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Care Transitions

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Care Transitions Critical to Quality and Patient Safety Society of Hospital Medicine Lakshmi K. Halasyamani, MD Society of Hospital Medicine Professional Society ... – PowerPoint PPT presentation

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Title: Care Transitions


1
Care Transitions Critical to Quality and
Patient Safety
  • Society of Hospital Medicine
  • Lakshmi K. Halasyamani, MD

2
Society of Hospital Medicine
  • Professional Society for Hospitalists and other
    hospital-based healthcare professionals (nurses,
    pharmacists, AHP, etc.)
  • Total number of members gt 6000

3
Areas of Interest/Focus
  • Management of patient populations in hospital
  • Teamwork
  • Hand offs
  • Care Transitions

4
Overview of Care Transitions
  • Admission to Hospital (From ED or Direct
    admission)
  • Transitions within hospitalization (shift/service
    change transitions/handoffs)
  • Transition from hospital to post-acute setting
    (home, subacute facility/nursing home, hospice,
    other acute care setting)
  • Transitions within outpatient care delivery
    settings

5
SHM and Care Transitions
  • Defining Standards
  • Developing Team-based Interventions
  • Evaluating Interventions
  • Influencing Policy

6
Defining Standards
  • Participation in consortiums regarding care
    transitions
  • SUTTP Stepping Up to the Plate
  • TOCCC Transitions of Care Consensus Conference
  • NTOCC National Transitions of Care Coalition
  • Development of Hospitalist Standards for
    Discharge and Shift/Service change transition

7
Key Messages
  • Patient-Centered
  • Transitions involve two-way communication of
    information
  • Timely
  • Clinician accountability
  • Development of standardized care transition data
    set
  • Need for communication infrastructure

8
Developing Interventions
  • SafeSteps pilot initiative to improve
    medication safety
  • Hartford BOOST initiative -- Better Outcomes for
    Older Adults through Safe Transitions
  • Common Theme Focus on Implementation and
    real-world sustainability of initiatives

9
SHM/Hartford Partnership
  • BOOST Advisory Board
  • American Geriatrics Society
  • American Society of Health-System Pharmacists
  • Case Management Society of America
  • Blue Cross Blue Shield Association
  • Centers for Medicare and Medicaid Services
  • The Families and Healthcare Project
  • Society of General Internal Medicine
  • Institute for Healthcare Improvement
  • John A Hartford Foundation
  • Joint Commission
  • Agency for Health Research and Quality
  • National Quality Forum

10
Philosophy of Initiative
  • Patient/Family/Caregiver centered
  • Multi-disciplinary Team-based
  • Embedded in care delivery to promote
    sustainability
  • Includes both academic and community settings
  • Includes rigorous evaluation

11
Components of Initiative
  • Develop Interventions to Improve Discharge Care
    Transition
  • Patient-centered risk assessment
  • Identification of Gaps
  • Engagement of patient/family/caregiver through
    teach back strategy

12
Components of Initiative
  • Develop Implementation Guide
  • Develop Network of Institutions to implement
    discharge interventions
  • Identify Facilitating Factors
  • Identify Barriers

13
Influencing Policy
  • Work with organizations developing care
    transition measures
  • Focus on discharge and shift/service change as a
    standardized team process
  • Work collaboratively with other organizations to
    develop a multi-disciplinary strategy to improve
    care transitions

14
Future Directions
  • Alignment of payers and systems around safe care
    transitions
  • Work with major HIT vendors regarding
    standardization of pathways to improve care
    transitions
  • Partner with home and community services to
    facilitate seamless care transitions across the
    continuum
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