplication of services 4

5 The PACT Assessment Moving beyond the basics Reducing 30 day readmissions requires an understanding of the unique drivers or readmission for each patient many of which are psychosocial 5

6 Role of PACT Social Worker: Their mission: Be a Patient/Family Navigator Extraordinaire from discharge for five weeks and/or ongoing in IMA PACT Clinic Hospital-based PACT Social Worker: Meet with patient/family w/in hours of hospital admission to identify areas of psychosocial strain and risk for readmission Share insights & collaborate with inpatient care team to enhance d/c plan Make referrals for inpatient/outpatient disease-specific services (e.g. diabetes education, respiratory, pharmacy consult; VNS Heart, IMA Heart) Do anything & everything possible to ensure seamless transition to home & to support patient in successfully managing care in the community Clinic-based PACT Social Worker: Meet with patient/family at first visit to update assessment & explain the clinic model Share insights & collaborate with clinic providers to enhance engagement & increase return rate Coordinate care & ensure access to collateral providers and community services Do anything & everything possible to ensure facilitate patient s continued connection to primary care at the clinic 6

7 Primary Care IMA PACT Clinic Mission: The IMA PACT Team is to serve patients for whom the current health care delivery system is insufficient. We shall provide patient-centered care for both the patient and their caregivers. The IMA PACT team will work relentlessly to address our patients medical and psychosocial needs. We welcome the challenge to deliver improved Continuity healthcare of while care decreasing provided hospital by utilization. 2 NP s (supervising MD) Open Access - patients will be seen as walk-in SW assessment at every visit Increased visit time and intensity Improved Communications - dedicated phone lines Home Visits as needed Intercept patient in ED 7

8 PACT Pilot Outcomes (9/1/10 9/30/12) MSH measured outcomes six months before and after PACT interventions: 43% reduction in hospitalizations 54% reduction in ED visits 91% of patients enrolled in PACT had 7-10 day follow up appointments 84% of patients kept their appointments Additional ED Visit reduction seen in patients also receiving primary care at IMA PACT Clinic 1 typical PACT/IMA PACT patient

9 Lessons Learned Patients at highest risk for readmission and with the most fragmented care are reachable and can be impacted if they are willing to PACT Helping patients connect to their healthcare means connecting them to a true medical home and to a specific provider whenever possible Evidence-based models: Necessary, but Insufficient A model that goes beyond the basics is key in reducing and sustaining the risk of readmission Issues that drive readmission and hospitalizations are not 30-day problems Engagement must be strong; intervention must be tailored 9

10 Getting Started Who needs enhanced services and how do you find them when you don t have a EHR? May 1, 2011 Epic Go Live

11 Contact Information Maria Basso Lipani, LCSW Program Director, PACT (Preventable Admissions Care Team) Mount Sinai Hospital PACT 11