Transitions of Care

1. For the Healthcare Provider Transitions of Care Atrial Fibrillation

2. Table of Contents • What is Transitions of Care? • Efficacy of Transitions of Care Approach • Project Scope • The Role of the Provider • The Role of the Patient • Resources • Action Requested and Timeline • Feedback Survey

3. Background and CHallenges • Most commonly diagnosed arrhythmia disorder • 2.3 million people in U.S. living with AF - 160,000 new cases annually • Patients with multiple chronic conditions can visit ~16 physicians annually • AF is responsible for 88,000 deaths per year - $16 billion in healthcare costs • Challenge of coordinating basic information (e.g., test results, prescription medications, diagnosis) • Poor coordination often leads to adverse clinical outcomes, increased re-admissions, over-utilization of health care services, and untimely follow-up

4. Transitions of Care Definition • Transitions of Care refer to the movement of patients between health care locations, providers, or different levels of care within the same location as their conditions and care needs change. • Specifically, they can occur: • Within settings • Between settings • Across health states • Between providers

5. Care coordination definition • Care coordination is a function that helps ensure the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time. Coordination maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and high-quality patient experiences and improved healthcare outcomes.

6. Principles • Care coordination is important for everyone • Some populations are particularly vulnerable • Care coordination measures may be appropriate at the clinician-level; others may be appropriate at the group, practice or organizational-level • Patient/family surveys are essential to measure care coordination; performed within close proximity to the healthcare event

7. Elements of transitions of care • Medication reconciliation • Follow-up tests and services • Changes in plan of care • Involvement of team during hospitalization, discharge, follow-up, etc. • Communication • Transfer of all information when site of care changes • Education of the patient and family

8. National care coordination goals • Healthcare organizations and their staff will continually strive to improve care by soliciting and carefully considering feedback from all patients and their families regarding coordination of their care during transitions. • Medication information will be clearly communicated to patients, family members, and the next healthcare professional and/or organization of care, and medications will be reconfirmed at each transition. • All healthcare organizations and their staff will work collaboratively with patients to reduce 30­-day readmission rates. • All healthcare organizations and their staff will work collaboratively with patients to reduce preventable emergency department visits.

9. Efficacy of transitions of care • Hospital to Home – ACC & IHI national quality improvement initiative to reduce cardiovascular-related hospital readmissions and improve the transition from inpatient to outpatient status for individuals hospitalized with cardiovascular disease (e.g., heart failure) • Medication management • Follow-up • Symptom management

10. Transitions of Care AND Provider Payment • Provider payments are shifting toward the key elements of Care Quality and Care Coordination • By 2015, providers will be required to document quality improvement indicators or face decreases in reimbursement • By 2017, Medicare reimbursement will be adjusted based on documented quality outcomes for all physicians • Capturing those indicator data will aid in either enhancing existing care protocols or developing new ones

11. Afib transitions of care goal Project Goal: • To develop practical resources to encourage best practices in clinical decision-making, patient-provider communication, and patient self-management.

12. role of the Care provider • Engaging Mended Hearts Volunteers • Making a referral to post-ablation patients • Review Patient Care Pathway • Patient Care Plan • Review Patient Discharge Checklist (provided in patient kits) • Review AF Educational Resources (provided in the patient kits)

13. Role of the Mended hearts volunteer • Understand the Patient Care Pathway • Peer-to-peer patient support • Patient Care Plan (No interpretation of orders/prescriptions) • And what is it and why is this important? • Patient Discharge Checklist (General) • And what is it and why is this important? • Atrial Fibrillation Educational Resources

14. role of the patient and caregiver • Understand the Patient Care Pathway • Patient Care Plan • And what is it and why is this important? • Patient Discharge Checklist • And what is it and why is this important? • Atrial Fibrillation Educational Resources

15. Provider/patient Kit resources • Patient Resource Kit • Elements of a care plan • Patient discharge checklist • Role of the caregiver • Guide to AFib brochure • AFib Patient DVD • Mended Hearts Info • Provider Resource Kit • Best practices • Patient care plan elements • Discharge checklist • Transition record checklist • Mended Hearts Info

16. Feedback surveys • Healthcare Provider • Web-based / monthly survey - 4 questions • Mended Hearts Volunteer • Telephone / Web-based surveys – Monthly/Quarterly • Patients • Postcard / Received during visit – 4 questions for 30 days post event

17. Questions? Thank You!