Care Transitions: How Can You Help?

Transcription

1 Better Health: It s Your Health, Take Charge Transitions of Care: Coordination and Management Care Transitions: How Can You Help? presented by: Anne Elwell, RN, MPH Principal and Vice President, Qualidigm June 5, 2015

2 Objectives Define care transitions (CT) Explain the challenges to care transitions Identify solutions to CT challenges 2

3 What are Care Transitions? A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing facilities, the patient's home, primary and specialty care offices, and long-term care facilities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient's goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs. Source: Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):

4 What is a Discharge? Hospital discharge is the process by which a patient is released from the hospital by healthcare professionals. 4

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6 Healthcare in the US Total health care spending in the United States is expected to reach $48 trillion in 2021, up from $2.6 trillion in Health care spending will account for nearly 20% of the gross domestic product (GDP), or one-fifth of the U.S. economy, by 2021.* Wayne, Alex (June 30, 2012). Health-Care Spending to Reach 20% of U.S. Economy by Retrieved from 6

7 Bloomberg Best (and Worst) Among advanced economies, the U.S. spends the most in health care on a relative cost basis with the worst outcome. Source: 7

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9 Data on Readmissions Roughly 20% of Medicare patients are readmitted within 30 days of hospital discharge Many hospital readmissions are thought to be preventable Readmissions: What s all the fuss? Many re-hospitalizations result from problems at care transitions Impacts approximately 2.6 million patients and costs approximately $26 billion per year 9

10 Nursing Home Readmission Data One in four patients admitted to a SNF are readmitted to the hospital within 30 days 45% of hospital readmissions among Medicare-Medicaid enrollees could have been avoided in 2005 (314,000 potentially avoidable hospitalizations) * Cost = $2.6 billion *from cms.gov 10

11 Triple Aim Better Care Triple Aim Healthy People/Healthy Communities Affordable Care 11

12 Hospital Readmission Penalties Based on 30 day readmission rates of Medicare patients Index hospitalization for o Heart failure o AMI o Pneumonia o COPD o THR, TKR 12

13 FY 2015 National Programs Penalties 2,610 hospitals were assessed penalties ranging from 0.01% to 3% of Medicare revenue in FY 15 o Readmission rates are assessed on three prior years of performance: July 2010 June 2013 Total penalties = $428 M vs. $280 M in FY 13 o Nationally, average fine increased from to 0.38% to 0.63% o 75% of hospitals penalized 13

14 Hospitalizations can cause many complications: Distress and discomfort for residents and families Delirium Polypharmacy Falls Incontinence Hospital acquired infections Unintentional weight loss and poor nutrition Immobility, de-conditioning, pressure ulcers 14

15 Data on ED Visits Misuse of EDs accounts for $4.4 billion in waste annually and contributes to the high cost of American health care* *Bailey, April. (March 25, 2015) Misuse of emergency rooms: A costly but avoidable error. 15

16 Why Do We Really Care? For the person 16

17 Care Transitions Challenges Consistency of Information Communication across providers/patient/family Care coordination Patient/family education Identification of high risk individuals Medication issues End of Life care Social issues 17

18 Care Transitions, Patient Safety, and Quality of Care How did we get here? How can we improve? 18

19 Health Care in the 1950s In the 1950s people went to the hospital, then they went home. 19

20 The Patient has Changed Multiple co-morbid conditions Many medications Living longer More available services/treatments Socioeconomic factors impact health 20

21 Transition Process Specialist Home Specialist Emergency Department Primary Care Physician Intensive Care Unit Home Step-down Unit Home with homecare Inpatient Room Short Term Rehab 21

22 Definition of Communication a process by which information is exchanged between individuals through a common system of symbols, signs, or behavior also : exchange of information.* *Communication. (n.d.) In Merriam-Webster online. Retrieved from 22

23 Types of Communication Written Face to Face Phone Non-verbal Electronic 23

24 Reasons for communication breakdown Expectations differ between senders and receivers of patients in transition Culture does not promote successful hand-off (e.g., lack of teamwork and respect) Inadequate amount of time provided for successful hand-off Lack of standardized procedures in conducting successful hand-off, e.g. use of SBAR (situation, background, assessment, recommendation Limited interoperability 24

25 What is a hand-off? A hand-off, also known as a handover or patient care transfer, is an interactive process of transferring patientspecific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient s care. 25

26 Hand-off Objective To provide accurate information about a patient s care, treatment and services, current condition, and any recent or anticipated changes. The information communicated during a hand-off must be accurate. 26

27 Consequences of a bad hand-off Delay in treatment Inappropriate treatment Adverse events Omission of care Increased hospital length of stay Avoidable readmissions Increased costs Inefficiency from rework Other minor or major patient harm 27

28 How do we fix this? 28

29 A CT Community Story 2010 Now Qualidigm Communities of Care o Goal: to reduce preventable readmissions of patients with heart failure o 25 hospitals o Hospital-based PDSA approach o 15 hospitals, 83 NHs, 40 HHAs o Interactive workshops, individual training and support 29

30 What Info Do You Need from other Providers? 30

31 Things to Consider Medical condition Social history Employment Living situation Family/caregiver Mobility Independence with ADL Reliance on others 31

32 Summary Define care transition Explain the challenges to care transitions Identify solutions to CT challenges 32

33 Care Transitions Challenges Consistency of Information Communication across providers/patient/family Care coordination Patient/family education Identification of high risk individuals Medication issues End of Life care Social issues 33

34 Brainstorming 34

35 Questions 35

36 Anne Elwell, RN, MPH Principal and Vice President Qualidigm (860)