The Care Transitions Program Lydia Alberghini, RN, BSN Elaine McMahon, RN, MS

1. The Care Transitions ProgramLydia Alberghini, RN, BSNElaine McMahon, RN, MS PRISM 6 - Preparing for an Aging Maine Thursday, September 25, 2008

2. Care Transitions Definition: The movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.

3. What can happen during care transitions? The negative consequences of fragmented care including : • duplication of services • discontinuity • medication errors • patient and family caregiver distress • unnecessary utilization and higher costs of care • National re-admission rate- 18% (Medicare data)

4. Why Care Transitions…. • Older patients often require care from different practioners in multiple settings. • During times that can be overwhelming, systems of care can fail to ensure that the essential elements of the care plan are communicated. • Patients and their caregivers are often the only common thread moving across settings.

5. The Care Transition Intervention* Evidence-based program developed by Eric Coleman, MD, MPH, and his team at the University of Colorado Health Sciences Center with funding provided by The John A. Hartford Foundation. Objective:To test whether an intervention designed to encourage older patients and their caregivers to assert a more active role during care transitions can reduce re-hospitalization rates. *Coleman, E., Smith, J., Frank, J., Min, S., Parry, C. & Kramer, A. (2004). Preparing patients and caregiver to participate in care delivered across settings: the care transitions intervention. Journal of the American Geriatrics Society, 52:1871-1825, 2004.

6. The Care Transitions Intervention Outcomes • Readmission Rates:(Intervention Group= 158 Control Group = 1,235) • The adjusted odds ratio comparing re-hospitalization of intervention group with control group: 0.52 at 30 days, 0.43 at 90 days, .57 at 180 days. • Patients with increased confidence levels • Self- management skills - 75% • Understanding warning signs and symptoms- 75% • Obtain information to manage their condition during physician visits- 87% • Understanding their medication regime: * Reason for taking meds - 87% * How to take meds -94% • * Side effects of all meds -69% (Coleman) • The Care Transitions Program is currently in over 100 locations nationwide.

7. MMC PHO & MaineHealth Elder Care ServicesCare Transitions Program Improve care transitions by: • providing patients and their caregivers with the support and tools that promote knowledge and self-management of their conditions. • encouraging patients and their caregivers to play a more active role in their care and share their preferences and goals.

8. Who are the patients ? Community-dwelling older adults age 65 and older who: • Can answer a brief 4-item cognitive screen or have a willing proxy • Live within a 30 mile radius of Maine Medical Center (or at coach discretion) • Have a working telephone • Have no plan to enter hospice • Are a non-psychiatric admission with at least one of 12 diagnoses (determined by likelihood of need for SNF/ home health)

9. CHF* COPD * Coronary Artery Disease Diabetes Stroke * Hip Fracture Peripheral Vascular Disease Cardiac Arrhythmias * Back Conditions (spinal stenosis) DVT * Pneumonia Pulmonary Embolism * Diagnoses * = particularly amenable to this type of program

10. Nurse Transition Coach During the 28 day intervention the coach: • Provides patients with tools and support that promote knowledge and self-management of their health conditions as they move from hospital to home. • Acts as a guide for the patient, addressing critical issues and self-management tasks rather than directly taking over and providing care.

11. Nurse Transition Coach Role Hospital • Establishes relationship • Introduces PHR and the Four Pillars • Visits every two days during hospital stay • Helps patient/caregiver to play a more active and informed role Skilled Nursing Facility/ Rehab Hospital • Visits or calls 1/week during SNF stay • Teaches patient/caregiver what to expect • Addresses each of the Four Pillars Home • Visits 24-72 hours post discharge (approx. 60 minute visit) • Three follow-up calls (~ day 2, 7, 14 post-discharge ) • Addresses each of the Four Pillars • Patient sets a personal health goal

12. Care Transitions: The Four Pillars • Use of a patient-centered record- Personal Health Record (PHR) • Medication self-management • Primary care and specialist follow-up • Knowledge of “red flags”- signs and symptoms to be reported

13. Pillar I Personal Health Journal • Belongs to the patient. • Contains the information every healthcare practitioner needs to know. The patient is encouraged to bring it everywhere & share. • Contact information for patient & caregiver • Hospitalization dates & reason for admission • Medical history & Medication Record • Discharge Preparation Checklist & action plan to better manage health • Mechanism for getting important questions answered.

14. ❏ I have been involved in decisions about what will take place after I leave the facility. ❏ I understand where I am going after I leave this facility and what will happen to me once I arrive. ❏ I have the name and phone number of a person I should contact if a problem arises during my transfer. ❏ I understand what my medications are, how to obtain them and how to take them. ❏ I understand the potential side effects of my medications and whom I should call experience them. ❏ I understand what symptoms I need to watch out for and whom to call should I notice them. ❏ I understand how to keep my health problems from becoming worse. ❏ My doctor or nurse has answered my most important questions prior to leaving the facility. ❏ My family or someone close to me knows that I am coming home and what I will need once I leave the facility. ❏ If I am going directly home, I have scheduled a follow-up appointment with my doctor, and I have transportation to this appointment. Discharge Preparation ChecklistBefore I leave the care facility, the following tasks should be completed • Developed by Dr. Eric Coleman, UCHSC, HCPR, with funding from the John A. Hartford Foundation and the Robert Wood Johnson Foundation.

15. Pillar II Medication Self-Management The patient: • knows medications: why, when and how to take what is prescribed? How long to take? • knows potential side effects and adverse drug reactions and what to do. • develops a system to take meds as prescribed. • keeps an up-to-date medication record & takes it everywhere.

16. Pillar III Primary care and specialist follow-up The patient: • schedules and completes follow-up visit with the primary care physician or specialist. • learns to be an active participant in these interactions. • uses the PHR to facilitate communication.

17. Pillar IV Red Flags The patient: • learns disease-specific warning signs & symptoms. • knows how to access healthcare system, including nights/weekends. • Example: “Call your doctor’s office immediately if any of the following occur: fever, bleeding, confusion, uncontrollable pain, increased tiredness”.

18. Care Transitions Program Results: Greater knowledge and confidence in self-care skills=Enhanced ability to ensure needs are being met during this vulnerable time. Patients and caregivers playing a more active role = Reduced re-hospitalization rates.

19. Care Transitions Program OutcomesFeb - August 2008 • Completed intervention: 78 • Average age: 79 • Women: 52 Men: 26 • Discharge locations: Home 80%, SNF 13%, NERH-P 6% Hospital re-admission rate within 30 days (N=67) • Same diagnosis = 6% (4) • Any diagnosis = 12% (8)

20. Medication Discrepancy Tool (MDT) • Tool for identifying and characterizing medication discrepancies during transitions. • Discrepancies can be identified at either the patient level or the practitioner/health system level. • Specific MDT items are designed to be actionable and ideally to recognize problems before patients experience harm. • Leads to a single reconciled list of medications, irrespective of the numberof prescribers involved.

21. Medication Discrepancy Tool (MDT) February -> August 2008 Medication discrepancies = 47 N= 36 patients (45%) • Dose discrepancy: 19 • Medication not taken: 9 • Prescription not filled: 6 • Incomplete D/C instructions: 8 • Lack of Knowledge: 4 • Financial barrier: 1

22. Patient Satisfaction Survey Care Transition Measures: (N= 31) 100 % of patients agree to strongly agree that their confidence levels have increased regarding : • Self-management skills • Understanding warning signs and symptoms • Obtaining essential information for managing condition during physician visits • Understanding their medication regime • Would recommend Care Transitions to others

23. Patient Satisfaction Survey Personal Health Goal: important to achieve one month after arriving home from the hospital (N=22). • I have not worked on it= 5% (1) • I have not met that goal, but am working on it= 23% (5) • I have met the goal as well as I expected= 45% (10) • I have met the goal better than I expected= 27% (6)

24. Patient Satisfaction Survey What changes have you made as a result of the Care Transitions Program? • Change in time of taking some medications. Weigh daily. More conscious about food intake. • Diet, reduce stress. • If I’m not feeling well, call the clinic and try to get an appointment. • It helped me to be even more careful of my health than before. • Learning to take charge. Other Comments: • I was very happy to have this program when I left the hospital. • I was very happy with all the people involved with my recovery and I know it will continue as long as I need it. • Find this to be very important for good health care.

25. Benefits to the hospital or health system • Improves quality of geriatric care • Reduces hospitalizations and days in the hospital • Advances patient-centered care • Supports shared decision- making • Promotes patient safety • Helps controls escalating Medicare costs

26. The Care Transitions Program Next Steps • Stephen’s Memorial Hospital • Miles Health Care • St Andrews Hospital

27. The Care Transitions Program For more information: MMC Physician-Hospital Organization 443 Congress Street, 5th Floor, Portland, ME 04101 207-482-7064 MaineHealth Elder Care Services 465 Congress St, Suite 701, Portland, ME 04101 207-775-1095