Clinical Strategies To Improve Patient Outcomes

1. Clinical Strategies To Improve Patient Outcomes Care Transitions Between Health Care Providers Christine Stegel RN, MS, CPHQ Performance Improvement Coordinator & Carol Ann Thomas RN, MS, CPHQ, COS-C Manager, Patient Safety and Quality Improvement St. Peter’s Home Care

2. Objectives • Define care transition • Describe two evidence-based models for patient care transition • Discuss one agency’s experience in improving communication between the hospital and the home health agency

3. Definition • Care transitions are patient transfers from one care setting to another • Transitional care includes all the services required to ensure the coordination and continuity of health care as the patient moves between one health care service provider to another

4. Care Transition - Discharge Planning • Referrals are received by fax or by telephone • Discharge Liaisons • HIPAA

5. Care Transition - Gaps • Communication gaps - Physician - Referral process • Patient self-management • Care coordination • Medication

6. Care Transitions • Two evidence-based care transition models • Dr. Eric Coleman’s “Transition Coach” • Dr. Mary Naylor’s use of an Advance Practice Nurse

7. Care Transition Model- Dr. Eric Coleman • Patient self-management - Medications - Know of signs of worsening condition • Personal Health Record • Primary Care Physician follow-up • Transition Coach

8. Care Transition Model- Dr. Eric Coleman • Patient Self-Management • Knowledge of medication – actions, side effects, and interactions • Medication management method • Medication reconciliation when patient returns home • Knowledge of signs of worsening condition

9. Care Transition Model - Coleman • Personal Health Record • Demographic information including Primary Care Physician & caregiver contact information • Medical history • Medication list & allergies • Checklist of activities that are needed prior to discharge • Area for patient’s health care questions

10. Transition Model - Coleman • Transition Coach • Facilitates interdisciplinary collaboration • Ensures continuity of care • Supports patient self-management activities • Encourages the patient to take a more active role in their disease management and care decisions

11. Transition Model - Coleman • Care Transitions Measure – measures the extent patients are being prepared to participate in post hospital self-care activities Source: www.caretransitions.org

12. Care Transition Model- Dr. Mary Naylor • Advance Practice Nurse • Identification of high-risk factors • Multiple chronic conditions • Evidence of depression or cognitive impairment • Patient rates their health as poor • Concerns with social supports • History of re-hospitalizations

13. Transition Model - Naylor • Early identification of problems • Collaborations with all care providers • Continuity of care • Utilizes frontloading of visits with telephone calls • APNs are expected to use their clinical judgment

14. Transition Model - Naylor • Strategies • Face to face interaction with the Physician while in hospital and then at first follow-up visit – ability to develop a relationship/trust • Medication reconciliation • Early symptom management

15. Summary – Similarities Between the Two Models • Used with patients who are complex/fragile • Continuity of care between settings • Interdisciplinary collaboration • Medication reconciliation • Regular timed follow-up post hospitalization