Joan Carroll RN, CDMS, CCM Director of Care Transitions Lee Memorial Health System

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1 Joan Carroll RN, CDMS, CCM Director of Care Transitions Lee Memorial Health System 1

2 Explain how patients experience transitions of care Identify variables that affect transitions due to lack of patient or practitioner understanding Discuss the relationship between communication, comprehension and successful transitions 2

3 1,423 Acute Care Operational Beds Not For Profit Public Hospital System with 10 Member Elected Board of Directors 10,000 Employees, 4,300 Volunteers & 1,200 Staff Physicians, 85 Employed Physicians 6 Hospitals, Sub Acute, Physician Group, Convenient Cares, Home Health, Skilled Nursing Facility, Rehabilitation, Regional Cancer Center, LPG united Way House 81,531 Admissions Annually 3

4 Complete a thorough assessment of medications including involvement with the neighborhood pharmacist, the PCP or specialist. Complete a list of over-the counter meds. Cover the American Heart Association low sodium diet and teach how to calculate 1500 to 2000 mgm of salt Instruct patient on fluid balance and limitations Provide and complete entries into the Personal Health Record Obtain orders for Home Health, PT/OT, pulmonary rehab, caregiver classes, balance evaluations when necessary 4

5 Discuss the Advanced Directive and help establish their choice of caregiver Assist with the setting of personal health goals and the steps necessary to reach those goals Assess patients ability to perform ADLs and IADLs Coordinate community services to support the patient and family such as transportation, shopping assistance etc. Do a safety check on the patients environment Help the patient write questions for their physician visit 5

6 Complete weekly phone calls Be sure the patient has seen their PCP and had all their questions adequately answered. If we cannot schedule an appointment with their PCP/Contact House Calls to see the patient. Do the second PAA and assess the patients self care knowledge and commitment. Subsequent home visits are done if necessary to assure the patient is safe and doing well. Review red flags and necessary actions Close the contact with assurance that the patient is ok and linked to appropriate community services. 6

7 7

8 Didn t know their diagnosis Had no idea what the diagnosis meant No understanding of acute or chronic Believed the hospital cured them Thought Recovery is a rest period No knowledge of their role No knowledge of red flags Reverted to meds they already paid for No medication management system Couldn t remember 3 of their meds and their purpose or side effects 8

9 Patient had prescriptions for meds that were not on the discharge instructions Patient had no prescriptions for new meds on the discharge instructions Patient had no idea of their limitations DME had not been delivered BIPAP not delivered / patient in trouble Patient extremely SOB 1days post discharge/ ankles still showing extreme edema / Poor discharge Home not safe Patient depressed or lonely 9

10 Couldn t find their discharge instructions Didn t remember anyone going over them Had not filled their new prescriptions Taking OTC meds unapproved Believed the salt shaker (which they didn t use) was the only source of sodium Had not scheduled their PCP appointment Drank glasses of water a day (per Dr. Oz) Used their inhalers incorrectly Couldn t read and follow direction Were unstable on their feet 10

11 Lack of patient knowledge of their disease Inadequate discharge orders Limited pharmacy Involvement No focus on a care plan after discharge Limited assessment of the patients needs Silos providing care Minimal caregiver education No balance screening 60% of our patients are discharged home with no post acute services 12

12 13

13 My staff did do the teaching The patient was in a hurry to get out Pointing Fingers PT evaluates for balance Respiratory teaches about nebulizers and inhalers Nursing teaches use of inhalers The discharge nurses do that Case managers assess the social needs The patient was too sick to comprehend 14

14 Hospitalists and Specialists Case management VP of Nursing Discharge Nurses Staff Nurses Nursing Education Pharmacists Respiratory Therapists 16

15 Discharge order sets for CHF and COPD/ simplified / disease specific Physicians include specific discharge orders for screening for balance/ medication review Improved cognitive assessment Increased referrals to Home Health and Hospice Teach Back education Consistent Standardized Handouts 17

16 Acute Care Post Acute System Wide Risk Stratification Tool Telehealth & Home Health Medical Home Tracking Readmission reasons Care Management Website Community Resources Teach Back and F/U appointment 3 out-patient Pharmacies CHF/COPD Unit Readmission work groups- Pulmonary & CHF Living Healthy Chronic Disease Self Mgmt House Calls Automated Discharge Calls Care Transition/ 30 Day Post Discharge Skilled Nursing Facility/Interact Community Collaboration COPD Management Program Nutrition Assessment /Meal Delivery 18

17 Readmission rates for CTI patients are lower than national benchmarks 3 out-patient pharmacies Bedside prescription delivery at discharge COPD Management Program Home Health and SNF collaboration INTERACT Training 20

18 Readmission committees at each facility Food vouchers Discharge packages from local agency Prescribed diet meal delivery/food as medicine Discharge orders to PCP within 24 hours Sensitivity Training for staff members 8 hour orientation to post acute services Depression screen COPD Program 21

19 Multi-disciplinary Committee formed 2012 Root cause Analysis done on readmissions Charter developed 3 month post-acute program began August of 2013 RTs added to the Care Transition Team COPD clinic opened Process Defined 22

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22 LMHS COPD 30 Day Readmission Rate of Medicare Patients: 14%

23 The COPD Care Transitions program taught me how to work with my doctors. My coaches are special people who care about me. They gave me the confidences I needed to take care of ME. I just love them to death.

24 Care Transitions Partners PATIENTS & CAREGIVERS Hospitalists Pulmonologist Case Managers/Social Workers Respiratory Therapists/Nurses Primary Care Physicians Pulmonary Function Lab COPD Educators Pulmonary Rehab Pharmacy Community Health Clinics Dept. of Human Services United Way 211 Area Food Pantries/Churches Home Medical Equipment Companies Home Health Agencies Fresh Harvest/LeeSar Veterans Administration Skilled Nursing Facilities Palliative Care Hospice Services SHARE Club COPD Support Groups Sleep Centers

25 Improve Functional Assessment and Nutritional Status In depth psycho-social evaluation Identify the caregiver and learner Teach back with patient and caregiver Explain Acute versus chronic and the necessity of understanding life changes that are necessary 28

26 Ask patients to remember 3 things / repeat Connect it to possible readmission Remind them of their fear Focus on the goal of not coming back to the hospital Focus on their attention span and their buy in of your discussion Do not overload Involve all caregivers, family 29

27 Who lives with you Who helps with your medication? Who makes your doctor s appointments Who goes with you to your appointments? Who prepares meals/ Who shops? Who does the housework? Who should be part of the discharge teaching? 30

28 Discharge education begins on admission Providers are alert to all the possible care needs after discharge Compassionate teach back is provided by all disciplines Literacy and health literacy are assessed and education is provided at the patient s level of understanding Appropriate caregivers are included in the discharge education 31

29 Care Transitions coaches follow the patient for 30 days Patients are referred to appropriate agencies for additional services The patient has transportation to the PCPs office within 8 days of discharge The patient has food and has obtained his medications The patient has knowledge of his medications and self management details The Patient s primary caregiver knows about the hospitalization and can access records 32

30 Thank you for your attention. Transition home safely! 33

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