MA STAAR Fall Learning Session Ensuring Post-Hospital Care Follow-up

1. MA STAAR Fall Learning Session Ensuring Post-Hospital Care Follow-up 2:45-4:00PM Breakout St. Anne’s Hospital, MetroWest Medical Center Peg Bradke and Kate Bones

2. Creating an Ideal Transition Home

3. How do we effectively and efficiently act on our assessment of post-discharge needs and collaborate with patients, their families, and the community (healthcare and support systems) to transition.

5. IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations Improved Transitions and Coordination of Care Reduction in Avoidable Rehospitalizations or * Additional Costs for these Services Patient and Family Engagement Cross-Continuum Team Collaboration Evidence-based Care in All Clinical Settings Health Information Exchange and Shared Care Plans

6. Requested Coordinating Activities and Communications • What information does the receiver need from hospitals… • What information the community providers can provide to the hospitals…

7. Potential Next Steps • Practice(s) and/or their representatives become part of the hospital’s STAAR CCT. • Hospital STAAR CCT chair appoint a contact who will work with the practices or community provider and report back to the CCT regularly. • At a CCT meeting (including the practices and/or their representatives) the CCT reviews a patient case where lack of coordination between the hospital and practice had an impact on patient care. • Based on the patient case, the practice(s) and/or their representatives and the hospital CCT select 2-3 areas to begin testing how to best coordinate activities and communications. • Community providers and the hospital contact develop a work plan for learning from testing and addressing all the agreed upon change areas.

8. Discussion • Who is working with practices and clinics now? • How are you cooperating to reduce risk for readmission?

9. Social Risk Assessment • Besides Meals on Wheels, what other social service and community resources do you refer your patients to? • Does anyone have a useful check list for identifying social risks (lives alone, little involvement of others in care, anxiety and/or depression, quality of life, and functional status, along with socioeconomic status)?

10. Social Support • Social support is broadly defined as theexistence or availability of people on whom one can rely; people who let one know that they are cared about, valued, and loved. Lack of social support is associated with increased morbidity and mortalityin patients with ischemic heart disease." (Vaglio, Conrad,  et al Testing the performance of the ENRICHD Social Support Instrument.  Health Qual Life Outcomes. 2004; 2: 24.) 

11. ENRICHD Social Support Instrument  "The results also provide conceptual insight into the nature of social support. The majority of questions on the ESSI consider general feelings about being loved and valued rather than instrumental types of support. This supports the theory that social support is not a tally of actual supportive "services" rendered, but rather a patient's belief that others care about them and are available if needed."

12. Health Literacy, Medication Adherence and Social Support "having a trusted confidant was the only type of social support associated with better medication adherence for limited-literacy patients” (Johnson, Jacobson et al.  Does social support help limited-literacy patients with medication adherence?: A mixed methods study of patients in the Pharmacy Intervention for Limited Literacy (PILL) Study.)

13. Discussion • How might we expand social support beyond the technical to include assessing for someone who cares about me? • How might this help us? Help patients?

14. What is one new thing you learned today that you would like to test?