Care Coordination Interventions with Promise

Transcription

1 Care Coordination Interventions with Promise

2 CMS Support The project described was supported by Funding Opportunity Number CMS-1C from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

3 Readmissions Program: From the beginning Spawned as a health system in 2010 to proactively respond to the national agenda to reduce readmissions As a health system: Identify and reduce preventable readmissions through the determination and implementation of best practice strategies Began implementation of comprehensive, evidenced based, care coordination bundle in 4/2011: Baked in the JHM Strategic Plan 3

4 What are the True Causes of Readmissions? Care coordination* During hospitalization At discharge Post discharge True complications of care* Patient characteristics Demographic Socioeconomic Access to community resources Disease progression Failure of the ambulatory environment

5 Recent Evidence Interventions to Reduce 30-Day Rehospitalization: A Systematic Review: (Annals of Internal Medicine, 10/2011) A paucity of high quality trials Taxonomy of studied interventions mimics JHHS bundle Conclusions: Isolated interventions may have small effects Bundled interventions may realize an additive effect or additional value through organizational or culture changes. the current evidence base may not be adequate to facilitate change even for highly incentivized hospitals, and reconsideration of planned penalties may be reasonable

6 Transforming JHHS Care Delivery A Trans-disciplinary Care Coordination Model Realigns daily care processes around the needs of ALL hospitalized patients Maximizes workforce synergies to increase accountability for outcomes Selection of evidenced based bundle of strategies based on patient risk Patient and family engagement in responsibility for healthcare outcomes

7 Strategic Decision Points For the Acute Care Episode Pre-Admission ED/A At Admission Early Screen During Hospitalization: Identification of Resources At Discharge: Readiness Assessment Post Acute Transitions/ Handoffs

8 JHHS Bundle of Strategies: JHHS Task Force Recommended Bundle of Strategies ED Management Risk Screens Interdisciplinary Care Planning Patient/Family Education Medication Management Primary Provider Handoff Transitions of Care Care Coordination Outcomes: Avoidable Readmissions and Optimized Utilization

9 Care Coordination Bundle ED Care Management ED Care Protocols Assess Risk and Ease Transition Back to Community Risk screening Early and periodic Patient family education: Comprehensive Platform Self-care management Condition-Specific Education Context specific Teach-back Multi-Media Interdisciplinary care planning Multidisciplinary team-based rounds: every day, every patient Mobility initiative Projected discharge date on every patient

10 Care Coordination Bundle Provider handoffs Provider communication on admission and DC Discharge summary within 5 days. PCP follow-up within 7-14 days. Medication Management Medications in hand before discharge. Medication reconciliation. Pharmacist Education. Transitions of Care Bridge to Home Home visits (Transition Guide/Pharmacy). Community Social Work JHH After Care Clinic PAL Line: Patient Anytime Line Post-discharge phone calls. After hours triage system.

11 Decision to Admit JHHS Conceptual Model for Care Coordination ED Outpatient In Depth Risk Screen Moderate Intense Intervention Follow Up Phone Call Follow-up Appt Post Acute Referrals High Intense Intervention Transition Guide Post Acute Referrals Follow-up Appt Early Risk Screen Interdis. Care Planning Education: AHDP Red Flags Self-Care Medications Who to call Meds in hand DC Risk Assessment Provider Handoff: DC Sum FU appt Adult Admission Hospitalization Access Transition

12 Transitions of Care: Early Findings Increased identification of at risk patients 60% of patients require something Majority are identified as high intense interventions Where to document How to track Issues: Conversion to correct post-acute intervention Patient refusal for interventions Lack of dedicated staff for follow-up phone calls calls Ability of patient s to follow-up with interventions Meds, Appts, etc. Strategies to increase conversion Collaboration with JHHC and JHCP for community handoffs PAL line

13 Outcomes Management: How do we know its working? 13

14 Building analytic capability through REDCap 14

15 Our Experience: Interventions with Promise PAL (Patient Access Line) Transitions Guides After Care Clinic Bridge to Home: Health Buddy

16 PAL Began Planning as an outgoing and incoming telephone triage Very different strategies Changed focus to outgoing calls Specific to post-discharge instructions and assessment of ability for self-care management Post DC follow-up for identified problems

17 Patient Access Line (PAL) What We Do: Contact patients within hours after discharge to home Following scripted survey tool and using Discharge Worksheet as a guideline, review: How patient is doing (better, same, worse) Medication regimen Instructions for self-care management (do s & don ts) Red flags, signs & symptoms, and who to call Appointments (and plans/ability to keep them) 17

18 Patient Access Line (PAL) What We Do: Identify any stop the call acute needs and make immediate referrals (e.g. 911, ED, inpatient clinical team) as appropriate Provide education using Teachback technique to reinforce instructions and highlight important aspects of self-care management Assess patient s ability to manage and, where appropriate, identify/recommend resources to provide additional support Document results in PAL database and Epic 4/2/

19 Patient Access Line (PAL) Possible Follow-Up Interventions: to clinical team (author of d/c instructions, attending MD, and any others pre-designated by service) informing them of question or concern and requesting receipt confirmation Referral to unit Case Manager or Social Worker for follow-up on arrangements started in-house or needs identified during call (e.g. vouchers, appts.)

20 Patient Access Line (PAL) Possible Follow-Up Interventions: Referral to Transition Guide to provide inhome and/or telephonic follow-up by RN for up to 30 days post-discharge Referral to Home Care Coordinator for arrangement (with provider) of skilled services where potentially appropriate Referral to Transitional Pharmacist for phone call(s) to provide additional teaching on high risk and/or new medications 4/2/

21 Patient Access Line (PAL) Possible Follow-Up Interventions: Referral to Service Excellence (via electronic Guest Relations reporting system) for recording, acknowledgement, and followup (where desired) on compliments or constructive comments Referral to PAL Medical Director or Physician Advisory Board where there are recurring issues that require review 4/2/

22 PAL Scenarios Upon PAL call discovered that pt. didn t know she was supposed to resume home meds (not listed on DCI). Also was taking a medication as prescribed that she was allergic to. Providers and pharmacy alerted high priority. Spanish-speaking patient reported he had vomited after taking meds last night. He could not state what he had taken. Upon review with English-speaking girlfriend, she realized patient had taken 4 x 300 mg Clindamycin instead of 2 x 300 mg Clindamycin on two occasions. In addition, they could not state rationale for listed medications including home meds. PAL notified providers and sent TG referral for Spanish-speaking TG for medication education. Patient was ordered Warfarin(Coumadin) 2.5 mg tab; dose of 7.5 mg by mouth every evening. Patient stated the pill bottle instructed him to take warfarin 5mg per oral tablet once a day. Provider was notified to clarify and a TG referral was sent. PAL spoke to husband of patient who had an aneurysm clipping. Husband informed PAL that his wife was doing fine but couldn t speak today. Referred emergently to ED and was admitted for a re-bleed.

23 Transitions Guide Program Modeled after Eric Coleman CTP Oriented, trained and deployed by JHHCG Patients identified as high risk without other post discharge support. TG s meet patients in the hospital Support by phone or visit for ~ 30 days

24 Transitions Guides Services Assist patients/caregivers in the home with post discharge self-care management, setting goals and identifying behaviors influencing self-care management failures. Reinforce DC instructions Perform Medication Reconciliation Ensure receipt of critical meds (prescriptions) Ensure provider follow-up and transportation to postdischarge appointments. Post acute referrals for ongoing problems Referral to community agencies for social needs (community social work referral) Hand-offs to Primary Care and Medical Home

25 Stories from the Field: Case #1 (Pt. KF) Bundle Element Early Risk Screen Scenario Stroke patient w/uncontrolled hypertension and newly-diagnosed diabetes ESDP of 13 (High Risk) Grade Inter- Disciplinary Care Planning Self-Care Mgmt/ Pt/Fam Education Care team concerned about patient s living situation Referred to HC for post-discharge diabetes teaching/med management Patient refused HC and assistance with scheduling follow-up appointments Extensive diabetes education provided by nursing, pharmacy and nutrition Educational plan re-reviewed with patient on day of discharge.

26 Stories from the Field: Case #1 (Pt. KF) Bundle Element Medication Mgmt Scenario Prescriptions written for glucometer, insulin, and all necessary diabetes-related supplies Supplies picked up at JHH pharmacy, with exception of glucometer (which was to be delivered to home) Grade Transitions Planning PAL post-discharge phone call made next day Patient had no received glucometer and was confused about med regimen and f/u appointments PAL nurse alerted care team and patient received Transition Guide who: - Procured glucometer - Reviewed medications - Assisted w/appts. - Reinforced self-care Patient released after 12 sessions over 30 days; has not been readmitted

27 Stories from the Field Case #1 (Pt. KF) Bundle Element Provider Handoffs Scenario Patient had no PCP and would not accept pre-discharge assistance TG helped link and ensured follow-up w/ specialty appointments (PT and SLP- Swallowing) Patient now under care of local internist Grade

28 Percent of Problems Found Patients Without follow-up appointment % Unable to list current medications % Unable to Describe Post D/C Care Plan % With concerns (HCAHPs) % Unable identify contact for Follow-Up % Taking Other Unlisted Medications % With medication discrepancies % Patients with Completed Calls % PAL Problems and Interventions 60% Connect Rate 77% Intervention Rate

29 Transition Guides: Converted and Not Converted Readmission Rates Facility TG Service Converted FYQ # of Readmissions # of Discharges Readmit Rate JHH and JHBMC No Yes 2013Q % 2013Q % 2014Q % 2014Q % 2014Q % 2014Q % 2015Q % 2013Q % 2013Q % 2014Q % 2014Q % 2014Q % 2014Q % 2015Q % Over all: 60% conversion rate Conversion dependent on referrals and patient type

30 Targeting the right intervention to the right patient! Variables PAL Eligible TG Eligible p value Median [IQR] Median [IQR] ESDP Score 6 [3 to 9] 7 [4 to 11] <0.001 HSCRC APRDRG-SOI expected Readmission Rate (%) 13 [8 to 20] 19 [12 to 24] <0.001 Box Plot of ESDP scores and HSCRC Expected RR for PAL/TG Eligible Patients

31 Outcomes for PAL and Transitions Guides TG Conversion Status and Readmission Rates 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 19.0% 30.8% Transitions Guides: N= eligible 5634 patients Those who did not get converted for TG services (N=2066) had a 77% increased odds of readmission compared to those who received TG services 0.0% Convert No convert Patient Access Line Intervention: N=8969 eligible patients Those who did not get connected (N= 3650) had a 35% increased odds of readmission compared to those who did get connected Controlled for: Age, Race, Sex, Payer, Service, Co-morbidity, LOS, HSCRC Expected Readmission Rate

32 Bridge To Home Health Buddy Program Designed to help patients prepare for discharge and engage patients and families in their goals for recovery. Focused on Self Care Management Encourages patients to identify a Health Buddy who can assist in the critical weeks after discharge Begins at admission and continues in the patient s home environment Time limited during the road to recovery Can be family/friend or a designee, but someone who wants to help Includes educational resource package Health Buddy Agreement Bridge to Home Video

33 Johns Hopkins After Care Clinic Hospital Hopkins After Care Clinic Medical Home Emergency Department Interdisciplinary Clinic: Safety net for patients discharged from Hospital or ED who need rapid follow-up but cannot secure timely appointments Bridge patients to community provider for ongoing care Intended to support at-risk patients prevent unnecessary readmissions and ED visits. It is not urgent care center or primary care

34 After Care Clinic (JHACC) Medical assessment, evaluation and treatment physicians and advanced practice providers (NPs and PAs) Phlebotomy Pharmacy Clinic administered medications take home prescription fulfillment Education: conditions, medications, equipment, wound care, and selfcare activities Nurses and pharmacists Tablet education/emmi-care Service coordination Social workers and case managers Post visit referrals Home care, Transition Guides, and provider appointments

35 ACC Pilot Patients Patient #1 52 y/o recently discharged after stroke (only one other touch at OSH and dx with HTN, Diabetes and Renal disease. PAL call revealed issues: TG assigned Presented to ED with BP 200/ new meds plus 4 more at ED; Referred to ACC ACC: BP 220/110 HgA1c 10 Confused as to meds and insulin (taking wrong dose of amlodipine) Involved all disciplines Pharmacy Med Rec with outside Pharmacy Nursing Education re BP, meds, glucometer, etc. Appt. with JAI next day

36 ACC Pilot Patients Patient # 2 41 y/o female with DUB x 1 month (presented to ED with Hgb of 6.3) No insurance ACC Medical Eval: Patient symptomatic but Hbg 6.3. Referred for Transfusion next day (medications..hormonal therapy) SW for insurance coverage and special needs voucher Follow-up appt with Gyn and Primary Care established

37 Lessons Learned! It absolutely takes a village!! It is one patient at a time Donebedian: Structure, Process, Outcomes Multidimensional There is no magic bullet It IS all about the patient!