MANITOWOC COUNTY CARE TRANSITION PROGRAM

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1 MANITOWOC COUNTY CARE TRANSITION PROGRAM A U G U S T 1 5, Judy Rank Director Cathy Ley Supervisor Care Transitions Coach

2 MANITOWOC COUNTY CARE TRANSITION PROGRAM Julie Place, Director of Nursing Marcia Donlon, Director of Home Health & Hospice Services Judy Culligan, Social Worker/Discharge Planner

3 BUILDING THE PARTNERSHIPS Acute Care for the Elderly (A.C.E.) Began with a grant from The Aurora Foundation Included Both Hospitals and 6 Nursing Homes

4 A.C.E. TEAM Acute Care for the Elderly Team Consists of : Hospital Staff Nursing Home Staff Physicians ADRC Home Care Agencies Other Long-Term Coalition Members

5 A.C.E. TEAM Purpose is to coordinate cares for the elderly to assure quality and continuity A.C.E. Team evolution to present Education related to needs of patients and staff Assisting different providers to work together Development of pathways Avoidable re-admissions and current issues

6 GETTING STARTED WITH CARE TRANSITIONS RESOURCES OFFERED BY THE AGING & DISABILITY RESOURCE CENTER (ADRC) Home-Delivered Meals Subsidized Transportation Assistance in accessing public benefits i.e.: Medicaid, Family Care & Foodshare Caregiver Support Programs Prevention Programs Information & Assistance

7 WHAT ROLE DO THE ADRC RESOURCES PLAY IN REHAB DISCHARGES? Could the ADRC be doing more??

8 PARTNERSHIPS ALREADY BUILT Hospitals and Rehab Centers providing space for Prevention Programs Staff from facilities are co-facilitating Prevention Programs Long-Term Care Coalition Social Worker/Discharge Planner Network

9 STUDIED OPTIONS Evidence-Based Something to Sell/Partner to Community Affordable

10 APPROACHING THE MEDICAL COMMUNITY Talked with Discharge Planners Talked with Management Staff Wanted opportunity to prove the program

11 CARE TRANSITION INTERVENTION THE ERIC COLEMAN MODEL Why Was This Model Chosen? Community-Based Model Low-Cost Intervention Eau Claire County was using this model and it was successful One of our Community Hospitals had worked with Dr. Coleman on a prior project This model would work in our community and with our partners

12 THE ERIC COLEMAN MODEL Model Consists of: A Transition Coach who makes: One Hospital Visit One Home Visit 3 Follow-Up Phone Calls The Four Pillars of the Model: 1. Medication Self-Management 2. Personal Health Record 3. Follow-Up Visit with Physician 4. Red Flags or Warning Signs of the Condition

13 THE ERIC COLEMAN MODEL Transition Coach Role The Transition Coach s role is based on teaching the skills, knowledge, and attitude necessary to empower patients to manage their own care. The goal is to teach people to fish, rather than just giving them the fish.

14 THE ERIC COLEMAN MODEL Transition Coach Role Coaching is not a replacement of any other current provider It does not attempt to replace discharge planners or home health nurses Coaching is intended to supplement any other service that a consumer receives and enhance their effectiveness in utilizing these services Coaching requires flexibility and letting go of rigid agendas

15 THE FOUR PILLARS 1. Medication Self-Management The goal is that the consumer is knowledgeable about his/her medications and has a management system The management system has to be realistic and individual to the person Coach is non judgmental and realistic

16 THE FOUR PILLARS 2. Personal Health Record (PHR) List of medications (dose, frequency, reason) how they actually take it, not necessarily as prescribed Space for the consumer s self-identified goal Space for patient s concerns &questions for followup visit with their physician Space for information about Red Flags/Warning Signs

17 THE FOUR PILLARS 3. Follow-Up Visit With Physician Coach will assist consumer in getting ready for their follow-up visit with physician o Is appointment scheduled? If not coach can work with consumer to build skills to effectively get a quick appointment o Are there any barriers in getting to this appointment and if so, what can consumer do to remove the barriers? o Are there any questions you have for your doctor?

18 THE FOUR PILLARS 4. Red Flags / Warning Signs Consumers will identify and write down the indications that their condition is worsening i.e., How were you feeling before you went to the hospital? What was happening? What is the consumer s plan when they experience these red flags/warning signs?

19 TRAINING PROCESS We participated in the Care Transition Program s Regional Training Prior to training, we needed to complete a Readiness Assessment Tool, which is designed to help you think through the elements of the Care Transitions Intervention. This document covers goals, commitment, role changes, implementation, documentation, and ongoing support. Training lasted one day and occurred in Aurora, Colorado Staff was trained in October 2012

20 PLANNING MOVING FORWARD Set up meetings with our 2 hospital partners Aurora Medical Center and Holy Family Memorial to plan for implementation The hospitals worked together to develop a screening tool which would work for the program and both hospitals As a group we determined which medical diagnoses would be included The hospitals identified which of their staff members would complete the forms and make the referrals to us and how the referrals would get to the ADRC Hospital staff did a test run of screening tool prior to start of program, to make sure form worked smoothly

21 IMPLEMENTATION Began the program in November 2012 Did the roll-out with both hospitals simultaneously Made the first hospital visit on November 6, 2012 Met with our partners more frequently in the beginning to address any issues or questions that came up Steady growth in the program since the start

22 FOCUS ON COMMUNITY HOSPITAL IMPLEMENTATION

23 STARTED WITH A.C.E. TEAM (ACUTE CARE FOR THE ELDERLY) Community focus versus competition 2011 Team selected for Chamber of Commerce Award for the work done together to improve the community ACE Team was known and respected within hospitals

24 ADRC INITIATED ACTION WITH HOSPITALS Introduced Care Transitions Initiative and Plan Important to identify right leads from the start Included Hospitals as Key Stakeholders from the start to develop the model

25 ATTENDED TRAINING SESSIONS IN DENVER TO LEARN ERIC COLEMAN MODEL 4 ATTENDEES Information & Assistance Workers from the ADRC who would become the actual coaches for Manitowoc County Representative from Felician Village Senior Care Complex Representative from Holy Family Memorial Why was this important???

26 OUR TEAM IN DENVER O C T O B E R

27 NEXT STEPS: Team meetings at both hospitals to educate physicians and staff on Care Transitions I organized and facilitated Develop referral tool to share at meetings and get staff familiar with and use Communicate, communicate, communicate information Ask staff often how things are going with referrals Invite coaches to numerous meetings & events to build relationships Reassure that coaches will NOT impede referrals to home care or hospice service

28 SHARING INFORMATION It is important to share information back with physicians and staff regarding the number of referrals and outcomes they love to hear the stories Also conveys that the coaches are improving care, and this is a partnership Late adapters..- keep moving on the journey and reinforcing positives Pharmacy connection

29 CARE TRANSITIONS PROCESS We identify potential clients for the Care Transitions Program upon admission and throughout the patient s stay The tool for Assessing Readmission Risk & Eligibility for the Care Transitions Program is used to identify these clients

30 CARE TRANSITIONS PROCESS Once a patient is identified through the screening process, a Care Transitions Coach at the ADRC is notified If we feel a particular patient would benefit from the Care Transition Program and does not meet the criteria on the screening tool, we will discuss the case with a Transitions Coach to see if they can take them on Response time for a Care Transitions Coach to make a hospital visit is usually on the same day the referral is made

31 CARE TRANSITIONS PROCESS Along with the program screening tool, Coaches are given the patient s History & Physical, Face Sheet with Demographics and Discharge Summary if applicable The patient information is placed in a folder in a designated area on each unit. Coaches will collect the information from the folder so that the Social Worker or Case Manager doesn t have to be present for the Coach to see the patient

32 CARE TRANSITION PROGRAM RESULTS NOVEMBER 3, 2012 JUNE 30, Total Referrals from Hospitals (2 main referral sources) and a few from Nursing Homes 23 of the 138 declined intervention. These people were discharge prior to a Care Transition Coach hospital visit 102 total of the 138 received or are still receiving intervention 49 of the 138 declined to continue the program after a hospital visit from the Coach or receiving their personal health record

33 CARE TRANSITION PROGRAM RESULTS NOVEMBER 3, 2012 JUNE 30, of out 138 were hospitalized while in the program; all in the first month of the program 2 of the 4 were re-hospitalized before ever being seen at home 29 of the 138 fully completed the program 0 Re-hospitalizations within 30 days for those who have completed the program

34 THE FUTURE OF CARE TRANSITION Current Funding o 100% Time Reporting o ADRC Budget Item Future Funding o 100% Time Reporting o Provider Participation

35 DEVELOPED PARTNERSHIPS Hospitals Nursing Homes Home Care Agencies

36 WHAT S NEXT? Future Partnerships Future Expansion of Prevention Programs Marketing to Community

37 A YEAR AT A GLANCE

38 QUESTIONS?

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