IMPROVING CARE TRANSITIONS: A Strategy for Reducing Readmissions Policy Issue Brief

IMPROVING CARE TRANSITIONS: A Strategy for Reducing Readmissions Policy Issue Brief September 2012 Prepared for the Center for Improving Value in Health Care Prepared by: Sarah Lonowski

TABLE OF CONTENTS OVERVIEW...1 What are Care Transitions?... 1 PROBLEM STATEMENT...1 Why Do Care Transitions Matter?... 1 The Gap... 2 Where Transitions Go Wrong... 2 KEY STAKEHOLDERS...3 OVERVIEW OF NATIONAL MODELS...3 The Care Transitions Program... 3 Transitional Care Model... 5 Project RED... 6 Project BOOST... 7 STAAR Initiative: STate Action on Avoidable Re-hospitalizations... 8 CARE TRANSITIONS INITIATIVES IN COLORADO...9 Colorado Foundation for Medical Care: Integrating Care for Populations and Communities Care Transitions... 9 Colorado Foundation for Home Care Technology and Education: Telehealth in the Home... 10 Adult Resources for Care and Help (ARCH): Mesa County Care Transitions Improvement Project... 10 Colorado Hospital Association: Reducing Avoidable Readmissions & Safe Transitions Collaborative... 11 Colorado Regional Health Information Organization: Long-term and Post-Acute Care Program to Improve Care Transitions through HIE... 12 Colorado Rural Health Center: icare Transitions Improving Communication and Readmission... 13 BEST PRACTICES/RECOMMENDATIONS... 14 CONCLUSION... 16 BIBLIOGRAPHY... 17 APPENDIX A: CTI Four Pillars... 20 APPENDIX B: CTI Utilization Outcomes... 20 APPENDIX C: Changes in Rehospitalization rates with CTI... 21 APPENDIX D: Transitional Care Model Nine Core Elements... 21 APPENDIX E: TCM Readmission Rates... 22 APPENDIX F: TCM Total Health Care Costs... 23 APPENDIX G: Eleven Components of Project RED... 24 APPENDIX H: Transitional Care Model Comparison... 25 APPENDIX I: Impact of Patient Engagement... 26

OVERVIEW What are Care Transitions? Care transitions can be defined as the movement patients make between health care practitioners and settings as their conditions and care needs change during the course of a chronic or acute illness (What do we mean by "Care Transitions?", 2007). In the United States health care system, patients frequently experience such transitions as their health condition and care needs change. The settings involved in care transitions include hospitals, nursing facilities, the patient s home, primary and specialty care offices, community health centers, rehab facilities, home health agencies, community-based settings, hospice, long-term care facilities, and others (Bonner, Schneider, & Weissman, 2010). In recent years, improving transitions between care venues has been identified as an important strategy in working toward the national goal of decreased readmission rates. Better care transitions have the potential not only to reduce readmissions, but also to improve patient health, enhance patient care quality and safety, reduce inefficiencies, and lower costs. Health care leaders in Colorado have recognized these potential benefits and a number of initiatives focused on improving care transitions have been formed throughout the state. This issue brief defines the current problems with care transitions, identifies key stakeholders, reviews major national care transitions models, describes Colorado s care transitions initiatives, and provides general recommendations for improved care transitions processes. PROBLEM STATEMENT Why Do Care Transitions Matter? Care transitions are of both clinical and nonclinical significance. Patients tend to be particularly vulnerable during care transitions due to the movement and uncertainty they experience as well as the changing environments they are exposed to. As such, changes in care location are often accompanied by deteriorations in health status. Furthermore, the problems that arise during transitions are generally unplanned, so patients and their families often do not know what to expect or how to handle them (Coleman and Fox, 2004). On the part of the provider, poorly executed transitions frequently lead to medical errors. For instance, one study concluded that 30% of patients have at least one medication discrepancy upon discharge from the hospital (Kwan et al., 2007). At best, such medical errors decrease efficiency and increase costs of the transition. At worst, they can lead to severe illness and loss of life. Unsatisfactory care transitions increase the probability of a decline in health status, thus increasing the likelihood of readmission for a given patient. As of the end of 2011, one in five Medicare beneficiaries was readmitted to the hospital within thirty days of discharge (Kahn, 2011). Improved care transitions have the potential to reduce readmissions by maximizing the communication and coordination among providers and minimizing the discomfort and uncertainty among patients. The nonclinical implications of care transitions are substantial as well. Perhaps most notable among these is the economic impact of poorly executed transitions. As summarized by experts Eric Coleman and Peter Fox, Poorly executed transitions are associated with inefficiencies and duplication of services that needlessly increase the cost of care and potentially lead to greater utilization of hospital, emergency, post-acute, and ambulatory services (Coleman and Fox, 2004). Poor care transitions create an environment of uncertainty and fear, which increases the chances that a patient will be readmitted. In 2009, readmissions cost Medicare $26 billion (Administration 1

Implements New Health Reform Provision to Improve Care Quality, Lower Costs, 2011). The Medicare Payment Advisory Commission estimates that up to 76% of hospital readmissions may be preventable, thereby greatly reducing this cost (Care Transitions FAQs). Medical errors during transition also directly increase costs. In 2009, medication error during transition cost a total of $2.1 billion (Care Transitions Performance Management Set, 2009). In the same year, Medicare spent an estimated $4.4 billion to care for patients who had been harmed in the hospital (Administration Implements New Health Reform Provision to Improve Care Quality, Lower Costs, 2011). Effective care transitions can be financially advantageous to hospitals, as hospitals often have to cover the costs of a second stay when a patient is readmitted for the same condition. The financial consequences of ineffective care transitions are likely to increase as the trend toward pay for performance methods continues and hospitals are reimbursed based on readmissions rates and other performance metrics. Beyond the financial implications, care transitions processes can also have an effect on provider image and reputation. Consistently poor transitions can lead to patient complaints, negative publicity, and even litigation (Coleman and Fox, 2004). The Gap The current problem of poor care transitions stems from a gap in coordination when a patient moves from one setting to another. This gap forms because in traditional health care delivery models, there are few mechanisms in place for coordinating care across settings; care delivery silos generally keep the focus within individual venues (Coleman and Fox, 2004). It is often unclear who is responsible for a patient in the period between discharge at one location and admission at another. This period of uncertainty has been called the white space and the no care zone (Coleman, 2010). The lack of clear roles and responsibilities during care transitions is exacerbated by poor technological coordination among venues. The hodgepodge of different systems in hospitals and medical clinics complicates the transition and adds to the lack of consistency (Implementing Health Reform, 2011). This apparent gap in coordination is not surprising given the high level of complexity of the US health care system. The sheer number of care settings, systems, and providers available to individual patients makes consistency and coordination across the continuum of care extremely difficult (Bonner, Schneider, & Weissman, 2010). The average Medicare beneficiary, for instance, sees 6.4 providers per year (Everhart, 2009). Patients with chronic conditions may see up to 16 physicians in one year (Bodenheimer, 2008). Frequent movement between settings and providers increases the need for consistent practices before, during, and after each care transition. The results of poor transitional care are evident. One in five patients discharged from the hospital suffers an adverse event (Coleman and Berenson, 2004). Only about half of all patients who leave the hospital follow up with their primary care provider (PCP) within 30 days of discharge (Implementing Health Reform, 2011). Even if a PCP does see a patient for follow-up, they may do so without detailed knowledge of what happened at the hospital or without knowing the patient had been admitted at all. In such instances, the patient must spend valuable time with providers explaining circumstances and reciting details rather than receiving the care he/she needs. Where Transitions Go Wrong So where, precisely, do care transitions go wrong? Of course, each patient is unique and any combination of factors can lead to a less-than-desirable outcome. There are, however, a number of 2

root causes behind most failed care transitions, some of which have been indicated in the preceding discussion. The first of these is an overall lack of provider coordination and information sharing. As indicated above, inconsistencies and miscommunications lead to general inefficiency and ineffectiveness as well as more specific problems such as medical errors, equipment-related problems, and even transitions to inappropriate locations. Related to insufficient provider coordination is the problem of lack of follow-up from physicians and other caregivers. Studies have shown that patients who fail to see their PCP in a timely manner are more likely than other patients to be readmitted to the hospital within 30 days (Care Transition Option, 2011). When patients do not receive follow-up care and do not know whom to contact, post-transition utilization is likely to increase. A third root cause of poor transitions is a lack of patient/caregiver knowledge and empowerment. Patients are too often transitioned without adequately understanding what their self-care plan is and without the self-confidence to successfully implement it. Instances of patients losing medication, forgetting to take medication, or taking medication at the wrong time are frequent outcomes of this problem. KEY STAKEHOLDERS Achieving successful care transitions requires that a number of parties be actively involved. The following groups have been identified as key stakeholders in the care transitions process: Consumer/patients and families Hospitals Providers (including primary care and specialists) Policymakers Post-acute care facilities/services (including skilled nursing facilities, home health, assisted living residences, hospice, and rehab) Each of these stakeholders, despite having distinct roles, needs, and priorities, has a vested interest in the goal of improved care transitions. Communication among these groups is crucial to overcoming the current coordination gap and to developing consistent, effective processes in the future. OVERVIEW OF NATIONAL MODELS The care transitions problem posed above makes it clear that providers need to move beyond traditional utilization management approaches, which focus primarily on coordination of care within an individual venue, to approaches that aim to achieve effective care across multiple settings. In recent years, multiple programs have been designed with this goal in mind. What follows is a discussion of four leading national programs in terms of their goals, distinguishing features, strengths and potential limitations, and outcomes (both clinical and financial). The Care Transitions Program The Care Transitions Program (also called the Care Transitions Intervention or CTI), pioneered by the work of Dr. Eric Coleman, is designed to address potential threats to quality and safety during care transition by providing patients and their caregivers with tools and support to encourage them to more actively participate in their care transitions (Coleman, Parry, Chalmers, & Sung-joon, 2006). While the program takes a multifaceted approach to improving care during transitions, its principal focus is on patient and caregiver empowerment. Dr. Coleman states that the primary goal 3

of the program is to turn providers into real advocates for patients by training providers to make patients and their families active participants in the care coordination process. This contrasts with traditional health care models, in which the passive patient is generally preferred. The mentality behind the Coleman model is well-described by the teach a man to fish proverb; the program aims to give patients and families the tools and knowledge they need to be in charge of their own health, rather than simply increasing the amount of care provided during and after transitions (Coleman, 2012). The CTI does not focus solely on patients and families, however. It also endeavors to raise the level of professional competency both in communication and in cross-setting collaboration (Coleman, Special Reports, 2010). The model is grounded in the following four pillars (see Appendix A for more details about the 4 pillars): 1) Assistance with medication self-management 2) A patient-centered record owned and maintained by the patient to facilitate cross-site information transfer 3) Timely follow-up with primary or specialty care 4) A list of red flags that would indicate a worsening condition and instructions on the proper responses The implementation of the CTI includes two key mechanisms: the personal health record (PHR) and the Transition Coach. The PHR is a patient-centered document containing core data elements needed to facilitate continuity of care across settings. It includes an active problems list, medications and allergies, whether advance care directives have been completed, and a list of red flags that correspond to the patient s chronic illness (Coleman, Parry, Chalmers, & Sung-joon, 2006). One differentiating element of this PHR is that it also contains space for the patient to write questions and concerns. Patients and caregivers are encouraged to continually update the PHR during and after the transition process. The second mechanism, the Transition Coach, is perhaps the most important. Transition Coaches serve as facilitators of patient and caregiver empowerment and independence. A Transition Coach meets with a patient in the hospital before discharge and at home 2-3 days after discharge. He/she then telephones the patient 3 times within a 28-day post-hospitalization period. The role of the Transition Coach contains unique and innovative features such as role-playing effective communication strategies, which helps the patient learn to articulate his/her needs (Coleman, Parry, Chalmers, & Sung-joon, 2006). The Transition Coach has the potential to have a significant and lasting effect on patient self-sufficiency, ultimately furthering the goal of reduced hospital readmissions. The beauty of the CTI lies, at least in part, in its practicability. The program is low-cost and lowintensity, with just the two core mechanisms described above. This relative simplicity may make the CTI more manageable than some other models and allows the program to be adopted by a wide range of providers, not just hospitals. To date, 570 health care organizations have adopted the Care Transitions Intervention. These organizations include home care agencies, health plans, hospitals, large physician practices, community organizations, Areas on Aging, and more. The effectiveness of the CTI has been further proven by ~30% lower rehospitalization rates and an average cost savings of per patient of $488 (See Appendices A-C for more details regarding this data). 4

Transitional Care Model Another growing national model is the Transitional Care Model (TCM), led by Dr. Mary Naylor. The model was developed by scholars at the University of Pennsylvania as a direct response to the national call for improvements in care coordination. Its primary goal is to address the negative outcomes associated with breakdowns in care when older adults with complex needs transition from an acute care setting to the home or other care settings (Transitional Care Model, 2008). Like the CTI, the TCM also places emphasis on the patient and family empowerment by focusing on patients stated goals and priorities and ensuring patient engagement (Meier & Beresford, 2008). The key figure in the TCM is the Transitional Care Nurse (TCN), who is generally an advanced practice nurse with a master s degree in nursing. The TCN follows the patient from the hospital to the home and then makes weekly home visits to the patient for an average time period of two months. During this time the TCN is available to the patient seven days a week via telephone access. The TCN also accompanies the patient to see his/her PCP the first time after leaving the hospital and subsequent appointments as necessary (Meier and Beresford, 2008). Like the Transition Coach, one of the primary roles of the TCN is to enable patients and caregivers to successfully manage their care at home. To this end, the TCN develops an individualized plan of care in coordination with patients and their family/caregivers. The tasks and priorities of the TCN are outlined in the program s nine core elements, which are listed in Appendix D. The Transitional Care Model differs from the Care Transitions Intervention in terms of the length and depth of the relationship between the patient and the transitional caregiver. While the Transition Coach only meets with the patient at home once, the Transitional Care Nurse may visit the patient s home (or other care setting) as many as 12-15 times. This increased contact gives the nurse a longer period of time in which to learn how to communicate effectively with the patient, which may lead to an increased level of trust between the patient and the caregiver. Further, by accompanying the patient to the first post-discharge appointment, the TCN serves as a critical link between the hospital and the PCP. This linkage may eliminate some of the medical errors and inefficiencies associated with a lack of communication among providers. On the other hand, the extensive role of the TCN makes this model more time-, money-, and labor-intensive than the CTI and therefore perhaps less scalable. This may be one reason the CTI has experienced more widespread adoption than the TCM. Hospitals may be more inclined to implement a model that costs less while still achieving similar results. Multiple studies have proven the positive outcomes of the TCM. The most recent study concluded that participants in this intervention had 36% fewer readmissions over a 52-week post-discharge period. Among patients who did require re-hospitalizations, the time between their primary discharge and readmission was longer and the number of inpatient days was shorter than among their non-tcm counterparts. The study also estimated total health care costs savings of about $5,000 per patient (Transitional Care Model, 2008). See Appendices E-F for more information on readmissions rates and health care costs under the TCM. 5

Project RED A third national model worthy of discussion is the Reengineered Hospital Discharges program (Project RED), developed by a research group at Boston University Medical Center under the leadership of Dr. Brian Jack. The goal of the project is to re-engineer the hospital workflow process in order to improve patient safety and reduce re-hospitalization rates (Implementing Project RED). The key caregiver in Project RED is the Nurse Discharge Advocate, who is generally a hospital nurse. The Discharge Nurse follows eleven discrete and mutually reinforcing components, each of which aims to improve the discharge process (Components of Re-Engineered Discharge (RED)). These components focus on patient communication and education as well as organization and coordination of post discharge documentation and procedures (see Appendix G for details). At discharge, each patient is given an individualized instruction booklet and asked to demonstrate his/her understanding of it. The Discharge Nurse then calls the patient two days after discharge to answer any questions the patient may have (Landro, 2011). One key innovation of Project RED has been its experimentation with the concept of a Virtual Patient Advocate. Researchers at the Boston Medical Center have developed Louise, a digital nurse that assists Discharge Advocates by teaching patients about their diagnoses, plans of care, medications, and more (See http://www.bu.edu/fammed/projectred/meetlouise.html to view videos of Louise). Louise s dialogue is personalized for each patient based on information entered into the workstation. In a pilot study of the automated system, 74% of hospital patients said they preferred receiving their discharge instructions from the virtual nurse over receiving them from their human nurses. They reported that the virtual nurse relayed instructions in a more understandable manner and was not rushed, as is commonly the case with nurses (Project RED Fact Sheet). By beginning to prepare patients for discharge as soon as they are admitted, Project RED significantly improves patient readiness for discharge. The eleven steps embedded in the model provide a detailed and straightforward framework for providers to follow. Because Discharge Advocates do not have to visit patients homes nor attend appointments with PCPs, the nurse training for Project RED is manageable. For this reason Project RED might be more quickly adopted than either the CTI or the TCM, which require more extensive nurse or coach training. It is worthy of note that in contrast to the two models discussed previously, Project RED primarily focuses on patient care before and during discharge. While it does call for telephone follow-up 2-3 days after discharge, it does not aim to provide more long-term support to patients after the transition. In fact, some hospitals have chosen to combine Project RED and the Transitional Care Model to ensure that the patient is adequately supported throughout the transition process (Landro, 2011). Additionally, Project RED does not have as strong a focus on patient and caregiver empowerment. While there is an element of patient education in the hospital, the goal of longterm patient self-sufficiency is not stressed to the same extent it is in the Coleman and Naylor interventions. Studies of Project RED also demonstrate both cost savings and decreased re-hospitalization rates. The results of a 2008 study show a 30% lower hospital utilization rate, concluding that one readmission of ER visit was prevented for every 7.3 subjects receiving the intervention. The study also showed an average cost savings per patient of $412, representing a 33.9% reduction in cost. This number is quite comparable to the cost-savings found with the Coleman model. Project RED tools and the nurse-training manual have been downloaded by over 500 hospitals in 49 states and 9 countries (Project RED Fact Sheet). See Appendix A for a detailed chart comparing the three models that have been discussed here. 6

Project BOOST Project BOOST, which stands for Better Outcomes for Older adults through Safe Transitions, is a national initiative sponsored by the National Society of Hospital Medicine to improve the care of patients as they transition from hospital to home. Project BOOST is led by a national advisory board of leaders in care transitions, hospital medicine, payers and regulatory agencies. The board is co-chaired by Eric Coleman MD, MPH and Mark Williams, MD, FACP, FHM and includes representatives from the Agency for Healthcare Research and Quality (AHRQ), Blue Cross and Blue Shield Association, Centers for Medicare and Medicaid Services, Centers for Disease Control and Prevention, Institute for Health Care Improvement (IHI), The Joint Commission, and Kaiser Permanente (Budnitz, 2012). The project s goals include identifying high-risk patients, reducing 30- day readmissions rates, reducing length of stay, improving patient satisfaction, and improving information flow among providers. To achieve these goals, Project BOOST is comprised of the following five key elements: 1) A Comprehensive Intervention developed by a panel of nationally recognized experts based on the best available evidence. 2) A Comprehensive Implementation Guide provides step-by-step instructions and project management tools, such as the TeachBack Training Curriculum, to help interdisciplinary teams redesign work flow and plan, implement, and evaluate the intervention. 3) Longitudinal Technical Assistance provides face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a train the trainer DVD and curriculum for nurses and case managers on using the TeachBack process, and webinars targeting the educational needs of other team members including administrators, data analysts, physicians, nurses and others. 4) The BOOST Collaboration allows sites to communicate with and learn from each other via the BOOST Listserv, BOOST Community site, and quarterly all-site teleconferences and webinars. 5) The BOOST Data Center, an online resource center, allows sites to store and benchmark data against control units and other sites and generates reports (Budnitz, 2012). As these elements indicate, Project BOOST is perhaps the most comprehensive of the national models described here in terms of the resources it supplies to participating provider sites. In addition to a care transitions intervention plan, the project offers hospitals a detailed implementation guide, a year of expert mentoring services, cross-site communication resources, and an online data center. Hospitals may choose to use any or all of these resources. As of February 2012, the project BOOST toolkit had been downloaded by approximately 3895 sites and the year-long mentoring program to implement the program was in place at 105 hospitals (Budnitz, 2012). Early data from six BOOST sites showed a reduction in their 30-day readmission rates from 14.2% before implementation to 11.2% after implementation, representing a 21% reduction in 30-day all cause readmission rates. Results indicate that BOOST tools improve communication and collaboration across hospital functions and outpatient physicians. Patients also reportedly perceive an increased level of service and medical attention (BOOST Preliminary Results from Pilot Sites, 2012). 7

It is important to note that Project BOOST is not mutually exclusive of the other national models discussed here. The tools and practices embedded in Project BOOST can be implemented in conjunction with these other models. The potential for collaboration between Project BOOST and the CTI, for instance, is evidenced by the fact that Dr. Eric Coleman, developer of the CTI, is also the co-chair of the advisory board for Project BOOST. STAAR Initiative: STate Action on Avoidable Re-hospitalizations The STate Action on Avoidable Rehospitalizations (STAAR) initiative is an initiative funded by The Commonwealth Fund with the goal of reducing avoidable initiatives in individual states. Launched in 2009 by the Institute for Healthcare Improvement (IHI), initiative aims to reduce rehospitalizations by working across organizational boundaries and by engaging payers, stakeholders at the state, regional and national level, patients and families, and caregivers at multiple care sites and clinical interfaces (STate Action on Avoidable Rehospitalizations, 2012). IHI is currently working with four STAAR states: Massachusetts, Michigan, Ohio, and Washington. IHI plans to make the program available to other states and regions in the future. STAAR participants are required to engage partners from across the continuum of care to facilitate joint problem solving and participative improvement design. As part of the initiative, these partners are provided with content review, process recommendations, an inventory of best practices, and suggested measurement strategies. One of the more unique elements of the STAAR initiative is its active recognition of the importance of both front-line process improvement and systemic improvement. To facilitate system-wide change, STAAR involves multi-stakeholder state leaders and steering committees to coordinate state-level leadership and facilitate policy and payment reform. In terms of implementation, STAAR hospital teams focus on achieving four key process-level improvements. These improvements, which require collaboration between hospitals and their community partners, are as follows: 1) Perform an enhanced assessment of post-hospital needs 2) Provide effective teaching and facilitate enhanced learning 3) Provide real-time handover communication 4) Ensure timely post-hospital care follow-up (More details on each of these improvements can be found at http://www.ihi.org/offerings/initiatives/staar/pages/improvement.aspx) The STAAR Initiative s measurement strategy includes both quantitative and qualitative components. It includes outcomes measures on 30-day all-cause readmissions rates; measures of patient experience from the Care Transitions Measure (CTM) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey; and customized process measures for each of the four key recommended changes mentioned above (STate Action on Avoidable Rehospitalizations, 2012). 8

CARE TRANSITIONS INITIATIVES IN COLORADO Colorado Foundation for Medical Care: Integrating Care for Populations and Communities Care Transitions As the official Medicare Quality Improvement Organization (QIO) for Colorado, the Colorado Foundation for Medical Care (CFMC) has identified the integration of care for populations and communities as one of its primary purposes (Quality Improvement Organization Priorities, 2011). Toward this end, CFMC has developed the Integrating Care for Populations and Communities (ICPC) program. As part of this program, CFMC works with medical providers, community-based organizations, and other stakeholders across the state to improve transitional care, increase care coordination, and reduce 30-day all cause readmissions among Medicare fee-for-service beneficiaries. Specifically, CFMC works with communities and providers to identify relevant stakeholders, partners, and patient populations. It aids communities in determining current 30-, 90-, and 100-day readmissions rates as well as emergency department and other utilization rates and assists them in performing root cause analyses. Based on this, CFMC Participants: Providers and community-based organizations in six communities throughout Colorado Objectives: 2% reduction in 30-day all cause readmissions for all Medicare fee-for-service beneficiaries statewide; 7% reduction in 30-day all cause readmissions in participating communities; 2% reduction in hospital cost based on Medicare data Current Status: Initial outcomes to be measured in March 2013; ongoing engagement with participating communities until July 2014 and communities can work together to choose an intervention(s) and to measure and monitor results over time. The principle objective of this initiative is to achieve a 2% reduction in all cause readmissions for all Medicare fee-for-service beneficiaries statewide by March 2013. In individual communities with whom CFMC has worked closely, the goal is to realize a 7% reduction in all cause 30-day readmissions as well as 2% reduction in hospital cost based upon Medicare data by March 2013. The ICPC program began in 2008 with a pilot project focused in the Northwest Denver region. From 2008 to 2011, CFMC worked with organizations serving Medicare beneficiaries in 44 zip codes throughout Northwest Denver. The project used data analysis, coaching, personal health records, Community Action Teams, and other tools to foster community unity and engage and empower patients (CFMC, 2012). At the conclusion of this pilot project in July 2011, CFMC measured a 9.3% relative improvement (decrease) in readmission per 1,000 beneficiaries. Currently, CFMC is supporting the following six communities throughout the state: Denver metro region (Denver Regional Care Connection) Grand Junction (Colorado Beacon Consortium) Loveland (Systems of Care Initiative) Greeley Boulder County Southern Colorado Each of these communities has engaged a different set of stakeholders, has unique areas of focus, and uses different outcome measures. In multiple communities, Area Agencies on Aging (AAAs) are playing a major role as community organizers. While the aforementioned goals are to be 9

measured in March 2013, CFMC plans to remain engaged with these six communities (and perhaps to engage other communities) until July 2014. Colorado Foundation for Home Care Technology and Education: Telehealth in the Home Telehealth in the Home is a chronic disease management project conducted by the Colorado Foundation for Home Care Technology and Education in partnership with the Colorado Department of Health Care Policy and Financing. The project, which supports access to telemedicine and telehealth services in the home setting for Colorado Medicaid patients, is funded by a $224,000 grant from the Colorado Health Foundation. This grant is matched dollar for dollar by CMS, making total funding for the project about $450,000. This funding is being used to provide telehealth services to 150 Colorado Medicaid clients. Home care agencies are able to monitor these patients health status and collect vital signs such as weight, temperature, blood glucose, blood pressure, pulse and breath sounds in real time without having to leave the agency s base station. Telehealth devices can also be used to educate patients and to provide medication reminders. Telehealth in the Home is designed to improve health and save money Participants: Select home health agencies and 160 CO Medicaid recipients Objectives: Improve access to care, reduce hospitalizations, and save state and federal tax dollars Current Status: In progress; Project duration from July 1, 2011 to June 30, 2013 by promoting earlier hospital discharges, reduced home visits, decreased hospitalizations and readmissions, reduced emergency room admittance, shortened length of stay (Colorado Foundation for Home Care, 2011). Adult Resources for Care and Help (ARCH): Mesa County Care Transitions Improvement Project The Mesa County Aging and Disability Resource Center, commonly known in Colorado as Adult Resources for Care and Help (ARCH), is currently in the second year of a two-year program focused on transitional care improvement. The program, funded by a $171,000 grant from the Administration on Aging and CMS, is centered on the implementation of Eric Coleman s Care Transitions Intervention (Commissioners, 2012). The majority of the grant funding is allocated to Home Care of the Grand Valley to execute the program; the rest is used to fund a part-time position at ARCH and to cover overhead costs. The program currently includes two transition coaches at St. Mary s Hospital. It is also worthy of note that Mesa County has Participants: Adult Resource for Care and Help (ARCH), Home Care of the Grand Valley, St. Mary s Hospital and Regional Medical Center Objective: Increase patients capacity for effective self-management in the post-hospitalization period in order to reduce unplanned rehospitalizations Current Status: In progress; Project duration from September 30, 2010 to September 30, 2012 been a participant community in the CFMC Transitions of Care pilot project described above. The primary goal of the program is the increase patients capacity for effective self-management in the posthospitalization period in order to reduce unplanned rehospitalizations. Specific objectives include standardizing and formalizing coaching processes, measuring decreases in hospital readmission rates at 14, 30, 60, and 90-10

days, formalizing the Care Transitions Taskforce structure as a subcommittee to the Quality Health network s Quality Oversight committee, and serving and coaching 800 patients over a 2 year timeframe (Aging and Disability Resource Centers). Colorado Hospital Association: Reducing Avoidable Readmissions & Safe Transitions Collaborative The Reducing Avoidable Readmissions and Safe Transitions Collaborative is an effort to re-engineer the hospital workflow process and improve inpatient and outpatient safety through increased patient preparedness, enhanced provider-patient relationship, and improved community infrastructure. The two-year initiative, funded by a $1.1 million grant from UnitedHealthcare, will help over 20 Colorado hospitals implement an evidence-based readmissions reduction program (Business Wire, 2011). The collaborative has two principal phases. The first focuses on implementing the 11 steps of the Project RED model described previously (see Appendix G details on these steps). The second phase concentrates on the implementation of elements from the Project STAAR (State Action on Avoidable Re-hospitalizations) model, which works to reduce the likelihood of readmission through partnerships with transitional care facilities in communities. Ultimately, the initiative intends to reduce avoidable readmissions, improve care coordination for patients, and drive cost savings from both patients and providers. Toward this end, each participating hospital has chosen a target population based on the individual needs of their organizations. For each target population, the collaborative aims to achieve 1) a 20% reduction from baseline, 30-day same cause readmission rates and 2) a 10% reduction from baseline, 30-day unplanned all cause readmission rates. Although the projected timeline is January 2012 through December 2013, the collaborative seeks longterm, continuous improvement over time. It is hoped that as the collaborative proceeds, hospitals will expand their efforts to new target Participants: Avista Adventist Hospital; Boulder Community Hospital, Colorado Acute Long Term Hospital, Community Hospital Grand Junction, Conejos County Hospital, Denver Health & Hospital Authority; Exempla Lutheran Medical Center; Exempla Good Samaritan Medical Center; Littleton Adventist Hospital; Longmont United Hospital; The Medical Center of Aurora; Melissa Memorial Hospital; Montrose Memorial Hospital; Plate Valley Medical Center; Porter Adventist Hospital; Rio Grande Hospital; San Luis Valley Regional Medical Center; Spanish Peaks Regional Health Center; Sedgwick County Health Center; St. Anthony Central Hospital; St. Anthony North Hospital; St. Mary Corwin Medical Center; Yuma District Hospital Objective: Reduce readmissions, improve care coordination for patients, and drive cost savings Current Status: In progress; Initial project duration from January 2012 to December 2013 populations and units, eventually integrating these models as standard practices within participating facilities. 11

Colorado Regional Health Information Organization: Long-term and Post-Acute Care Program to Improve Care Transitions through HIE As the state-designated Health Information Exchange (HIE), the Colorado Regional Health Information Organization (CORHIO) has been awarded a $1.7 million grant by the Office of the National Coordinator for Health Information Technology (ONC) to facilitate adoption and measure the Participants: Eligible LTPAC organizations in Boulder County, Colorado Springs, Pueblo, and the San Luis Valley Objective: Develop a statewide minimum template model of technology, process, and product for successful LTPAC care transitions Current Status: In progress; Project duration from January 2011 to February 2014 impact of HIE on long-term an postacute care (LTPAC) transitions. The $1.7 million received by CORHIO is part of $16 million in grants awarded by ONC with the goal of encouraging breakthrough innovations for health information exchange that can be leveraged widely to support nationwide HIE and interoperability (Health Information Exchane Challenge Grant Program, 2011). CORHIO is currently offering compensation from the ONC grant to eligible LTPAC organizations in Boulder County, Colorado Springs, Pueblo, and San Luis Valley to adopt HIE and assist in CORHIO s LTPAC Transitions Program (LTPAC Transitions Program). Participating organizations include skilled nursing facilities, assisted living, home health, hospice, LTACs, and RCF-DD program. These participants receive technical assistance and access to the CORHIO HIE through CORHIO s PatientCare 360 Web portal, which includes results delivery inbox, community health record, CCD, referral tool, and secure messaging. By participating in HIE, long-term care organizations have access to more accurate and comprehensive patient information, leading to fewer treatment errors and duplicative tests and overall better coordination during care transitions (CORHIO, 2011). The three-year initiative is being implemented in two phases. Phase I focuses on community-based design and implementation of standard HIE technology, with each of the four targeted communities identifying critical elements for successful LTPAC transition, setting care transitions goals, and implementing strategies to achieve those goals. This phase will also encourage LTPAC providers to participate in the statewide HIE, compensating them for their participation to incentivize sustained and increased involvement. Phase II concentrates on convening community and statewide stakeholders to review processes and strategies developed by the four targeted communities for improving LTPAC transitions, utilizing HIE as an important tool in delivering health information. Stakeholders will build upon existing care transition models and knowledge to develop a statewide minimum template for improving LTPAC transitions. Data and information will be collected throughout Phase II to ensure rigorous analysis of the impact the community HIE-based interventions have on improving LTPAC transitions. Throughout these phases CORHIO plans to broadly disseminate the process, implementation, and outcomes of the project. 12

Colorado Rural Health Center: icare Transitions Improving Communication and Readmission The icare (Improving Communication and Readmission) project engages Colorado s rural Critical Access Hospitals (CAH s) in a statewide improvement program aligning with national trends and funding priorities demonstrating sustainable improvement and outcomes (icare - Improving Communication and Readmission). The project is funded by Colorado s Medicare Rural Hospital Flexibility Grant and has three primary goals: 1) improve communications in transitions of care, 2) Improve the clinical process and systems to reduce readmissions, particularly for heart failure and pneumonia patients, and 3) Maintain low readmission rates. icare participants set individuals goals related to one of these goals, as relevant to their CAH. Participating hospitals have access to a number of resources to assist in setting and achieving goals. These resources include training in Lean/Six Sigma and Quality Improvement practices, monthly webinars, peer networking with other CAHs, roadmaps, templates/checklists, opportunities to increase public awareness and to align with state and federal initiatives, and more. The project is currently in its second year and plans to expand in future years. All Colorado CAHs are encouraged to join. Participants: icare Year One participants: Conejeos County Hospital, Estes Park Medical Center, Gunnison Valley Hospital, Heart of the Rockies Regional Medical Center, Kremmling Memorial Hospital, Pikes Peak Regional Hospital, Pioneers Hospital, Rio Grande Hospital, St. Vincent General Hospital District, Sedgwick County Health Center, Southeast Colorado Hospital, Southwest Memorial Hospital, Spanish Peaks Regional Health Center Objective: improve communications in care transitions and improve clinical processes and systems in order to reduce readmissions Current Status: In progress; Currently in second year (Sept 2011-August 2012) 13

BEST PRACTICES/RECOMMENDATIONS Moving forward with the care transitions initiatives described above, it is beneficial to determine a list of best practices for improving care transitions. The first of these is provider knowledge. While this may seem obvious, data reveals that providers frequently have inadequate knowledge to provide efficient, high-quality care to their transitioning patients. Providers must have an understanding of patients needs, goals, functional status, medical and behavioral health history, medication, and family or other support system before they enter the examination room (Coleman and Fox 2004). Precious face time with the physician should be spent treating immediate needs, not getting the physician up to speed on a patient s recent history. Additionally, providers should be trained to provide the care that meets patients stated goals and priorities, not simply the care they believe will be most effective. Finally, providers should place more emphasis on preparing patients for self-management, thereby reducing their reliance on the health care system (Coleman E., What Will It Take?, 2011). Many of the initiatives described here attempt to enhance provider knowledge through standardized information exchange, improved communication among providers, transitions coaches, and other tools. Closely paired with provider knowledge is the need for accountability at all stages in the transition process. Accountability requires clearly defined roles and responsibilities for all providers throughout the transition process, particularly in the immediate post-discharge timeframe. Most importantly, there should always be an easily identifiable provider available to the patient. The Transition Coaches in the Coleman model and the Transitional Care Nurses in Mary Naylor s model achieve this goal. There are also alternative strategies for ensuring patients access to a provider during transitions, such as the implementation of physician housecall services or the utilization of Community Health Workers. Of course, health care providers must evaluate the cost and resources involved as well as the level of patient need in choosing an appropriate care transitions strategy. Whichever model is chosen, however, provider accountability is critical. A third best practice, emphasized in a number of the initiatives discussed here, is patient and family/caregiver education and engagement (See Appendix I). Engaging the individual requires a cultural shift from the passive patient to the active patient, a shift which is already beginning to take place. An empowered patient is one who frequently has chances for direct input and who feels that his/her preferences are considered and valued (Coleman E., What Will It Take?, 2011). An empowered patient is also one who has realistic expectations and understands the transition process. Patients and their caregivers should be treated as essential members of the healthcare team and, as long as they are able, should be in charge of their own care to the greatest extent possible (Coleman E., What Will It Take?, 2011). Another obvious yet critical piece of care transitions is effective cross-venue coordination. Communication and synergy between sending and receiving teams minimizes the stress to the patient and reduces the risk of error. Coordination may be catalyzed in some instances by the creation of contracts between hospitals, SNFs, and home health agencies (Coleman and Fox 2004). These contracts should provide clear guidelines for performing transfers and must be adhered to by all parties involved. The CMS Community Based Care Transitions Program (CCTP), bundled payments, ACOs, and patient-centered medical homes all reflect the move toward greater coordination among care venues (E. Coleman, What Will It Take? 2011). The highest level of cross-venue coordination is possible when processes are standardized across settings. The existence of multiple protocols, standards, and information systems is a major barrier to smooth transitions. Any intervention should include a detailed workflow/process schematic that is understood by everyone involved. Such standardized processes allow providers to plan ahead and 14

minimize room for error. By endeavoring to develop a statewide minimum template for improving LTPAC transitions, CORHIO s LTPAC Transitions Program is helping to move Colorado toward the kind of standardization that is necessary to make care transitions as effective as possible. Perhaps the best way to achieve standardization is the effective use of information technology during transitions. According to Christopher Langston, PhD, and program director of the John A. Hartford Foundation, "It is increasingly clear that health information technology, implemented in a patient-centered way, has vast potential to help us reduce the number of injuries, accidents and rehospitalizations that are causing stress and harm to patients, particularly older patients, every year" (Kahn, 2011 ). In terms of care transitions, IT should be used to create patient intake and assessment tools that are consistent throughout a given health care community. The same core data elements should be included in transfer summaries throughout the continuum of care and should be communicated in a consistent way throughout care settings (Coleman and Fox 2004). Innovations in IT provide frequent opportunities to improve the transition process. Finally, any care transitions program should include performance assessment tools. The best care transitions programs will be those that consistently measure their success in both qualitative and quantitative terms. Most of the Colorado initiatives described above have quantitative evaluation plans, many of which are focused on percentage reductions in readmissions rates. Such metrics are critical in measuring short and long-term success. Despite the importance of these quantitative metrics, qualitative data must be gathered and considered as well. The Coleman model, for instance, contains the Care Transitions Measure (CTM), which is used to assess the quality of care transitions from the perspective of the patient. The CTM asks patients to respond to comments such as Before I left the hospital, the people that were going to help me when I got home clearly understood what my health care needs were. CTM scores are significantly associated with a patient s propensity to return to the hospital or ED after discharge (Coleman and Fox 2004). Overall, the CTM has been found to provide meaningful, patient-centered insight into the quality of care transitions it also provides information that may be useful to clinicians, hospital administrators, quality improvement entities, and third party payers (Coleman, Mahoney, & Parry, 2005). The LTPAC Transitions Program also plans to go beyond quantitative assessment through the administration of a qualitative statewide survey to statewide stakeholders. 15

CONCLUSION Despite the many factors impacting the quality of care transitions and readmission rates, improving care transitions is not an impossible task. As existing models demonstrate, there are many strategies, tools, and tactics that can be employed to improve both the efficiency and the effectiveness of care throughout the transition process. Even more encouragingly, the majority of the tools and tactics utilized in these models are not rocket science; most of them simply make sense. HCOs in Colorado and across the country are beginning to recognize the feasibility and importance of implementing care transitions programs. Yet despite the progress that has been made, improving care transitions remains a national challenge. As of the end of 2011, one in five Medicare beneficiaries was still readmitted to the hospital within thirty days of discharge, and many of these readmissions are believed to be preventable (Kahn 2011). To alleviate the ongoing problem of high readmissions, widespread adoption of complementary intervention strategies is needed. Such widespread adoption will require collective provider buy-in, high levels of crosssetting collaboration, and long-term commitment from all involved parties. 16

BIBLIOGRAPHY Administration Implements New Health Reform Provision to Improve Care Quality, Lower Costs. (2011, April 29). Retrieved July 5, 2012, from HealthCare.gov: http://www.healthcare.gov/news/factsheets/2011/04/valuebasedpurchasing04292011a.html Aging and Disability Resource Centers. (n.d.). Aging and Disability Resource Centers Implementing the Affordable Care Act: Making it Easier for Individuals to Navigate Their Health and Long-Term Care through Person- Centered Systems of Information, Counseling and Access Evidence Based Care Transition Program. Retrieved April 24, 2012, from http://www.aoa.gov/aoaroot/aoa_programs/hcltc/adrc_caretransitions/docs/co.pdf Bonner, A., Schneider, C., & Weissman, J. (2010). Massachusetts Strategic Plan for Care Transitions. Policy Brief, Massachusetts Executive Office of Health and Human Services, Massachusetts State Quality Improvement Institute. BOOST Preliminary Results from Pilot Sites. (2012). Retrieved April 17, 2012, from Society of Hospital Medicine: http://www.hospitalmedicine.org/am/template.cfm?section=home&template=/cm/htmldisplay.cf m&contentid=27577 Budnitz, T. (2012). Improving the Care of Patients as They Transition from Hospital to Home. Retrieved April 17, 2012, from Project BOOST: http://www.hospitalmedicine.org/resourceroomredesign/rr_caretransitions/pdfs/project_boos T_Fact_SheetFinal.pdf Business Wire. (2011, August 24). UnitedHealthcare and Colorado Hospital Association Work Together on Innovative Program to Reduce Avoidable Hospital Readmissions. Retrieved May 2, 2012, from Business Wire News: http://www.businesswire.com/news/home/20110824005115/en/unitedhealthcare- Colorado-Hospital-Association-Work-Innovative-Program Care transition option involves house calls. (2011, June). Discharge Planning Advisor. Center, D. (2011, June 15). CommunityConnections Blog. Retrieved May 1, 2012, from The Colorado Trust: http://www.coloradotrust.org/news/blog/blog-entry/tools-for-the-home-health-care-transition CFMC. (2012, February 23). Improving Care Transitions in Northwest Denver. Retrieved April 24, 2012, from http://www.avoidreadmissions.com/wwwroot/userfiles/documents/98/arc-learning-sessionpresentation-hayes-022312-final.pdf Coleman, E. (2010, August 27). University of Colorado-Denver's Eric Coleman on the Need for Better Care Transitions. (C. Healthline, Interviewer) Coleman, E. (2012, February 27). (S. Lonowski, Interviewer) Coleman, E. (2011). What Will It Take to Ensure High Quality Transitional Care? Retrieved March 2, 2012, from The Care Transitions Program: http://www.caretransitions.org/what_will_it_take.asp Coleman, E., Mahoney, E., & Parry, C. (2005). Assessing the quality of preparation for posthospital care from the patient's perspective: the care transitions measure. MEDLINE, 43 (3), 246-55. Coleman, E., Parry, C., Chalmers, & Sung-joon. (2006, September 25). The Care Transitions Intervention. Arch Intern Med, 66, pp. 1822-1828. Colorado Foundation for Home Care. (2011, January 5). The Colorado Health Foundation Supports Telehealth in the Home. Retrieved April 24, 2012, from 17

http://www.assnoffice.com/hcaconline.org/telehealth/chfgrant/newsrelease.pdf. Commissioners, B. o. (2012, February 2012). Regular administration meeting. Components of Re-Engineered Discharge (RED). (n.d.). (A. f. Quality, Producer, & Agency for Healthcare Research and Quality and the Heart, Lung and Blood Institute) Retrieved April 17, 2012, from Project RED: http://www.bu.edu/fammed/projectred/components.html CORHIO. (2011, Novermber 9). CORHIO Will Soon Offer Grants to Long-term and Post-Acute Care Facilities. Retrieved May 3, 2012, from CORHIO Connect E-Newsletter: http://www.corhio.org/news/corhioe-newsletter/corhio-will-soon-offer-grants-to-long-term-and-post-acute-care-facilities-to-measureimpact-of-hie-on-care-transitions-11-9-2011.aspx Everhart, Carol, Communication Across the Continuum of Care, presentation to the Massachusetts Health Data Consortium, September 22, 2009. Health Information Exchane Challenge Grant Program. (2011, Febraury 23). Retrieved May 4, 2012, from The Office of the National Coordinator for Health Information Technology: http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objid=3378 icare - Improving Communication and Readmission. (n.d.). Retrieved May 4, 2012, from Colorado Rural Health Center: http://www.coruralhealth.org/programs/cah/icare.htm Implementing health reform: community based care transitions program. (2011). Family Practice News, 41 (6), 67. Implementing Project RED. (n.d.). Retrieved March 1, 2012, from Project RED: http://www.bu.edu/fammed/projectred/implementing.html Institute for Engaged Aging. (2009). News. Retrieved March 5, 2012, from Institute for Engaged Aging: http://www.clemson.edu/aging/news_sept_09.html Integrating Care for Populations and Communities. (2011). Retrieved May 1, 2012, from CFMC: Leadership in Healthcare Quality Improvement: http://www.cfmc.org/provider/provider_integrating-care.aspx Kahn, R. (2011, October 11). Putting the IT in Care Transitions. Retrieved March 4, 2012, from Kaiser Permanente New Center: http://xnet.kp.org/newscenter/pressreleases/nat/2011/101111caretransitions.html Kwan, Y, Fernandes, OA, JJ et al., Pharmacist medication assessments in a surgical preadmission clinic, Arch Intern Med. 2007; 167:1034-40. Landro, L. (2011, June 7). Don't Come Back, Hospitals Say. Retrieved March 7, 2012, from The Wall Street Journal: http://online.wsj.com/article/sb10001424052702304474804576369452547349050.html# LTPAC Transitions Program. (n.d.). Retrieved May 4, 2012, from CORHIO: http://www.corhio.org/forproviders/long-term-care/ltpac-transitions-program.aspx Meier, D., & Beresford, L. (2008). Palliative Care s Challenge: Facilitating Transitions of Care. Journal of Palliative Medicine, 11 (3), 416-421. Press Release: CFC Receives Grant To Adress Nursing Workforce Issues. (n.d.). Retrieved May 1, 2012, from Caring for Colorado Foundation: A Health Grantmaker: http://www.caringforcolorado.org/newsandevents/pressreleases/c8216adb-fff1-7f72-223a12ceea7ae6d2/ 18

Project RED Fact Sheet. (n.d.). Retrieved March 7, 2012, from Project RED: http://www.bu.edu/fammed/projectred/meetlouise.html Quality Improvement Organization Priorities. (2011). Retrieved April 24, 2012, from CFMC: http://www.cfmc.org/provider/provider_qio-priorities.aspx STate Action on Avoidable Rehospitalizations. (2012). Retrieved May 17, 2012, from Institute for Healthcare Improvement: http://www.ihi.org/offerings/initiatives/staar/pages/default.aspx Transitional Care Model. (n.d.). Retrieved April 17, 2012, from www.transitionalcare.info: http://www.nursing.upenn.edu/media/transitionalcare/documents/information%20on%20the%20mod el.pdf Transitional Care Model. (2008). (Health Workforce Solutions LLC) Retrieved April 16, 2012, from Innovative Care Models: http://www.innovativecaremodels.com/care_models/21/overview Traynor, K. (2012, January 1). Rhode Island Program Targets Care Transitions. Retrieved March 8, 2012, from American Society of Health-System Pharmacists: http://www.ashp.org/menu/news/pharmacynews/newsarticle.aspx?id=3647 What do we mean by "Care Transitions?". (2007). Retrieved March 1, 2012, from The Care Transitions Program: http://www.caretransitions.org/definitions.asp 19

APPENDIX A: CTI Four Pillars Source: (Coleman, Parry, Chalmers, & Sung-joon, 2006) APPENDIX B: CTI Utilization Outcomes Source: (Coleman, Parry, Chalmers, & Sung-joon, 2006) 20

APPENDIX C: Changes in Rehospitalization rates with CTI Source: (Coleman, Parry, Chalmers, & Sung-joon, 2006) APPENDIX D: Transitional Care Model Nine Core Elements 1. In-hospital assessment, preparation and development of an evidence-based plan of care. 2. Consistency of provider across the entire episode of care with the transitional care nurse (TCN) as the primary coordinator of care. 3. Regular home visits with available, ongoing telephone support (24 hours per day, 7 days per week) through an average of 2 months post-discharge. 4. Comprehensive, holistic focus on each patient s needs, including the reason for the primary hospitalization as well as other complicating or coexisting events. 5. Active engagement of patients and their family and informal caregivers, including education and support. 6. Emphasis on positioning older adults and their family/caregivers for longer term, positive outcomes that result in early identification and response to health care risks and symptoms, and avoidance of adverse and untoward events that lead to readmissions. 7. Multidisciplinary approach that includes the patient, family, informal and formal caregivers as part of a team. 8. Physician nurse collaboration. 21

9. Communication to, between, and among the patient, family, and informal caregivers, and health care providers and professionals. Source: Mary Naylor, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing. See: <www.nursing.upenn.edu/ncth/>. APPENDIX E: TCM Readmission Rates 1. Naylor MD, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, & Pauly M. Comprehensive discharge planning for the hospitalized elderly. Ann Intern Med. 1994;120:999-1006. 2. Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, & Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-620. 3. Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, & Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684. Source: Transitional Care Model. (n.d.). Retrieved April 17, 2012, from www.transitionalcare.info: http://www.nursing.upenn.edu/media/transitionalcare/documents/information%20on%20the%20model.pdf 22

APPENDIX F: TCM Total Health Care Costs * Total costs were calculated using average Medicare reimbursements for hospital readmissions, ED visits, physician visits, and care provided by visiting nurses and other healthcare personnel. Costs for TCM care is included in the intervention group total. ** Naylor et al., JAMA, 1999; www.transitionalcare.info *** Naylor et al., JAGS, 2004 Source: Transitional Care Model. (n.d.). Retrieved April 17, 2012, from www.transitionalcare.info: http://www.nursing.upenn.edu/media/transitionalcare/documents/information%20on%20the%20model.pdf 23

APPENDIX G: Eleven Components of Project RED 1. Educate the patient about his or her diagnosis throughout the hospital stay. 2. Make appointments for clinician follow-up and post-discharge testing and Make appointments with input from the patient regarding the best time and date of the appointment. Coordinate appointments with physicians, testing, and other services. Discuss reason for and importance of physician appointments. Confirm that the patient knows where to go, has a plan about how to get to the appointment; review transportation options and other barriers to keeping these appointments. 3. Discuss with the patient any tests or studies that have been completed in the hospital and discuss who will be responsible for following up the results. 4. Organize post-discharge services. Be sure patient understands the importance of such services. Make appointments that the patient can keep. Discuss the details about how to receive each service. 5. Confirm the Medication Plan. Reconcile the discharge medication regimen with those taken before the hospitalization. Explain what medications to take, emphasizing any changes in the regimen. Review each medication s purpose, how to take each medication correctly, and important side effects to watch out for. Be sure patient has a realistic plan about how to get the medications. 6. Reconcile the discharge plan with national guidelines and critical pathways. 7. Review the appropriate steps for what to do if a problem arises. Instruct on a specific plan of how to contact the PCP (or coverage) by providing contact numbers for evenings and weekends. Instruct on what constitutes an emergency and what to do in cases of emergency. 8. Expedite transmission of the Discharge Resume (summary) to the physicians (and other services such as the visiting nurses) accepting responsibility for the patient s care after discharge that includes: Reason for hospitalization with specific principal diagnosis. Significant findings. (When creating this document, the original source documents e.g. laboratory, radiology, operative reports, and medication administration records should be in the transcriber s immediate possession and be visible when it is necessary to transcribe information from one document to another.) Procedures performed and care, treatment, and services provided to the patient. The patient s condition at discharge. A comprehensive and reconciled medication list (including allergies). A list of acute medical issues, tests, and studies for which confirmed results are pending at the time of discharge and require follow-up. Information regarding input from consultative services, including rehabilitation therapy. 9. Assess the degree of understanding by asking them to explain in their own words the details of the plan. May require removal of language and literacy barriers by utilizing professional interpreters. May require contacting family members who will share in the care-giving responsibilities. 10. Give the patient a written discharge plan at the time of discharge that contains: Reason for hospitalization. Discharge medications including what medications to take, how to take them, and how to obtain the medication. Instructions on what to do if their condition changes. Coordination and planning for follow-up appointments that the patient can keep. Coordination and planning for follow-up of tests and studies for which confirmed results are not available at the time of discharge. 11. Provide telephone reinforcement of the discharge plan and problem-solving 2-3 days after discharge. Source: (Components of Re-Engineered Discharge (RED)) 24

APPENDIX H: Transitional Care Model Comparison Goals Structure/Elements Scope Rehospitalization Rates Cost reductions Eric Coleman Model Mary Naylor Model Brian Jack Model Empower patients, Address the negative Patient safety and reduce families, and caregivers outcomes associated rehospitalization rates by giving them the tools, with breakdowns in care knowledge, and support when older adults with they need to manage complex needs transition their own care from an acute care setting to the home or 2 key elements: Patient Health Record and Transition Coach 570 health care organization have adopted the Intervention including home care agencies, health plans, hospitals, large physician practices, community organizations, and Areas on Aging 30-day rate reduced by 30.25% and 90-day rate reduced by 26.78% Cost per patient reduced by 19.17% at 180 days; an average savings of other care 9 core elements and implemented by Transitional Care Nurses (See Appendix F) Could not find data 36% fewer readmissions over a 52 week postdischarge period Estimated mean perpatient savings in total health care costs of 11 key components (See Appendix E) primarily implemented by nurses in hospital settings RED tools and nurse training material have been downloaded by over 500 hospitals from 49 states and 9 countries 30% reduction in readmissions 33.9% lower observed cost per patient; an average savings of $412 $488 $5,000 ***Unfortunately, these programs do not use exactly the same metrics to gauge their results in terms of rehospitalization rates and cost reductions; therefore direct comparison is somewhat difficult. It is notable, however, that rehospitalization rates experience reductions in the realm of 30% with each of the three models. 25

APPENDIX I: Impact of Patient Engagement 26