From the Ground Up: The implementation of a Transition Care Program (TOC) and its impact in COPD 30-day readmissions

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1 From the Ground Up: The implementation of a Transition Care Program (TOC) and its impact in COPD 30-day readmissions Cristiane L. Fukuda RN, MSN, ANP-BC Office: Northside Hospital Atlanta-GA Northside Hospital 852-bed, not-for-profit 150 locations across Georgia 3 acute care hospitals in Atlanta, Cherokee and Forsyth County. Northside Hospital leads the U.S. in newborn deliveries Diagnoses and treats the most cancer cases in Georgia and performs the most surgeries in Georgia Ranked #4 on the U.S. News list of the Best Hospitals in Georgia The only Georgia hospital on the Forbes list of America's Best Employers More than 2,500 physicians and 11,000 employees Serve nearly 2 million patient visits annually across a full range of medical services 1

2 Objectives Discuss Northside Hospital s Transition of Care Program implementation steps Present 30-Day readmission data before and after program implementation Readmission Prevention Driving Forces Aging population, increase in complexity of care 30-day readmission publicly reported Complex care needs, increase healthcare costs CMS financial penalties 2

3 Readmission Driving Forces: Health Care Spending Thomas, V. (2002). What works in care coordination? Activities to reduce spending in Medicare fee-for-service. accessed 3/13/2015 Readmission Driving Forces: Medicare Spending per Beneficiary (MSPB) Affordable Care Act CMS to include efficiency measures in the Hospital Value-Based Purchasing (VBP) Program Hospital measure, reported as a ratio Total Parts A and B spending for 3 days prior to hospital admission to 30 days post discharge Home Health Hospice Services Skilled Nursing Facility Durable Medical Carrier 3

4 TOC Program Development Steps GAP analysis Define Model Hire & Train Resources Develop TOC Program Pilot Program Evaluate Outcomes Gap Analysis Admission reduction strategies must be based on risk stratification and potential impact of TOC Interventions Medication management is a complex process Patients are often readmitted with issues unrelated to index admission TOC team cannot add more layers of complexity to care; it needs to simplify transition process Reducing readmissions cannot be done within the hospital walls alone There is virtually nothing positive that can be associated with the word DISCHARGE (Coleman 2015 NICHE Conference) 4

5 Transition Care Models Care Transitions Intervention Dr. Eric A. Coleman, MD, MPH, University of Colorado Denver Medication Management Patient centered record PCP/ Specialist Follow up Knowledge of Red Flags Transition Care Model Mary Naylor, PhD, RN, University of Pennsylvania School of Nursing Daily Hospital Visits Interventions focused on higher risk patients Post discharge home visits PCP visit Telephone Support Northside Program combined components of both programs Resources & Training Pilot Program Nurse Practitioner Registered Nurse Pharmacist Case Manager (part time) Focus on COPD Training Webinar: 20 hours 21 participants: 4 NPs 4 RNs 5 Case managers 6 Pharmacists 2 Clinical Data Abstractors Clinical Core Team Meets every other week Working group Action Plan 5

6 Risk Stratification Lessons Learned: Comorbidity is a non-modifiable risk factor Function may be a better indicator of patient s ability to do well after discharge Risk assessment tools are not perfect It should guide, not determine who will be enrolled in the program Always consider potential impact of interventions 6

7 TOC Program Inpatient Visit Comprehensive assessment Goals of care Coordination of Care Education Discharge Summary Prepare patient/ family for transition Communicate with next level of care provider for continuity of care Post Discharge Phone Calls Coordination of care Symptom management Tele monitoring Education TOC Interventions with COPD Patients Build patient-provider relationship Helps to connect and influence adherence to changes after discharge Goals of care Disease progression, what to expect Inhaler review and education Appropriateness of medication regimen Prevention of exacerbation Smoking Cessation Activity (energy conservation) Diet Oxygen Education Pulse Oximeter for home use COPD action Plan (American Lung Association) Pulmonary Rehab 7

8 Collaborating Structure NSH Forsyth: 30-day COPD Readmission Rate Jan-Aug 2014 (before TOC) compared to Jan-Aug 2015 (after TOC) 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Jan Feb March April May June July August Linear (2014) Linear (2015) 8

9 NSH Readmission Penalties Trend CMS Data / FY FY13 FY14 FY15 FY16 Discussion points 1. TOC Programs can be an excellent tool to improve care for the older adult. How can we align our goals with the driving forces behind CMS 30 day readmission penalties? 2. Have you identified any gaps in the coordination of care for patients at your hospital? 3. Does you hospital has a TOC Program? 4. Challenges of implementing a TOC Program 9

10 References/ Resources Avarele Consultants. Achieving Positive ROI via Targeted Care Coordination Programs. The SCAN Foundation September Coleman EA, Parry C, Chalmers S, Min SJ. The Care Transitions Intervention: results of a randomized controlled trial. Archives of Internal Medicine. 2006;166(17): Coleman EA,Ground KL, Maul A. The Family Caregiver Activation in Transitions (FCAT) Tool: A New Measure of Family Caregiver Self-Efficacy. Joint Commission Journal on Quality and Patient Safety 41(11): Coleman EA, Sung-Joon M. Patients and Family Caregivers Goals for Care During Transitions Out of the Hospital. Home Health Care Services Quarterly 34(3-4): Coleman EA, Roman SP. Family caregivers experiences during transitions out of the hospital. Journal for Healthcare Quality. 2015:37(1):2-11. Coleman EA, Roman SP, Hall KA, Min SJ. Enhancing the Care Transitions Intervention Protocol to Better Address the Needs of Family Caregivers.. Journal for Healthcare Quality. 2015:37(1):12-21 Gardner R, Li Q, Baier RR, Butterfield K, Coleman EA, Gravenstein S. Is Implementation of the Care Transitions Intervention Associated with Cost Avoidance after Hospital Discharge? J Gen Intern Med 29(6): Naylor, M. Advancing High Value Transitional Care. The Central Role of Nursing and Its Leadership. Nurs Admin Q. Vol. 36, N.2, pp Naylor, M. et all. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. JAGS 52: , 2004 Naylor, et al., THE CARE SPAN--The Importance of Transitional Care in Achieving Health Reform. Health Affairs, 30(4): Naylor MD, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, & Pauly MV. Comprehensive discharge planning for the hospitalized elderly. Ann Intern Med. 1994;120: Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, & Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281: Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, & Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52: Shiou-Liang Wee, Chok-Kang Loke, Chun Liang, Ganga Ganesan, Loong-Mun Wong, and Jason Cheah, Effectiveness of a National Transitional Care Program in Reducing Acute Care Use. JAGS 62: ,

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