Partnering Across Settings to Reduce Avoidable Hospitalizations

1. Partnering Across Settings to Reduce Avoidable Hospitalizations  Welcome to Partnering Across Settings to Reduce Avoidable Hospitalizations (Introductions) We are going to discuss how effective transitional care potentially improves patient safety and reduces avoidable acute care hospitalizations. The work that we will be referencing specific to home health agencies is from one of the packages that was released for the Home Health Quality Improvement campaign. We’ll give you the website and other contact information at the end of our presentation.Welcome to Partnering Across Settings to Reduce Avoidable Hospitalizations (Introductions) We are going to discuss how effective transitional care potentially improves patient safety and reduces avoidable acute care hospitalizations. The work that we will be referencing specific to home health agencies is from one of the packages that was released for the Home Health Quality Improvement campaign. We’ll give you the website and other contact information at the end of our presentation.

2. Objectives Objectives are…Objectives are…

3. Transitional Care CoordinationGoes Both Ways Sending Receiving Transitional care coordination is a multidimensional best practice intervention which includes both sending and receiving patient information. One must understand the concepts of care transitions and care coordination and then synchronize the meanings to formulate this best practice, transitional care coordination, to decrease avoidable hospitalizations. We’ll take a brief look at care transitions and care coordination to better understand the evolution of transitional care coordination.Transitional care coordination is a multidimensional best practice intervention which includes both sending and receiving patient information. One must understand the concepts of care transitions and care coordination and then synchronize the meanings to formulate this best practice, transitional care coordination, to decrease avoidable hospitalizations. We’ll take a brief look at care transitions and care coordination to better understand the evolution of transitional care coordination.

4. Care Transitions Refers to the patients moving between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness (Care Transitions Program, University of Colorado). http://www.caretransitions.org First let’s look at Care Transitions. The term “care transitions” refers to patients moving between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness (Care Transitions Program, University of Colorado). http://www.caretransitions.org The findings of the ongoing research of Dr. Eric Coleman and The Care Transitions Program at the University of Colorado at Denver Health Sciences Center suggest that effective care transition intervention leads to improved self-management knowledge and skills for many patients, primarily in the areas of: (1) medication management, (2) condition management and (3) patient confidence regarding what was required during the transition and beyond (Coleman, Parry, Chalmers, & Min, 2006). The intervention activities were see as 4 pillars or conceptual domains. As you will see this was the model we used to build the home health interventions for transitional care coordination. Dr Coleman’s First let’s look at Care Transitions. The term “care transitions” refers to patients moving between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness (Care Transitions Program, University of Colorado). http://www.caretransitions.org The findings of the ongoing research of Dr. Eric Coleman and The Care Transitions Program at the University of Colorado at Denver Health Sciences Center suggest that effective care transition intervention leads to improved self-management knowledge and skills for many patients, primarily in the areas of: (1) medication management, (2) condition management and (3) patient confidence regarding what was required during the transition and beyond (Coleman, Parry, Chalmers, & Min, 2006). The intervention activities were see as 4 pillars or conceptual domains. As you will see this was the model we used to build the home health interventions for transitional care coordination. Dr Coleman’s

5. Transitional Care Model (TCM) Advanced practice nurse performs discharge planning and initiates a more intensive home follow-up Fewer multiple readmissions, fewer hospital days and increased time until readmission (Naylor, 2004) Since 1989, a multidisciplinary team of researchers directed by Mary D. Naylor, PhD, FAAN, RN based at the University of Pennsylvania has been testing and refining an innovative model of care coordination delivered by advanced practice nurses (APNs) for older adults making the transition from hospital to home. Findings from the team’s three completed National Institute of Nursing Research funded randomized clinical trials have consistently demonstrated the ability of this care model to improve quality and substantially decrease health care costs Since 1989, a multidisciplinary team of researchers directed by Mary D. Naylor, PhD, FAAN, RN based at the University of Pennsylvania has been testing and refining an innovative model of care coordination delivered by advanced practice nurses (APNs) for older adults making the transition from hospital to home. Findings from the team’s three completed National Institute of Nursing Research funded randomized clinical trials have consistently demonstrated the ability of this care model to improve quality and substantially decrease health care costs

6. Care Coordination Targets the chronically ill who are at risk for elevated health care and provides services that fill the gaps in our traditional, reactive system Combines the elements to keep the chronically ill and elderly as healthy as possible, and to reduce the use of costly services such as the emergency room and inpatient hospitalization (Meckes, 2005) Now we’ll discuss Care Coordination. The term “care coordination” targets the chronically ill who are at risk for elevated health care and provides services that fill the gaps in our traditional, reactive system. Care coordination combines the best elements of home health, disease management and case management to organize a personalized health care system to keep the chronically ill and elderly as healthy as possible and to reduce the use of costly services such as the emergency room and inpatient hospitalization (Meckes, 2005). Now we’ll discuss Care Coordination. The term “care coordination” targets the chronically ill who are at risk for elevated health care and provides services that fill the gaps in our traditional, reactive system. Care coordination combines the best elements of home health, disease management and case management to organize a personalized health care system to keep the chronically ill and elderly as healthy as possible and to reduce the use of costly services such as the emergency room and inpatient hospitalization (Meckes, 2005).

7. Transitional Care Coordination Transitional care has been defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location (Coleman and Berenson, 2004). This leads us to transitional care coordination. The formal definition of Transitional Care Coordination includes the concepts of care transitions and care coordination. Transitional care has been defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location (Coleman and Berenson, 2004). Transitional care, which primarily concerns the relatively brief time interval that begins with preparing a patient to leave a setting and concludes when the patient is received in the next setting, poses challenges that distinguish it from other types of care. The American Geriatric Society (2006) stated that transitional care encompasses both the sending and receiving aspects of the transfer and is essential for those with complex care needs. Effective transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well educated in chronic care and have current information regarding the patient’s goals, preferences and clinical status. This leads us to transitional care coordination. The formal definition of Transitional Care Coordination includes the concepts of care transitions and care coordination. Transitional care has been defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location (Coleman and Berenson, 2004). Transitional care, which primarily concerns the relatively brief time interval that begins with preparing a patient to leave a setting and concludes when the patient is received in the next setting, poses challenges that distinguish it from other types of care. The American Geriatric Society (2006) stated that transitional care encompasses both the sending and receiving aspects of the transfer and is essential for those with complex care needs. Effective transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well educated in chronic care and have current information regarding the patient’s goals, preferences and clinical status.

8. Transitional Care CoordinationHandoffs/Handovers The transfer of patient information from one setting to another has become known as ‘handoff’ or ‘handover’. Both terms handoff and handover are being used in healthcare related to transitions of care. We adopted the term handover for the Transitional Care BPIP to represent transitions of care of the patient to and from settings. A handover is a significant patient safety issue. Handovers are error-prone and variable. They are a vulnerable gap in patient care. An exchange of information does not require that the other person understands what is being transmitted by simply conveying information. Information is often acquired and transmitted without determining comprehension. A Handover implies transfer of information as well as professional responsibility to both deliver the information and assure it is understood.   The transfer of patient information from one setting to another has become known as ‘handoff’ or ‘handover’. Both terms handoff and handover are being used in healthcare related to transitions of care. We adopted the term handover for the Transitional Care BPIP to represent transitions of care of the patient to and from settings. A handover is a significant patient safety issue. Handovers are error-prone and variable. They are a vulnerable gap in patient care. An exchange of information does not require that the other person understands what is being transmitted by simply conveying information. Information is often acquired and transmitted without determining comprehension. A Handover implies transfer of information as well as professional responsibility to both deliver the information and assure it is understood.  

9. Patients cross many settings for health care. Our handovers must be consistent, detailed and appropriate to each setting. Transitional care coordination is like putting pieces of the puzzle together to improve patient health care and to reduce avoidable acute care hospitalizations. Home care agencies are in a key position to assist patients and caregivers to connect the care provided back and forth across the settings. As Eve mentioned, the care transitions intervention by Dr. Coleman’s team has been built on four pillars or conceptual domains. The illustration on the next slide adapts the four pillars concepts into the home health arena. Patients cross many settings for health care. Our handovers must be consistent, detailed and appropriate to each setting. Transitional care coordination is like putting pieces of the puzzle together to improve patient health care and to reduce avoidable acute care hospitalizations. Home care agencies are in a key position to assist patients and caregivers to connect the care provided back and forth across the settings. As Eve mentioned, the care transitions intervention by Dr. Coleman’s team has been built on four pillars or conceptual domains. The illustration on the next slide adapts the four pillars concepts into the home health arena.

10. Here are the four pillars adapted for home health using the Care Transitions model. The four pillars is the primary tool for this package. The pillars are: 1. Assistance with medication self-management: Patient is knowledgeable about medications and has a medication management system.  2. Use of a patient-centered record: Patient understands and utilizes the Personal Health Record (PHR) to facilitate communication and ensure continuity of care planning across providers and settings. The patient or caregiver manages the PHR.  3. Timely, informed primary care/specialist follow-up: Patient schedules and completes follow-up visit with the primary care physician or specialty practitioner and is prepared to be an active participant in these interactions.  4. Knowledge of “red flags”: Patient is knowledgeable about indicators that suggest his/her condition is worsening and instructions regarding how to respond. Agencies may work on one or more pillars at a time until all of the pillars are incorporated for improved care transitions processes.      Here are the four pillars adapted for home health using the Care Transitions model. The four pillars is the primary tool for this package. The pillars are: 1. Assistance with medication self-management: Patient is knowledgeable about medications and has a medication management system.  2. Use of a patient-centered record: Patient understands and utilizes the Personal Health Record (PHR) to facilitate communication and ensure continuity of care planning across providers and settings. The patient or caregiver manages the PHR.  3. Timely, informed primary care/specialist follow-up: Patient schedules and completes follow-up visit with the primary care physician or specialty practitioner and is prepared to be an active participant in these interactions.  4. Knowledge of “red flags”: Patient is knowledgeable about indicators that suggest his/her condition is worsening and instructions regarding how to respond. Agencies may work on one or more pillars at a time until all of the pillars are incorporated for improved care transitions processes.      

11. Four Pillars Patient Centered Record (PHR) The four pillars are operationalized through two mechanisms: (Parry, Coleman, Smith, Frank and Kramer --2003), Personal Health Record and Patient/Caregiver Coaching (self-management support). How does home health fit with the patient/caregiver-coaching model? In many cases there is not the availability of an external coach and therefore to optimize the quality and effectiveness of care transitions, the home health clinician needs to function as the patient/caregiver coach. Detailed information showing how the home health clinician can provide patient-centered coaching is in the BPIP. The four pillars are operationalized through two mechanisms: (Parry, Coleman, Smith, Frank and Kramer --2003), Personal Health Record and Patient/Caregiver Coaching (self-management support). How does home health fit with the patient/caregiver-coaching model? In many cases there is not the availability of an external coach and therefore to optimize the quality and effectiveness of care transitions, the home health clinician needs to function as the patient/caregiver coach. Detailed information showing how the home health clinician can provide patient-centered coaching is in the BPIP.

12. Transitional Care Coordination BPIP Personal Health Record Medication Discrepancy Tool Leadership Track Discipline Tracks

13. Transitions of Care Program CMS funded special study (18 months) Goal to implement a well-proven intervention that would address 14- and 30-day readmissions CTI developed by Dr. Eric Coleman www.caretransitions.org Short-term intervention, long-term results Address most vulnerable period . . . during transition Shown to reduce readmissions (50% up to six months) MARSHA – Slide 1 Brief overview of TOCPMARSHA – Slide 1 Brief overview of TOCP

14. Role of Home Health The classic CTI Dedicated coaches One from the HHA – integrated system One from a MCO Not disease-specific Created PHR and tracking tools Mapped ideal process – together Free program to patients Weekly one hour conference calls Marsha - Slide 2 Role of HHA Marsha - Slide 2 Role of HHA

15. Strategies Our recipe: Convene provider communities (one hospital, one HHA, one SNF, one ambulatory clinic) 1) Observe and map transition-related processes in all settings 2) Site exchange visits 3) CTI training 4) Collaboratively develop new models 5) Test the models and make recommendations/rapid improvements Find common ground for partnering Successful examples of improved care coordination Marsha - Slide 3 model not exempt from other settings - Identify transitional care strategies to help home health agencies partner with hospitals, skilled nursing facilities, outpatient physician offices, and managed care organizationsMarsha - Slide 3 model not exempt from other settings - Identify transitional care strategies to help home health agencies partner with hospitals, skilled nursing facilities, outpatient physician offices, and managed care organizations

16. Tools and QIO support Support and involvement Stakeholders Providers Patients CTM ‘Community’ workgroups/taskforces MDT PHR QIO support throughout implementation Marsha - Slide 4 Tools and strategies helpful for supporting improved transitional care coordination using CTI in provider groups Marsha - Slide 4 Tools and strategies helpful for supporting improved transitional care coordination using CTI in provider groups

17. Contact Information Transitions of Care Program – www.cfmc.org/value/ Marsha Thorson – mthorson@cfmc.org HHQI Campaign – www.homehealthquality.org Sean Hunt – shunt@wvmi.org Eve Esslinger – eesslinger@wvmi.org Misty Kevech – mkevech@wvmi.org