Strategies to Improve Healthcare Transitions: Patient

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Strategies to Improve Healthcare
TransitionsPatient Caregiver Engagement and
Activation

• Sara Butterfield, RN, BSN, CPHQ, CCM
• New York State Wide Senior Action Council, Inc.
• 2011 Annual Convention
• October 11, 2011

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• Centers for Medicare Medicaid Services (CMS)
• Leads a national healthcare quality improvement
  program, implemented locally by an independent
  network of Quality Improvement Organizations
  (QIOs) in each state
• IPRO
• The federally funded Medicare Quality Improvement
  Organization (QIO) for New York State, under
  contract with the Centers for Medicare Medicaid
  Services (CMS).

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CMS GoalsNational Statewide Level

• Six Priorities
• Making care safer
• Promoting effective coordination of care
• Assuring care is person and family-centered
• Promoting the best possible prevention and
  treatment of the leading causes of mortality,
  starting with cardiovascular disease
• Helping communities support better health
• Making care more affordable for individuals,
  families, employers and governments by reducing
  the costs of care through continual improvement

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National Perspective

• 17.6 of Medicare beneficiaries are
  re-hospitalized within 30 days of discharge,
  accounting for 15 billion in spending
• Estimates show that 76 of these readmissions may
  be preventable
• Of Medicare beneficiaries re-admitted within 30
  days, 64 receive no post-acute care between
  discharge and re-admission
• Source MedPACJune 2007 Report To Congress
  Promoting Greater Efficiency in Medicare

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New York State Perspective
New York State 30-Day Hospital Readmission Rates Medicare FFS Beneficiaries Age 65 or Older New York State 30-Day Hospital Readmission Rates Medicare FFS Beneficiaries Age 65 or Older New York State 30-Day Hospital Readmission Rates Medicare FFS Beneficiaries Age 65 or Older
CY 2009 CY 2010
All Cause 20.5 20.9
Acute Myocardial Infarction 25.2 23.8
Heart Failure 28.8 28.6
Pneumonia 21.3 21.1
Chronic Obstructive Pulmonary Disease 26.2 26.4
Diabetes 24.3 22.3
End Stage Renal Disease 37.1 35.4
Source CMS ISAT Data Source CMS ISAT Data Source CMS ISAT Data
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Consumer Perspective

• AARP Report Chronic Care A Call to Action for
• Health Reform
• According to the results of the patient survey
• Nearly one in four patients reported experiencing
  a medical error, and 61 percent of this subgroup
  said they had experienced a major problem as a
  result
• About one in five reported that their health care
  providers did not communicate well with each
  other about the their individual condition or
  treatment, which some said compromised their
  health
• Nearly one in seven said they didn't get a
  follow-up appointment after they were discharged
  or, if they did, it was more than four weeks
  later and
• Almost one in five said their transitional care
  was not well coordinated.

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Contributing Factors

• Patients are more chronically ill, more frail,
  and have more complex care needs
• Multiple diagnoses
• May see several physicians
• Average 13-16 medications per day
• May be cognitively impaired
• May not have a Primary Care Physician
• Lack of involving a caregiver for safe transition
  to home
• Access to and/or lack of community services

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Other Contributing Factors

• Not remembering / understanding physician
  instructions
• Difficulty communicating with health
  professionals
• Unrealistic expectations
• Difficulty arranging for assistance
• Finances/affordability
• Not enough time for competing demands
• Loss of mobility
• Language barriers
• (Source Beyond 50.09 Chronic Care A Call to
  Action for Health Reform, AARP, March 2009)

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Dilemmas

• Focus is on discharge versus transition
• No ownership of transition
• Burden of coordination is placed on patient
• Caregiver may not be available / involved at
  discharge
• Absence of common medical record
• Absence of cross setting medication
  reconciliation
• Lack of advance directives screening for
  palliative care
• No reassessment of patient and goals at each
  transition
• Communication gaps exist between disciplines and
  health care settings

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The Driving Forces.

• American Geriatrics Society Health Care
• Systems Committee Position
• Clinical professionals must prepare
  patients/caregivers to receive care in the next
  setting actively involve them in decisions
  related to the formulation execution of the
  transitional care plan
• Bi-directional communication between clinical
  professionals is essential to ensuring high
  quality transitional care
• The opportunity to collaborate with a
  coordinating health professional functioning
  across health care settings to reduce care
  fragmentation may enhance the care that these
  professionals deliver
• Source J Am Geriatric Soc 51556-557, 2003

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Centers for Medicare Medicaid Services Care
Transitions Initiative August 2008-July 2011
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New York Care Transitions Target Community

• Five county region in Upper Capital Region of New
  York State with integrated referral patterns
  incorporating urban, suburban and rural
  communities within 84 zip codes
• Warren, Washington, Saratoga, Rensselaer
  Saratoga
• Fifty providers
• Hospitals (6), Home Health (6), Skilled Nursing
  Facilities (28), Hospice (5),
• Dialysis Centers (5), Multiple Physician
  Practices
• Impacting 68,206 Medicare Fee for Service (FFS)
  beneficiaries

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Where We Began Our Journey
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Cross-Setting PartnershipsOur Patient
Patient Within Our Community
The Paradigm Shift Discharge Versus Care
Transition

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Targeted Opportunities for Improvement

• Assessment of patient / caregiver understanding
  of discharge medications instructions using
  Teach-Back Method
• Identification and referral of high-risk
  readmission patients for follow-up care
• Inclusion of 7-day follow-up physician visit
  appointment in discharge instructions with
  follow-up phone call
• Cross setting medication reconciliation
  education
• Support of patient / caregiver learning for
  self-management (signs / symptoms / red flags /
  action)
• Improved cross setting partnerships and
  communication for care coordination and
  management
• Streamlined and standardized cross setting
  information transfer

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Patient Engagement / Activation

• The persons ability to manage their health
• and health care
• Self efficacy in managing their behavior
• Readiness to change - motivation
• Knowledge, skill, beliefs, and behaviors
• Linked to the persons health outcomes

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Patient Engagement / Activation

• Patients who were not interested or less
  involved in care tended to
• Have more problems with transitioning between
  care settings
• Reported more problems with care
• Less confident with there ability to manage their
  chronic condition
• Worse health status and more chronic conditions
• Required more assistance to arrange for care
• (Source Beyond 50.09 Chronic Care A Call to
  Action for Health Reform, AARP, March 2009)

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Key Practices Leading to Results

• Collaborated with target community providers and
  stakeholders to identify sites where seniors
  gather for social and health activities
• Senior Centers , Housing Units, Independent
  Assisted Living Facilities, Churches, Libraries
• Organized one hour beneficiary outreach sessions
  at each site
• 20 educational sessions completed to date
  reaching over 315 Medicare beneficiaries in
  community
• 3 community caregiver outreach exhibits with over
  160 attendees
• 2 senior health fairs with over 150 attendees
• Developed large font, fifth grade level
  educational materials to share and reference
  during each session
• Hospital Discharge Planning Golden Rules
• Medication Management Golden Rules
• Personal Health Record
• Caregiver Resource Handout
• United Hospital Fund Next Step In Care Resources
• Opened sessions by asking seniors to share their
  health care experiences and then used their
  stories in conjunction with the educational
  materials to discuss importance of self
  empowerment self-management skills
• Shared beneficiary feedback perceptions with
  target community providers

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Heart Failure Zones
Determine your zone every day! Every day Weigh yourself in the morning before breakfast, and enter your daily weight in a log. Take your medicine as directed by your doctor. Check for swelling in your feet, ankles, legs and stomach. Eat low-salt food. Balance activity and rest periods.

Green Zone This zone is your goal Your symptoms are under control. You have No shortness of breath. No weight gain of more than two pounds. No swelling in your feet, ankles, legs or stomach. No chest pain.

Yellow Zone Caution This zone is a warning Call you doctor's office if You have a weight gain of two or more pounds in one day or a weight gain of four pounds or more in one week You have increased shortness of breath. You experience more swelling of your feet, ankles, legs or stomach. You feel more tired and lack energy. You have a dry or moist hacking cough. You experience dizziness. You feel uneasy you know something is not right. It is harder for you to breathe when lying down you need to sleep sitting up in a chair. If any of the above symptoms is severe or getting worse, call 911 or go to your hospitals emergency room.

Red Zone Emergency Go to the emergency room or call 911 if you have any of the following Difficulty breathing unrelieved shortness of breath while sitting still. Chest pain. Confusion or inability to think clearly.
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Next Step In Care Guides and Checklistshttp//www
.nextstepincare.org

• Discharge
• Family Caregivers Guide to
• Medication Management
• Going Home What You Need to Know
• Next Steps
• A Guide to the ER
• When the Next Step Is Home Care A
• Family Caregivers Guide
• When the Next Step Is Rehab A
• Family Caregivers Guide

• Admission
• HIPAA Questions and Answers for Family
  Caregivers
• Your Family Members Personal Health Record
• Medication Management Form
• A Family Caregivers Guide to Advance Directives
• Planning for Discharge
• The Next Step in Care What Do I Need as a Family
  Caregiver?
• Hospital-to-Home Discharge Guide

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Medicare Beneficiary Feedback Following IPRO Care
Transitions Outreach Sessions
After attending this session I now feel more
prepared to.
Source IPRO Medicare Beneficiary Outreach
Program Evaluations
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Medicare Beneficiary Feedback on IPRO Care
Transitions Outreach Sessions

• I am a retired public health nurse that practiced
  before the times of Medicare and Medicaid. I
  think the guidance you shared here with us today
  on how to navigate the health care system and
  take charge of managing our health information
  has been very helpful. It is not our way to ask
  questions of the people who provide us health
  carewe often feel we do not have the right and
  quite often when we do our questions and concerns
  go unanswered. Thank you for giving us permission
  to become empowered!
• After participating in this session I am now
  aware of todays health care environmental
  routines/personnel and the fact that I need to be
  more aware of the details of my health care.
• The information shared will be very helpful to
  organize my health information. I feel more
  comfortable knowing it is okay to ask the health
  care team questions to enable me to become more
  involved in my care.
• Before today I never thought about involving my
  Pharmacist to answer questions and concerns I
  have about my medications. Thank you for the
  suggestion!
• I was so anxious in the hospital I did not even
  think about what I needed to plan for once I got
  home. This information and my experience over
  the past year will help me plan ahead next time.
• The information you provided regarding the
  Hospitalist role was very helpful. I had never
  heard about that before and had no idea that my
  doctor I have gone to for the past 16 years may
  not even know I was in the hospital to be
  involved in my care

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Our Destination

• Ten New Rules to Redesign Improve Care
• Care is based on continuous healing relationships
• Care is customized according to patient needs and
  values
• The patient is the source of control
• Knowledge is shared and information flows freely
• Decision making is evidence-based
• Safety is a system property
• Transparency is evident
• Needs are anticipated
• Waste is continuously decreased
• Cooperation among clinicians is a priority
• Source Adapted from the Institute of Medicine,
  2001

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For more information

• Sara Butterfield, RN, BSN, CPHQ, CCM
• 518 426-3300 x104
• sbutterfield_at_nyqio.sdps.org
• httpcaretransitions.ipro.org

CORPORATE HEADQUARTERS 1979 Marcus Avenue Lake
Success, NY 11042-1002 REGIONAL OFFICE 20
Corporate Woods Boulevard Albany, NY
12211-2370 www.ipro.org
This material was prepared by IPRO, the Medicare
Quality Improvement Organization for New York
State, under contract with the Centers for
Medicare Medicaid Services (CMS), an agency of
the U.S. Department of Health and Human Services.
The contents do not necessarily reflect CMS
policy. 10SOW-NY-AIM8-11-07