Transitional Care: Minding the Gap

1. Transitional Care: Minding the Gap Adam Thompson, Regional Partner Director Northeast/Caribbean AIDS Education and Training Center – South Jersey Regional Partner aidsetc.org

2. Overview aidsetc.org Introduction Transitions of Care (ToC) Transitions in HIV Care Questions and Comments

3. Northeast/Caribbean AIDS Education and Training Centers aidsetc.org

4. The AETC Program aidsetc.org The AIDS Education and Training Center (AETC) Program, a national program ofleading HIV experts,provideslocally based, tailored education and technical assistance to healthcare teams and systems to integrate comprehensive care for those living with or affected by HIV. The AETC Program transformsHIV care by building the capacity to provide accessible, high-quality treatment and services throughout the United Statesand its territories.

5. Requisite Steps to Optimal Outcomes Mugavero MJ, Norton WE, Saag MS. Health care system and policy factors influencing engagement in HIV medical care: piecing together the fragments of a fractured health care delivery system. Clin Infect Dis. 2011;52:S238-S246

6. HIV Care Continuum Centers for Disease Control and Prevention National HIV Surveillance System and Medical Monitoring Project, 2011

7. Integration aidsetc.org We can each say, I have done my job well … but collectively we are not doing our job well.

8. Transitions of care: Hospitals tackle readmissions aidsetc.org

9. Hospitals and Transitions aidsetc.org

10. Transitions and Error Accessed From: https://psnet.ahrq.gov/perspectives/perspective/52 on May 16, 2017 Half of patients experience a medical error after discharge, usually one related to medication continuity, follow-up of test results, or completion of diagnostic work-ups. Approximately 20% of patients suffer an adverse event within 3 weeks of discharge. Studies have suggested that most errors and adverse events could be prevented or ameliorated through better communication and coordination of care.

11. aidsetc.org

12. Transitions of Care Dr. Kathleen McCauley, PhD, RN, ACNS-BC, FAAN, FAHA @ NACNS 3.8.12, Chicago, IL Transitions of Care are a range of time limited services and environments that complement primary care and are designed to ensure health care continuity and avoid preventable poor outcomes among at risk populations as they move from one level of care to another, among multiple providers and across settings.

13. Transitions of Care • Transitions of Care occur: • Within Settings • Between Settings • Across Health States

14. Transitional Care Coleman, E. A. and Boult, C. (2003), Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society, 51: 556–557. Transitional Care is 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.

15. Complex Health Systems aidsetc.org

16. Root Causes of Ineffective Transitions The Joint Commission. Transitions of Care: The need for a more effective approach to continuing patient care. Hot Topic in Health Care June 27, 2012 Accessed from: https://www.jointcommission.org/hot_topics_toc/ on May 3, 2017 Communication Breakdowns Patient Education Breakdowns Accountability Breakdowns

17. Factors that affect readmission • Diagnoses associated with high readmissions • Co-morbidities • Polypharmacy • A history of readmissions • Psychosocial and emotional factors • The lack of a family member, friend or other caregiver who could provide support or assist with care • Older age • Financial distress • Deficient living environment The Joint Commission. Transitions of Care: The need for collaboration across entire care continuum. Hot Topic in Health Care, Issue 2; February 19, 2013 Accessed from: https://www.jointcommission.org/toc.aspx on May 3, 2017

18. Positive Effect on Transitions • Strong leadership support for new transitions processes • Positive relationships between the sending and receiving providers • Interdisciplinary team involvement • Handoffs that involve interpersonal communication (instead of only written or electronic communication) • Medication reconciliation, with the involvement of pharmacists • Two-way patient and family education • Electronic health records (EHRs), as long as they were not relied upon as a sole method of communication. • Assigned accountability for transitions-related tasks and outcomes The Joint Commission. Transitions of Care: The need for collaboration across entire care continuum. Hot Topic in Health Care, Issue 2; February 19, 2013 Accessed from: https://www.jointcommission.org/toc.aspx on May 3, 2017

19. Transitions Best Practices The Joint Commission. Transitions of Care: The need for collaboration across entire care continuum. Hot Topic in Health Care, Issue 2; February 19, 2013 Accessed from: https://www.jointcommission.org/toc.aspx on May 3, 2017 • Screening Process in place to identify patients at higher risk for health care problems that could possibly lead to a readmission after discharge • The process commonly involves an interdisciplinary team, including a physician (or in some cases, a nurse practitioner), working together to determine what the patient will likely need after he or she leaves the setting. • Formal Assessment to identify the factors for readmission after discharge • case managers and/or discharge planners (who are often registered nurses or social workers) work with physicians and other team members to plan and coordinate the transition to the next setting.

20. Key Components of Effective Care Transitions Tyrell, R. Care Transformation Center Blog. The 6 key components of an effective care transition process. September 7, 2016 Accessed from: https://www.advisory.com/research/care-transformation-center/care-transformation-center-blog/2016/09/care-transitions-process on May 3, 2017 Perform an initial risk stratification to identify patients at moderate or high risk of readmission Conduct an in-depth patient assessment for the highest-risk patients Determine the next site of care and assign clear points of contact Engage the right participants, leveraging warm handoffs before discharge Tailor post-discharge support to patient needs and site of discharge Connect the patient to the primary care team, ideally via warm handoff

21. Transitions of care in HIV

22. Youth to Adult Transitions

23. Corrections to Community

24. Linkage Collaboratives

25. Transitions for HIV-infected Patients

26. Transitions aidsetc.org

27. How to ensure successful transitions?

28. Care Coordination McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 7—Care Coordination. Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services; June 2007 Care Coordination is the deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.

29. Care Coordination Reducing Care Fragmentation: A Toolkit for Coordinating Care accessed from http://improvingchroniccare.org/index.php?p=Care_Coordination&s=326 on May 16, 2017

30. Challenges (or Strengths?) Reducing Care Fragmentation: A Toolkit for Coordinating Care accessed from http://improvingchroniccare.org/index.php?p=Care_Coordination&s=326 on May 16, 2017 Accountability for the process is shared, which contributes to ambiguity as to who is responsible for making it work well. Many PCPs no longer have the personal relationships with consultants and hospitals that make communication easier. The added time and effort required to achieve an effective referral/consultation or transition is generally not reimbursed. Most primary care practices do not have the dedicated personnel or information infrastructure to coordinate care effectively.

31. Defragmenting through Coordination Decide as a primary care clinic to do care coordination Develop a tracking system Organize a practice team to support patients and families Identify, develop, and maintain relationships with key stakeholders Develop formal agreements with key stakeholders Develop and implement an information transfer system Reducing Care Fragmentation: A Toolkit for Coordinating Care accessed from http://improvingchroniccare.org/index.php?p=Care_Coordination&s=326 on May 16, 2017

32. Framing Questions aidsetc.org How do we strengthen our medical neighborhoods? What are the factors that can predict poor linkages and how can we identify them before a patient experiences a gap or is lost to care? What balancing measures can we put in place to strengthen linkages? Who are the stakeholders not in the room?

33. aidsetc.org