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

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Preparing Patients and Caregivers to Participate
in Care Delivered Across Settings  The Care
Transitions Intervention

• Monique Parrish, Dr.PH, MPH, LCSW

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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

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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

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Randomized Controlled Trial
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Variable Intervention Control P-Value
Age (years) 76.0 76.4 0.52
Female () 48.2 52.3 0.26
Married () 58.2 53.8 0.23
Lives alone () 30.9 30.8 0.99
Sad or Blue () 30.3 26.4 0.24
CHF () 16.5 12.9 0.17
COPD () 17.0 18.5 0.61
Arrhythmia () 12.8 19.0 0.02
CAD () 14.1 13.5 0.81
Chronic Disease Score 6.8 7.1 0.31
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Variable Intervention Control P-Value
Prior Hosp () 1 past 6 mo 29.3 26.1 0.36
Prior ED () 1 past 6 mo 40.3 38.9 0.69
D/C Destin. Home () Homecare () SNF () Other () 50.8 24.7 21.0 3.5 52.9 25.9 19.3 1.9 0.71
Friday D/C () 14.6 16.5 0.48
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Variable Intervention Control Adjusted P-value
Re-hospitalized w/in 30 days 8 12 0.048
Re-hospitalized w/in 90 days 17 23 0.04
Re-hospitalized w/in 180 days 26 31 0.28
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Variable Intervention Control Adjusted P-value
Readmit for Same Dx w/in 30 days 3 5 0.18
Readmit for Same Dx w/in 90 days 5 10 0.04
Readmit for Same Dx w/in 180 days 9 14 0.046
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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.

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The Care Transitions Intervention

• Designed to encourage older patients and their
  caregivers to assert a more active role during
  care transitions

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The Four Pillars
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Four Pillars

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

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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

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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

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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

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Goal Attainment

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

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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

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Findings

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

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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

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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

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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

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Intervention Activities

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

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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)

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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

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Coaching

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

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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

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Took Kit for Coaches

• Medication Discrepancy Tool (promoting Medication
  Safety)
• Intervention Activities Checklist
• PHR

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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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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

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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

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D/C Instructions Incomplete or Illegible

• The patients hospital discharge instructions
  were written as follows
• KCl 10 mEq BID

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14 Percent Experienced 1 Med Discrepancies

• 62 percent experienced one
• 25 percent experienced two
• 8 percent experienced three
• 5 percent experienced four or more

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Patient-Level Contributing Factors
Non-intentional non-adherence 34
Money/financial barriers 6
Intentional non-adherence 5
Didnt fill prescription 5
Other 1
Subtotal 51
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System-Level Contributing Factors
D/C instructions incomplete/illegible 16
Conflicting info from different sources 15
Duplicative prescribing 8
Incorrect label 4
Other 7
Subtotal 49
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30-Day Hospital Re-Admit Rate
Patients with identified med discrepancies 14.3
Patients with no identified med discrepancies 6.1
P0.041
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The lack of quality measures for care transitions
remains a significant barrier to quality
improvement
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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
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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

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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

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Qualitative Evaluation

• To evaluate the efficacy of the intervention
• To augment the quantitative findings

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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

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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.