Coordinating Transitions of Care: It Takes a Village

Coordinating Transitions of Care: It Takes a Village Ken Laube RN, BSN, MBA: Vice President Clinical Excellence

Situation/Background Patients face significant challenges when moving from one health care setting to another. Poor patient preparedness for transitions of care or incorrect selection of the appropriate post acute level of care can compromise patient safety and patient health outcomes. Nurses, collaborating with our physician partners and the multidisciplinary team, identified opportunities to improve patient safety, quality and the service provided to patients. Here is our story

AdvocateCare Programs Coordination of Care Transitions Outpatient Acute Care Post-Acute Embedded Care Managers Multi Condition Centers Advanced Medical Practice Practice Operations Coaches Urgent/ Walk-In Care Community Outreach ED ED Care Coordination Optimization Post-ED Care Transitions Level Of Care Transitions Inpatient Inpatient Readmission Risk Assessment & Focused Interventions Interventions Inpatient Care Inpatient Coordination Care Redesign Coordination Redesign Acute To Post Acute Transitions Acute To Post Acute Transitions Hospital to Home Transition Coach Program SNF Care Model Palliative Care Data & Analytics Population Health Management

KEY QUESTION: How do we integrate care delivery, acute care coordination and transition management into continuum care coordination? Acute Care Coordination + Transitions Guiding Principles* Patient centric care, providing each patient with the right care, at the right time, in the right amount in the proper setting; Achievement of world-class clinical outcomes, guided by the best evidence and practices that are subject to rigorous data analysis and continuous improvement; Patient engagement by challenging, encouraging and ultimately expecting patients to take an active role in their own care management; Reliably exceptional and safe experience for our patients, their families and referring providers wherever they receive care in the system; Effective collaborative partnerships between caregivers across our system and continuum partners; Cost efficient care ensuring resources are available for those activities that impact value the most; and Continuous innovation and improvement by understanding that advances in automation, information technology and training will likely render today s models obsolete in the near future. 5

Key Optimization Areas Identified Care Coordination Activities Transitions with Referring Provider/PCP Patient/Family Engagement Nurses provide key care Nurse Case Managers provide coordination Nurses provide activities key care for patient care delivery, and collaborate on care seamless Nurse Case coordination Managers of provide coordination activities for patient care transition care delivery, coordination and collaborate on care between seamless the coordination acute and post-acutesetting between the acute and post-acute- of care Nurses transition innovate coordination and standardize processes Nurses innovate and tools and for standardize managing setting and processes monitoring and patient tools for Nurse Case Managers Innovate and progress managing toward transition standardize Nurse Case processes Managers and Innovate tools to and and monitoring patient progress Innovative toward transition & Standard Processes for support standardize patient processes transitions. and tools to Patient Innovative Education & Standard Processes for support patient transitions. 1. Teach Patient back Education method Implementation of High Yield 2. 1. Ask Teach me 3 back method Transition Implementation Recommendations of High Yield 2. Ask me 3 Transition Recommendations 3. Protected discharge times 4. 3. Going Protected home discharge envelopes times 1.Risk Stratification 5. 4. White Going boards home envelopes 2.Health 1.Risk Care Stratification Team Coordination. 5. White boards 3.Teach 2.Health Back Care Methodology Team Coordination. Patient 6. Hand-offs Education 3.Teach Back Methodology Patient Ensuring 6. Hand-offs accurate information flow 4.Med Education Rec/Adherence to Ensuring the continuum accurate of care information flow to the continuum of care 5.Post 4.Med Acute Rec/Adherence Follow-up Appointment 6.Post 5.Post Acute Acute Partnerships Follow-up Appointment 7.Post-Acute 6.Post Acute Handoffs Partnerships 8.Post-Acute 7.Post-Acute Follow-up Handoffs Call 8.Post-Acute Follow-up Call A common approach to patient and family A common engagement approach in acute to patient care and coordination family engagement and transitions, in acute focuses care on providing coordination patients and and transitions, families with focuses the on right providing information patients in the and right families amount with at the the right information time the in right the way right amount at the right time in the right way standard processes and tools for patient Standard family processes engagement and tools. for 1. patient A and family engagement. 1. AIDET 2. Peer Coaching 2. Peer Coaching Patient Self Management: Patient Self Management: Patient fear and apprehension is reduced Patient as fear the and patient apprehension is prepared is for transition reduced through as the patient teach back is prepared education for methods transition at the through literacy teach level back and education language methods of at the the patient literacy level and language of the patient

The AIMMC Approach to Perfect Transitions Nursing Physician and Multidisciplinary Team Nursing Case Management Ready, Set, Go, Phase 1 Literacy, Education Process Improvement Tools Ready, Set, Go, Phase 2 Knowledge and skills competency validation and emphasis on discharge education. Assessing and documenting the patient preferred learning method, ability to learn, barriers and outcomes Ready, Set, Go, Phase 3 Monitoring and evaluation practice change to ensure sustainability Bedside shift report Provide and receive information from nursing and nursing case management Collaborative sharing of information to coordinate care and patient transitions Ensure patient care is delivered in the most appropriate setting and if the Acute Setting the most appropriate Level of care. Connect Unassigned Patients to PCP s Initiate risk readmission stratification tool Work with PCP to arrange post acute follow up visit prior to discharge Recommend In-Network home health, home infusion, therapies, SNF s to better manage transitions back to PCP/Specialists and to reduce readmissions. Educate patients regarding the importance and benefit of coordinated care within the Advocate system

Ready, Set, Go! Innovation and Peer Support Launch our Patients to a Successful Discharge The purpose of the CPC process improvement project was to improve the patient discharge process in an acute care facility with an outcome measure of patient satisfaction scores.

Iowa Model EBP Implementation: Phase I Direct Care RNs on discharge team identified key areas for improvement: Health Literacy Process Improvement Protected discharge time Going home envelopes Patient and Staff Education: EMR patient discharge resources Teach back technique CBT with contact hours awarded upon quiz completion Peer Coaching

Phase I: How to use the Teach Back Technique Healthcare providers ask patients to state in their own words (i.e. teach back) key concepts, decisions, or instructions just discussed. What is my main problem? What do I need to do? Why is it important for me to do this?

Iowa Model EBP Implementation Phase II: Knowledge and Skills Competency Validation Emphasis on Discharge Education

Iowa Model EBP Implementation Phase III: Monitoring and Evaluating Practice Change Ensuring Sustainability 1. Ongoing monthly documentation audits 1. Conducted by Discharge Team Members 2. Peer coaching 2. Continued emphasis regarding teach back technique 3. Reinforcing protected discharge time during patient/family discharge teaching (sign on door, others covering call lights, etc). 4. Discharge CBT: 1. New on boarding requirement for GNO and RN Residency 2. Updated on an annual basis 5. All units to utilize the yellow Going Home envelopes for the written discharge instructions

Results: Stay Tuned!

AdvocateCare Post Acute Transitions The Long Walk Home Just Got Easier for Advocate Patients

VSA Scope Post Acute Transition LTACH Home w/home Care

Post-Acute Referral Decision Process This decision tree does not cover all dispositions Care Managers to consider other post-acute care options such as assisted living, custodial care, palliative care etc. as appropriate This decision process starts with discharge planning assessment on admission and is re-assessed daily. The goal is to ANTICIPATE DISCHARGE needs as early as possible, to explore alternatives, and advance as needed. Re-admission risk assessment also completed (within 24 hours) Re-assess daily and develop alternate plans until clarity emerges Unclear Will patient be safe and appropriate to go home? Yes Patient meets criteria for Home Care?* Yes Refer to Home Care No No Patient transitions to Home Patient transitions to SNF* No Will patient need post-acute hospital level care? (if unclear, consult Physiatry) Is patient s risk score >=8? # Yes Refer to Transition Program** No Yes Patient transitions to LTACH* Medical Will primary need be functional recovery or medical? Functional Patient transitions to Acute Inpatient Rehab* Note: In general, acute spinal cord and brain injury patients and complex stroke are most appropriate for acute inpatient rehab * Patient meets criteria based on applicable Milliman guidelines. Refer to Post-Acute Service Availability Grid; Home Care patients must meet home-bound status ** Transition program offered by Advocate at Home: check with your site for availability and specific patient inclusion criteria # The readmission risk tool should be used in conjunction with sound clinical judgment when used to help determine post acute care setting and/or intensity. The expected probability of readmission increases with an increase in score, but for any individual patient, other factors (i.e. literacy, social, financial) may impact whether or not the patient actually is actually readmitted

Post Acute Information Exchange Grid

Transition of Care Tool

Measurement: HCAPHS Discharge Domain: Patient satisfaction with the service we provide 30 Day-Readmissions: Transitioning patients to the right level of care at the right time. A patient readmitted within 30 days of transition is being correlated with substandard quality Results accentuated by the dual approach

HCAHPS Two Global Questions: 1. What number would you use to rate this hospital during your stay? (1 to 10) 2. Would you recommend this hospital to your family and friends? 7 Domains 1. Communication with Nurses 2. Responsiveness of Hospital Staff 3. Communication with physicians 4. Cleanliness and quietness of environment 5. Pain Control 6. Communication about Medications 7. Discharge Instructions

Milestones and Outcomes of Discharge Education Project 100.0 90.0 80.0 70.0 KRA Benchmark 2010 COTH 400+ 2011-2012 All Press Ganey DB AIMMC Inpatient - Patient Satisfaction with Discharge HCAHPS Discharge Domain Percentile Ranks by Discharge Date (KRA Benchmark) 84.0 85.0 68.0 69.7 84.0 668 Surveys Returned (Quarterly Avg) 67.3 60.0 62.0 58.7 50.0 40.0 May 2009 First Discharge Team Meeting: Goals Set PowerPoint Drafted February 2010 Presentation of Discharge Policies to CPC 30.0 20.0 10.0 0.0 Intervention Preliminary Data Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Q3 2012 1 2 3 4 5 6 7 8 August 2009 Development of Discharge Policies for ED and Inpatient February 2010 Rollout of CareConnection view module August 2010 Inpatient and ED Discharge Policies published online INTERVENTION November 2010 CBTs available in ALEX, including INA credit for quiz completion January 2011 CBT quiz completion & skills validation for Inpatient and ED nurses April 2011 Monthly chart audits begin (tracking documentation compliance)

Care Transition HCAHPS Continue to Exceed Target AIMMC Leads System 23

Hospital Readmissions Prevalent (CMS, 2012) National rate ~ 17% National average ~ 19% for Medicare beneficiaries Highest in Chicago Hospital Region ~27%

How Are We Doing? Discharged and Readmitted to AIMMC: Great!!!!! Rolling 6 month all patients: 9.3% - AIMMC and LGH Top Quartile performers nationally Medicare: 15% Medicaid: 7.1% BCBSI attributed: Discharged and Readmitted to any Hospital: OFI Medicare: PEPPER Report: Includes Behavioral Health, Acute Rehab CHF: 24.7% - Same as: Pneumonia: 19.7% -Same as: AMI: 15.5% - Same As: BCBSI: Advocatecare Index: Solid Medicaid: OFI

AIMMC Adult Acute Care 30 Day Readmissions 2010 Baseline 2011 Target 2012 Target 11.6% 11.3% 11.0% January February March April May 97 84 113 83 76 77 530 530 10.1% 8.8% 10.9% 9.2% 9.0% 8.6% 9.5% 9.5% 958 957 1036 901 848 896 5596 5596 June Rolling 6 Month Average 2012 YTD Percent Readmission by Discharge Disposition Percent Readmission by Payer Percent Medicare Readmission by Diagnosis 2010 Baseline 2010 Baseline State Benchmark 2011 Target 2011 Target National Benchmark 2012 Target Total Skilled Nursing Facilities 24% 18% 18% Long Term Acute Care 12% 12% 12% Total Home Health Care 13% 11% 10% Total Home/Self Care 9% 8% 8% All Other Dispositions 11% 11% 11% 2012 Target Medicare 18% 17% 15% Medicaid 15% 12% 11% Blue Cross Blue Shield of Illinois 8% 7% 6% All Other Managed Care 9% 8% 7% Other 11% 11% 10% 2012 Target Pneumonia* 19.1% 18.3% 17.5% January February March April May 18 18 22 22 21 15 116 116 11.7% 12.2% 13.5% 15.2% 15.9% 10.7% 13.2% 13.2% 154 147 163 145 132 140 881 881 1 1 1 0 0 1 4 4 11.1% 14.3% 14.3% 0.0% 0.0% 14.3% 9.5% 9.5% 9 7 7 8 4 7 42 42 24 18 28 18 15 16 119 119 8.5% 7.5% 9.5% 5.8% 8.1% 7.2% 7.8% 282 240 295 308 186 221 1532 1532 44 40 44 34 35 31 228 228 10.5% 8.8% 9.5% 10.2% 8.1% 7.2% 9.0% 9.0% 420 456 462 332 433 429 2532 2532 17 7 18 9 3 14 68 68 18.3% 6.2% 16.5% 8.3% 3.2% 14.1% 11.1% 11.1% 93 113 109 108 93 99 615 615 Rolling 6 Month January February March April May June 2012 YTD Average 63 38 54 42 39 32 268 268 16.1% 11.4% 14.4% 12.7% 12.3% 10.7% 13.1% 13.1% 391 334 374 330 318 298 2045 2045 6 15 16 7 6 5 55 55 4.6% 12.7% 10.0% 5.9% 5.0% 3.8% 7.1% 7.1% 130 118 160 118 121 132 779 779 12 13 13 12 14 17 81 81 5.7% 6.1% 6.0% 6.1% 8.7% 9.2% 6.9% 6.9% 209 212 217 197 161 185 1181 1181 4 8 18 14 9 11 64 64 3.9% 4.4% 10.2% 9.0% 6.9% 6.4% 7.0% 7.0% 103 180 176 155 131 171 916 916 12 10 11 8 8 12 61 61 8.5% 8.8% 10.1% 7.9% 6.8% 10.9% 8.8% 8.8% 141 113 109 101 117 110 691 691 January February March April May Rolling 6 Month Average 2012 YTD 4 5 3 3 5 1 21 21 14.8% 16.1% 8.6% 12.5% 10.0% 5.3% 11.3% 11.3% 27 31 35 24 50 19 186 186 June June Rolling 6 M onth Average 2012 YTD 7.8%

Performance Improvement Results: Look What We Have Accomplished. We Are Ahead of the Curve! Improved safety, quality care and patient service Improved care coordination Reduced readmissions Improved patient satisfaction results Increases staff satisfaction

Patient Preparedness for Transition Home Care Skills: Expected behaviors for patient or family member/significant other to demonstrate prior to discharge Communicate understanding of disease process Communicate signs and symptoms of complications Know when to call physician or to call or return to the hospital Demonstrate necessary skills for home care by teach back

Care Transition Management Past State: Discharge Planning Focus on discharge out of hospital Risk Stratification Target patients at highest risk Standardized across system Focus Areas by Organizational Accountability Hospital Medication Management Patient Self-Management Post Acute Follow-up Skilled Nursing Facilities Palliative Care Current State: Transition Management Focus on transitioning from within hospital to next setting Physician Hand-offs Post Acute Follow-up Palliative Care

Realities in Healthcare Today Key market realities throughout the remainder of the decade We will be judged by the value we provide for the overall health of the population we serve The bar for safety, quality and service will continue to be raised We must decrease cost since we will be paid less for the same service There will be financial penalties for complications in care delivery

Stakeholders working together Physicians/Nurses/NCT s/case Manager/LCSW/Post Acute Partners Patient

We are a community of HealthCare Providers, and It takes a Village to safely transition a patient