Care Transitions: Chasms, Bridges
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1 Care Transitions: Chasms, Bridges NH-VT ACP Chapter Meeting October 2013 Julius Yang, MD, PhD Medical Director of Health Care Quality Beth Israel Deaconess Medical Center Boston, MA
2 Care Transitions: Definition occur when information about or accountability for some aspect of a patient s care is transferred between two or more health care entities or is maintained over time by one entity. Across settings (e.g., hospital to physician s office) As coordination needs change (acute episodes and chronic disease management) Care Coordination Measures Atlas
3 Care Transitions A view into the chasm
4 Patient s Experience
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6 Adverse Events after Discharge: Occurred in almost 1/5 of discharges 2/3 classified as adverse drug events 1/3 deemed preventable, 1/3 deemed ameliorable
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8 Care Transition: Risk and Complexity Patient- Level System- Level Care Transition Success or Failure Condition- Specific Medication Management
9 System-level Risks
10 Discharge Disposition: A broader view
11 System-level Risks Provider discontinuity (hospitalists, specialists, PCPs) Non-compatible electronic health records Unreliable information transfer amongst providers Pending results at discharge Ambiguous provider responsibility
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16 41% of discharges included pending test results Of these, 9% deemed potentially actionable Of these: 62% of MDs were unaware of the result 33% of MDs were unaware that test had been ordered
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18 Medication-level Risks Take as directed
19 Medication-level Risks Medicare patients typically discharged with high number of different medications Hospital-to-home medication reconciliation Multiple prescribing and dispensing sources Safety monitoring Medication list accrual High-risk: anticoagulants, insulin, antipsychotics
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22 Condition-level Risks
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25 Condition-level Risks Heart failure COPD Diabetes mellitus Active cancer End-stage renal disease End-stage liver disease
26 Patient-level Risks
27 Patient s Experience
28 Patient-level Risks Activation Health care literacy Caregiver support Mental illness Financial resources Transportation/mobility Food options
29 Recovering from acute illness perturbed physiologic systems Stress Sleep deprivation Disruption of normal circadian rhythms Poorly nourished Have pain and discomfort confront a baffling array of mentally challenging situations Receive medications that can alter cognition and physical function Can become deconditioned by bed rest or inactivity Lead to impairments in the early recovery period Inability to fend off disease Susceptibility to mental error
30 Transitional Care Building bridges
31 Transitional Care: Definition A broad range of time-limited services designed to: Ensure health care continuity Avoid preventable poor outcomes among at-risk populations Promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another. Complementary to but not the same as primary care, care coordination, discharge planning, disease management, or case management Health Affairs, 30, no.4 (2011): The Importance Of Transitional Care In Achieving Health Reform Mary D. Naylor, Linda H. Aiken, Ellen T. Kurtzman, Danielle M. Olds and Karen B. Hirschman
32 Transitional Care Health Affairs, 30, no.4 (2011): The Importance Of Transitional Care In Achieving Health Reform Mary D. Naylor, Linda H. Aiken, Ellen T. Kurtzman, Danielle M. Olds and Karen B. Hirschman
33 Transitional Care Health Affairs, 30, no.4 (2011): The Importance Of Transitional Care In Achieving Health Reform Mary D. Naylor, Linda H. Aiken, Ellen T. Kurtzman, Danielle M. Olds and Karen B. Hirschman
34 Transitional Care Health Affairs, 30, no.4 (2011): The Importance Of Transitional Care In Achieving Health Reform Mary D. Naylor, Linda H. Aiken, Ellen T. Kurtzman, Danielle M. Olds and Karen B. Hirschman
35 Transitional Care Health Affairs, 30, no.4 (2011): The Importance Of Transitional Care In Achieving Health Reform Mary D. Naylor, Linda H. Aiken, Ellen T. Kurtzman, Danielle M. Olds and Karen B. Hirschman
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37 3026 Section 3026 of the Affordable Care Act of 2010 : Community- Based Care Transitions Program. The program $500 million from 2011 to 2015 to health systems and community organizations that provide at least one transitional care intervention to high-risk Medicare beneficiaries. Interventions may include Initiation of services no later than twenty-four hours prior to patients hospital discharges Timely postdischarge follow- up services to patients and their family caregivers; Assistance to ensure productive and timely interactions between patients and postacute and outpatient providers Assessment and active engagement of patients and their familycaregivers through self-management support Comprehensive medication review and management. Health Affairs, 30, no.4 (2011): The Importance Of Transitional Care In Achieving Health Reform Mary D. Naylor, Linda H. Aiken, Ellen T. Kurtzman, Danielle M. Olds and Karen B. Hirschman
38 Hospital Readmissions Reduction Program Program.html
39 Patient Satisfaction Surveys
40 Transitional Care Models Exemplars
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42 For Whom: Hospitalized elders hospitalized with specific diagnoses with at least one risk factor for poor discharge outcome By Whom: Gerontological Advanced Practice Nurses (APNs) Intervention Protocol: Initial APN visit within 48h of hospital admission APN visits at least every 48h during hospitalization APN home visit within 48h after discharge APN home visit 7-10 days after discharge Additional APN home visits based on patients needs APN telephone availability 7 days/week APN-initiated telephone contact with patients/caregivers, at least weekly
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44 Patient experience: Often unprepared for self-management in the next care setting Receive conflicting advice regarding chronic illness management Often unable to reach an appropriate health care practitioner who has access to their care plan when questions arise Have minimal input into their care plan
45 For Whom: Community-dwelling elders hospitalized with one of 11 specific conditions By Whom: Advanced Practice Nurses (APNs) as Transition Coaches (TCs) Intervention Protocol: Personal health record (PHR) TC visit during hospitalization (establish rapport, introduce PHR, arrange home visit) TC visits/calls to SNF weekly TC home visit 48-72h after discharge Medication management Communication coaching and PHR reinforcement Contingency planning TC telephone follow-up x 3 next 28 days
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48 For Whom: Adults admitted to medical teaching service By Whom: Nurse Discharge Advocates (DA), Pharmacists Intervention Protocol: DA visit during hospitalization Education Create After-Hospital Care Plan (AHCP) DA transmits discharge summary to PCP Pharmacist phone call 2-4 days after discharge
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54 Building a Transitional Care Program What type of bridge to build?
55 Building a Transitional Care Program Which patients need transitional care? What are the critical actions/interventions? Who should perform each action? Where should those providers be based? What is the source of funding for those providers?
56 Who is the target population? All patients leaving the hospital Those with specific high-risk conditions Those with high-utilization patterns Affiliations with primary care practices Based on payer incentives/penalties
57 What are the critical actions/interventions? Coordination of Hospital-based Providers Post-discharge Outreach Coordination of Ambulatory Providers Assessment of Post-hospital Needs Post-discharge Logistics Support Chronic Disease Care Management Patient/Caregiver Education/Activation Medication Reconciliation Communication with Ambulatory Providers Post-discharge Education/Activation Post-discharge Medication Reconciliation Post-discharge Follow-up Visit Post-discharge Follow-up Appointments Post-discharge Condition Monitoring Standardized Discharge Communication Contingency Management
58 Who will be providing the care? Physicians Clinical Nurses Social Workers Pharmacists Case managers Community health workers
59 Where are these providers based? Hospital Primary care clinic/patient-centered medical home Specialty clinic (Cardiology, Oncology) Provider organization Payer
60 What is their source of funding? Penalty avoidance (Readmissions) Quality incentives Global payment model (ACO) Research/development grant
61 Lessons from the field It s not just what you do, it s how you do it Telephone outreach: Careful how you ask Post-discharge follow-up: Sooner not always better than later PCP or specialist Who s calling me now?
62 Care Transitions Team Play
63 Care Transition: More than a handoff? Handoff o Unidimensional, instant o Independent of conditions Pass o Linear, unidirectional o Trajectory/target o Dependent on fixed conditions o Coordination between passer and receiver Team Play o Non-linear o Dynamic conditions o Anticipatory coordinated action o Iterative steps towards a common goal
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