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Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transit

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Title: Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transit


1
Preparing Patients and Caregivers to Participate
in Care Delivered Across Settings  The Care
Transitions Intervention
  • Monique Parrish, Dr.PH, MPH, LCSW

2
Background Coleman Care Transitions Model
  • Qualitative Studies
  • Inadequately prepared for next setting
  • Conflicting advice for illness management
  • Inability to reach the right practitioner
  • Repeatedly completing tasks left undone

3
The Silent Care Coordinators
  • By default, older patients and family caregivers
    function as their own care coordinators
  • First line of defense for transition related
    errors
  • Model explicitly recognizes their role as
    integral members of the interdisciplinary team

4
Randomized Controlled Trial
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9
Care Transitions
  • Care Transitions refers to the movement
    patients make between health care practitioners
    and settings as their condition and care needs
    change during the course of a chronic or acute
    illness.

10
The Care Transitions Intervention
  • Designed to encourage older patients and their
    caregivers to assert a more active role during
    care transitions

11
The Four Pillars
12
Four Pillars
  • Medication Self-Management
  • Patient Centered Health Record (PHR) Primary
    Care Provider/Specialist Follow-Up
  • Knowledge of Red Flags

13
Pillar 1 Medication Self-Management
  • Focus reinforcing the importance of knowing each
    medication when, why, and how to take what is
    prescribed, and developing an effective
    medication management system

14
Pillar 2 Personal Health Record (PHR)
  • Focus providing a health care management guide
    for patients the PHR is introduced during the
    hospital visit and used throughout the program

15
Key Elements of the Personal Health Record
  • Record of patients medical history
  • Red flags, or warning signs
  • Medication list and allergies
  • Advance Directives
  • Structured Checklist of critical activities
    (instructions, f/u appointments)
  • Space for patient questions and concerns

16
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17
Goal Attainment
  • What is one personal goal that is important for
    you to achieve one month after you get home?

18
Response Categories
  • I have not worked on it
  • I have not met that goal, but am working on it
  • I have met the goal as well as I expected
  • I have met the goal better than I expected

19
Findings
  • Patients who worked with the Transition Coach
    were more likely to achieve their goals around
    symptom control and functional status

20
Pillar 3 Primary Care Provider/Specialist
Follow-Up
  • Focus enlist patients involvement in scheduling
    appointment(s) with the primary care provider or
    specialist as soon as possible after discharge

21
Pillar 4 Knowledge of Red Flags
  • Focus patient is knowledgeable about indicators
    that suggest that his or her condition is
    worsening and how to respond

22
Key Elements of Intervention
  • Transition Coach (Nurse or Nurse Practitioner)
  • Prepares patient for what to expect and to speak
    up
  • Provides tools (Personal Health Record)
  • Follows patient to nursing facility or to the
    home
  • Reconciles pre- and post-hospital medications
  • Practices or role-plays next encounter or visit
  • Phone calls 2, 7 and 14 days after discharge
  • Single point of contact reinforce, ensure follow
    up

23
Intervention Activities
  • Hospital Visit
  • Home Visit
  • 2-Day Follow-Up Call
  • 7-Day Follow-Up Call
  • 14-Day Follow-up Call

24
First Interaction (Hospital or Home Visit)
  • Introduce the Program
  • Structure of the intervention visits and calls
  • Role and purpose of the coach
  • Accessibility of the coach
  • Introduce and complete the Personal Health Record
  • Assure Coverage of Intervention Activities
    Checklist (Four Pillars)

25
2, 7 and 14-Day Phone Calls
  • Follow-up on issues discussed during
    hospital/home visit.
  • Review the Four Pillars as they apply to each
    patient at the appropriate stage in the
    transition (see Intervention Activities
    Checklist)

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Anticipated Cost Savings
  • For 350 chronically ill older adults with an
    initial hospitalization, anticipated net costs
    savings over 12 months
  • US 295,594

28
Coaching
  • What is coaching?
  • How does coaching differ from what nurses, social
    workers, and community workers do to help
    patients?

29
Key Attributes for the Transition Coach
  • Ability to shift from a doing role to a
    coaching role
  • Skill and knowledge to manage and reconcile
    medications
  • A strong enough sense of empowerment to empower a
    patient and/or caregiver
  • Ability to engage in critical thinking within the
    framework of a care plan

30
Took Kit for Coaches
  • Medication Discrepancy Tool (promoting Medication
    Safety)
  • Intervention Activities Checklist
  • PHR

31
Introducing the Medication Discrepancy Tool (MDT)
  • Patient-centered
  • Applicable across a variety of health settings
  • Identify patient- and system-level factors
  • Items need to be actionable at point of care

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33
Non-Intentional Non-Compliance
  • Prior to hospitalization, a patient was
    prescribed Digoxin 0.25 mg daily
  • The patients discharge instructions read,
    Digoxin 0.125 mg daily
  • The patient had only the pre-hospitalization 0.25
    mg Digoxin pills and had been taking these since
    discharge

34
Intentional Non-Compliance
  • A patient was admitted to the hospital for COPD
    exacerbation
  • Following discharge, he was not using his
    maintenance steroid inhaler because he believed
    that that medication makes my breathing worse

35
D/C Instructions Incomplete or Illegible
  • The patients hospital discharge instructions
    were written as follows
  • KCl 10 mEq BID

36
14 Percent Experienced 1 Med Discrepancies
  • 62 percent experienced one
  • 25 percent experienced two
  • 8 percent experienced three
  • 5 percent experienced four or more

37
Patient-Level Contributing Factors
38
System-Level Contributing Factors
39
30-Day Hospital Re-Admit Rate
P0.041
40
The lack of quality measures for care transitions
remains a significant barrier to quality
improvement
41
Brief History of the Care Transitions Measure
(CTM)
  • Qualitative studies shaped items
  • Transition-specific items gt Common set of items
  • Items discriminate among facilities
  • CTM endorsed by NQF in May 2006

Supported by The National Institute on Aging
and The Commonwealth
Fund
42
CTM Items
  • The hospital staff took my preferences and those
    of my family or caregiver into account in
    deciding what my health care needs would be when
    I left the hospital
  • When I left the hospital, I had a good
    understanding of the things I was responsible for
    in managing my health
  • When I left the hospital, I clearly understood
    the purpose for taking each of my medications

43
Demand for the CTM
  • Over 1400 requests for permission to use from 15
    Countries
  • Adopted by WHO multi-national (Europe) hospital
    quality collaborative
  • Highmark Blue Cross Blue Shield P4P
  • Maine to vote on statewide public reporting

44
Qualitative Evaluation
  • To evaluate the efficacy of the intervention
  • To augment the quantitative findings

45
Conclusion Qualitative Data
  • Patients appreciated the follow-up, expertise,
    support and accessibility of the Transition
    Coach.
  • Reception of the PHR was mixed, with ½ using it,
    and ½ not at 30 days post-intervention.
  • Barriers to successful implementation of
    intervention

46
Transition Coach
  • Competence
  • She was always able to answer my questions
  • Accessibility
  • There was somebody I could go to if I needed, if
    I had any questions, I knew I had somebody I
    could call.
  • Security
  • I was pretty skeptical about it. But it turned
    out to be a real beneficial thingthe program
    gives you a real inner comfortwhen youve
    confirmed that youre doing it right and you know
    what to expect.
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