Hospital Based Transitions of Care Program. Dr Jeffery Liles, MD FHM. Providence Health Care

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1 Outcomes and Applications of a Hospital Based Transitions of Care Program. Dr Jeffery Liles, MD FHM Medical Director Care Management Providence Health Care

2 -Importance of D/C planning and transitions of care in current medical environment. -Difference between D/C Planning and Transitions of Care. -Current D/C Planning and Transitions of Care Projects at PSHMC. -Future State of Change.

3 -Changing face of medicine in last 20 years. -Tighter financial margins with focus less on production and more on pay for performance.

4 My role models during medical school.

5 My role models during residency.

6 Earliest medical show I remember ( )

7 Your patients ideal physician. ( )

8 Changing face of medicine nationwide and locally.

9 D/C Planning at SHMC 2006

10 Changing Payment Systems Penalties for readmission. 300 Million, 2200 hospitals will have money withheld from CMS. 1% % % 2015 Value Based Purchasing. Starts at 1% of DRG payment, up to 2% by 2017.

11 D/C Planning VS Transitions of Care Focus is on efficiently managing the patients stay in the hospital. Proactive process that starts on admission. Helps aligns patients t disposition iti needs with post acute services and providers. Is the set up for a good transition. Hospital focused. Metric Multiple transitions of care Home to hospital Hospital to home Hospital to ECF/Rehab Etc. Focus is to guide the patient through each transition. Patient and Provider focused. Metric LOS Patient Satisfaction Readmission i Rate Patient Satisfaction D/C Planning Transitions of Care

12 Home Homeless Rural Relationship between D/C planning and Transitions of Care. Transfer Center Home no services Home with services Homeless ECF Hospice Emergency Hospital Home Health Facility Hospital Room (D/C Planning) ECF/Rehab Hospice Hospice/ ECF/Rehab Transitions of Care Palliative care GIH Hospice House Home/ECF

13 Providence D/C planning Project Project Vision A Providence owned proactive discharge planning process that considers the comprehensive financial, social, spiritual and medical needs of patients, meeting those needs to provide a seam-less transition through the continuum of care Know Me, Care for Me, Ease my Way

14 Providence D/C planning Project Upon Admission Ease my way Form is filled out by patient/family. Daily D/C meeting between: Charge Nurse Social Worker Case Management Clinical information from provider to one of the above. Outcome of meeting: ADOD Discharge Pathway(Blue, Yellow, Green, Red) Barriers to D/C

15 Patient Name Sticker Here We care about you and your needs. You and your family are part of our health care team and it is important for you to have a say in decisions affecting you. This will help us plan your discharge better. Please read the following, check the boxes that apply to you, and give this to your nurse. Medications Transportation I may need help: Paying for my prescriptions I need somebody to drive me to a pharmacy so I can pick up my prescriptions I would like to use the pharmacy at Sacred Heart /7-6 weekdays/9-5 weekends New prescriptions ready in approximately 2 hours I don t understand how to take my medicine at home I may need information on available resources to help me pay for: My hospital stay My housing, electricity, food My equipment, oxygen, assistance at home Equipment I may need help obtaining: Equipment Walker or cane Wheelchair h Bed Bathroom aids Oxygen or other breathing equipment Safety equipment changing your home to meet your medical needs Imay need help getting: a ride home upon discharge a ride to my doctor appointments a ride to my other medical visits or therapy Financial Home I may need help with: Stairs, location of bed and bathroom access Ability to move around, walk, move from bed to chair, to bathroom Personal help for bathroom, bathing, dressing, personal care Cooking meals Getting groceries Housekeeping Pets Who will help you or provide care at home? Home Health Care Agency: How much help/care can family or friends provide? # of Hours per Day: # of Hours per Week: Know Me, Care for Me, Ease My Way

16 Transitional Care Projects D/C transitional care project. ARNP Hospitalist at SJCC. SLRI Hospitalist Pharmocotherapy Clinic. Homeless Respite. Single Joint Replacement prospective transitions of care. Admit Call Transfer Center. Telemedicine (Tele-Stroke/hospitalist)

17 D/C transitional care project Based on work by Dr Eric Coleman High risk patients were identified on admission and given enhanced services prior to D/C and after D/C. Allowed for submission of 3026 funding from CMS (awaiting outcome) Selected by WSHA for participation in Partnerships for Patients' (PfP) Care Transitions Demonstration Pilot Project

18 Results of D/C Transitional Care Project Growth Charts Data reveals a 30% relative risk reduction in 30 day ED visits and a 9% relative risk reduction in 30 day readmission rates when high risk patients enrolled in the Transitional Care Program are compared to the population of high risk patients % 30 Day Acute Care Use (03/11 06/11) 6.00% 4.00% 3M Patients (n=303) 2.00% 0.00% 30% Relative Risk Reduction ED Visits 9% Relative Risk Reduction Readmission TC Patients (n=272)

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20 ARNP Hospitalist at SJCC SJCC 160 bed ECF, 40 beds are for TCU. ARNP on site 5 days a week, with hospitalist back up by phone at nights and on weekends. Priority of duties See acute issues as they arise at ECF. Perform H&P on new patients. Review D/C meds prior to D/C

21 Pharmocotherapy Clinic Pharmacist run clinic specifically for medication reconciliation and medication counseling. Patients can access clinic pre or post discharge. Works with physicians offices to clarify and rectify any discrepancies. Worked as integral part of Transitional Care D/C project.

22 What does the future hold? Dammit Jim I m Doctor, Not a Magician

23 Patient Satisfaction