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Improving Transitions in Care

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Title: Improving Transitions in Care


1
Improving Transitions in Care
From Hospitals to Community
2
Care Transitions
  • Poorly executed care transitions lead to poor
    clinical outcomes, dissatisfaction among
    patients, and inappropriate use of hospital,
    emergency, and post acute services.

3
Care Transitions
Nursing home
Hospital
Rehab Facility
Home
4
Readmissions
  • Reflect a breakdown in the process, a failure in
    our ability to effectively transition clients
    between care settings and providers.

5
The Problem
  • Hospital Readmissions are costly and can be
    avoided
  • 90 of patients nationally who were readmitted to
    the hospital have experienced a breakdown of
    post- discharge care
  • Costs to Medicare for hospital readmissions is
    estimated at 15 billion a year, 12 billion of
    which is for cases considered preventable

6
Root Causes?
  • Medication discrepancies
  • Lack of patient follow up with PCP
  • Poor communication and handoffs
  • Lack of ownership personal responsibility over
    their own care
  • Variety of complex family, psychosocial problems
  • Lack of alignment with payment incentives and
    provider risk

7
Southwest Ohio Community Care Transitions
Collaborative
  • Includes
  • Council on Aging of Southwestern Ohio
  • Greater Cincinnati Health Council
  • Hospitals
  • University Hospital
  • The Christ Hospital
  • Jewish Hospital
  • Mercy Fairfield
  • Clinton Memorial Hospital
  • Health Collaborative
  • Healthbridge
  • Health Care Access Now
  • Mental Health and Recovery Services Board

8
Affordable Care Act
  • Beginning in October 2012, Medicare can withhold
    a portion of payments to hospitals that have high
    readmission rates for patients with certain
    conditions such as heart failure and pneumonia
  • Section 3026 created a Community-based Care
    Transitions Program (CCTP)

9
CMS Community-based Care Transitions Program
  • The Community Based Care Transitions Program
    (CCTP) goals are
  • to reduce hospital readmissions
  • test sustainable funding streams for care
    transition services
  • maintain or improve quality of care
  • document measureable savings to the Medicare
    program

10
Eligibility
  • 65
  • Medicare FFS
  • Admitted to one of five participating hospitals
  • CHF, AMI, Pneumonia, and/or multiple chronic
    conditions
  • Patient agreement and activation assessment

11
By the numbers
  • We are one of the first seven funded
  • Will serve 5,400 patients each year
  • Scheduled to begin March 19th
  • Annual net savings to Medicare of 1 Million
  • Two year project with extension of another three
  • Not a grant bundled payment

12
Council on Aging Care Transitions Program
Background
  • Developed a Care Transitions Pilot
  • December 2010 University Hospital
  • June 2011 The Christ Hospital
  • November 2011 Jewish Hospital

13
COA Care Transition Program
  • Two Outcomes
  • 1 Reduce avoidable re-hospitalizations.
  • 2 Reduce unnecessary long-term nursing facility
    placements.

14
Admitting Diagnoses for Participants(n311)
Admitting Diagnosis
23 of the total were admitted with a diagnosis
considered to be high risk for readmission by CMS.
Source Council on Aging of Southwestern Ohio,
10/27/11 n 170 Note Respiratory includes
shortness of breath, pulmonary edema, bronchitis
and related issues. In addition to items
considered to be other, other also includes
AFIB (2), CVA (1), and HTN (2).
15
Our Initial Results 65 were discharged
directly to a community setting
Of those who were discharged to a short term
nursing facility or in-patient rehab, 37 (41)
were discharged back to the community for a total
of 239 (77) of CTI participants successfully
transitioning back to their homes and communities.
Source Council on Aging of Southwestern Ohio,
3/5/12 n311 Note N/A includes individuals
discharged from CTI and individuals who are still
in the hospital. Not equal to 100 due to
rounding.
16
Care Transitions Intervention
  • Designed to encourage older patients and
    their caregivers to assert a more active role
    during care transitions.

17
Transition Coach
  • Role is NOT to be a service broker, Assessor, or
    Care Manager
  • Client empowerment and skill transfer is key for
    continued success after the intervention

18
Transition Coach
  • Do not fix problems
  • Do not provide skilled services
  • Do model and facilitate new behaviors and
    communication skills for clients and caregivers

19
The Care Transition Intervention
  • Hospital/NF Visit
  • Home Visit
  • Follow up Phone Calls

20
The Four Pillars
  1. Medication self-management
  2. Use of a dynamic patient-centered record The
    Personal Health Record
  3. Timely primary care/specialty care follow up
  4. Knowledge of red flags that indicate a worsening
    in their condition and how to respond.

21
Client personal goal
  • What is one personal goal that is important for
    you to achieve in the next 30 days?

22
1 Medication Review
  • Client collects all medications (prescription and
    non-prescription) for review during the home
    visit.
  • Client describes medications they are taking and
    how
  • Compares what the client is actually taking with
    the pre and post-hospitalization lists and
    identifies discrepancies.
  • Shows client how to update the medication list in
    the Personal Health Record.
  • Discusses with client how he or she will follow
    up with practitioners and PCP

23
2 Patient-centered record
  • Teach the client how to complete the Personal
    Health Record
  • Discuss the importance and how to update the PHR
    on a continual basis
  • Discuss the value of taking the PHR to all health
    care encounters and sharing its contents with
    health care professionals
  • The consumer/caregiver assumes ownership of the
    PHR to facilitate cross-site communication and
    ensures continuity of core information across
    different practitioners and settings.

24
3 Timely primary care and specialty care follow
up
  • Have client contact PCP.
  • Schedule appointment
  • Prepare questions
  • Identify barriers like transportation

25
4 Knowledge of Red Flags
  • The client identifies signs and symptoms that his
    or her condition may be worsening
  • Determines how she/he would respond to those red
    flags
  • Use the PHR for the client to list red flags and
    plan of action.
  • Use educational materials about condition given
    at the hospital

26
COAs Fifth Pillar
  • Community Resources such as
  • Ongoing care coordination
  • Home delivered meals
  • Medical transportation
  • Home Care Assistance

27
Coming soon
  • Improved targeting of care transition
    intervention
  • Integration with patient centered medical home
  • Assistance with finding physicians and access to
    behavioral health care
  • Shared medical information across care providers
    and settings

28
Care Transitions in Action
Its been really wonderful to help me stay at
home. DONNA, CARE TRANSITIONS CLIENT WITH HER
COACH, BETH
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