Transitions of Care Coordination of Care Across Settings

1. Transitions of CareCoordination of Care Across Settings Mark Hawk, MSN, ACNP Carla Graf, MS, CNS Bree Johnston, MD

2. Objectives • Identify all potential acute care setting disciplines/departments that are involved in the care of this population. • Explain current evidence-based research regarding “models of care” for transitions across acute settings/units. • Identify all potential disposition avenues (SNF, rehab, home, etc.) for acutely hospitalized elders. • Recognize common obstacles in providing seamless transitions between acute care settings/providers.

3. Transitions of Care • Insurance • Placement needs • Need for SNF with on-site dialysis • Support System • Occupying inpatient med-surg bed • Unable to schedule elective surgery • Patient outcome

4. Discontinuity Errors • 3 types of errors: • Medication continuity • Test result follow up • Workup • 49% had at least one error (Moore JGIM 2003; 18: 646-51)

5. Transition • Passage from one place, state, stage of development to another; also the period or place where such a change is effected (Fletcher 2005)

6. What is “Transitional Care”? • …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. (Coleman, 2003)

7. Transitional Care • Encompasses both sending and receiving aspects of transfer • Appropriate information sharing • Logistical arrangements • Education of patient and caregivers • Coordination among varied HCP • Absolutely NECESSARY for those with comp,ex care needs (Fletcher, 2005)

8. An 82 yr old with a hip fracture in an acute hospital setting sees… • Paramedics • Emergency Physician • Nursing • Orthopedic Surgeon • Hospitalist/Intensivist • PT/OT • Social Services • Nutrition

9. This 82 yr old with a hip fracture then is “transitioned” to a Skilled Nursing Facility where he/she sees… • SNF Physician • SNF Nursing • SNF PT/OT

10. Then they are “transitioned” home where they see… • Home Care Nurses • Home Care PT/OT • PCP • PCP Nurse • PC Pharmacist

11. What is the common thread? • The patient • And the caregivers

12. What breaks the common thread? • From the patients’ perspective: • Deficiencies in preparing caregivers and the patient themselves for the transition • Transferring of information across settings • Supporting self-management of chronic conditions • No encouragement to express own preferences of the patient or caregiver (Coleman, 2003)

13. Patient Perspective • According to a California Health Care Foundation survey, patients rated transition to home lower than ANY other health care experience • Qualitative studies suggest that patients often don’t understand medication SEs, whom they should direct questions to, what warning signs to look for, or when to resume normal activities

14. What breaks the common thread? • From the caregivers’ perspective: • Lack of preparation in “what to expect” and how to respond to the changing needs of their loved ones moving between settings (Coleman, 2003)

15. Often, all that is needed is 1 or 2 more days of acute care!

16. Transitional Care for Learners • Helps address the systems based practice (and possible practice based learning) competency • May help move learners beyond the culture of rewarding all discharges • “You’re awesome - you diuresed the service! • (but with what patient outcomes?) • May help learners see patients in the context of their own lives

17. Prevalence • In 2000 for every 1000 people aged 65 and over they averaged: • 400 ambulatory care visits • 300 emergency department visits • 200 hospital admissions • 46 SNF admissions • 106 home care admissions (Coleman, 2003)

18. Prevalence • 2001 Harris Poll commissioned by Robert Wood Johnson Foundation • On average, older people with one or more chronic conditions sees how many different physicians over the course of one year? • Eight! (Coleman, 2003)

19. Prevalence • 23% of hospital patients aged 65 and over are discharged to another institution. • 11.6% are discharged with home care. • 19% of SNF patients are transferred back to an acute care hospital within 30 days, 42% within 24 months. • Ma, et al (2002) studied 920 community dwelling elders DCed from hospital to SNF/Rehab… • Nearly 50% had four or more additional institutional transitions over a 12 month period. (Coleman, 2003)

20. Why do poor transitions happen? • Fragmented Care • Institutional isolation from one another • Lack of financial incentives • Regulatory • Medicare directed towards each “setting” rather than each “episode” of care • Few quality indicators to measure performance • Professional barriers

21. Why do poor transitions happen? • Multiple providers unfamiliar with “scope of care/services” at receiving facility • PCP doesn’t have privileges at receiving facility • Conflicting recommendations about chronic condition management • Confusing medication regimens-error and duplicity • Lack of follow-up care • Inadequate preparation of patient and caregiver for receiving care at next facility • Passive Role of the patient/caregiver • Transitions often urgent and unplanned

22. Care Transitions Intervention-Four “Pillars” • Medication self-management • A patient-centered record • Personal Health Record • Use of a Transition Coach • Primary care and specialist follow-up • Knowledge of “red flag” warning symptoms or signs indicative of a worsening condition (Coleman et al, 2004)

23. Medication Reconciliation • 2001 Harris Poll for RWJ Foundation… • 16 million adult Americans with chronic illness revealed that their pharmacist told them that medications prescribed by one or more of their physicians had potentially harmful interactions. • (Coleman, 2003)

24. Medication Reconciliation • Forster et al, 2003-19% of patients discharged from a hospital experienced an associated adverse event within 3 weeks. • 66% of those were adverse drug events

25. 2006 JCAHO National patient Safety Goals • Goal 8A: • Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medication the organization provides to those on the list.

26. Goal 8B: • A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization.

27. Anatomy of a “good transition” • Communication of vital elements of the care plan • A Common Plan of Care • The patient’s goals and preferences • An “updated” list of problems, baseline physical and cognitive functional status, current medications and allergies • Contact information for the patient’s caregiver and PCP • Preparation of the patient and caregiver

28. Anatomy of a “good transition” • Reconciliation of medication list “pre” and “post” transfer • Transportation of the patient • Completion of Follow-up care with a practitioner and/or diagnostic studies • Availability of diagnostic results • Availability of advance care directives • “warning signs” and contact information

29. Why Coordinate Care? • Advance “patient-centered” care • Support for shared decision-making • Promote patient safety • Medication use/errors • Control Medicare costs • Reduce unnecessary utilization/redundancy of care • JCAHO

30. What needs to be done? • System level performance measurement • Process measures • Is the patient prepared for transfer? • Is the appropriate information promptly transmitted? • Reconciliation of “pre-” and “post”- transition care regimens • Information technologies

31. What needs to be done? • Intervention from “oversight” level • Medicare • JCAHO • Change payment policies • Financial incentives for institutions/providers • Coding and Billing Changes

32. Research • How to best integrate patient and caregiver into interdisciplinary care team • How to foster collaboration • How to identify those patients at high risk for poor transition-related outcomes • Development of performance indicators to track quality of transitions

33. What does work?-A “Bridging” Model • Use of APNs to identify those at high risk for re-admission, follow them through hospitalization and then after discharge to home. • APNs assume responsibility for comprehensive care in collaboration with the PCP for 4 weeks post discharge

34. Transition Coach • Usually Nurse or NP • Prepares patient for what to expect • Provides tools • Follows patient to home or nursing facility • Reconciles pre- and post- discharge medication • Practices role play of next MD visit • Phone calls after discharge • Reinforce plan, ensure follow up

35. Tools for transitional care • Medication Discrepancy Tool • Personal Health Record • Care Transitions Measure

36. CARE TRANSITIONS MEASURE (CTM-3) 1. The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital. Strongly Disagree Disagree Agree Strongly Agree N/A/dont’ know 2. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. Strongly Disagree Disagree Agree Strongly Agree N/A/dont’ know 3. When I left the hospital, I clearly understood the purpose for taking each of my medications. Strongly Disagree Disagree Agree Strongly Agree N/A/dont’ know

38. What does work?-Other Models • APNs enhancing and encouraging the patient’s & caregiver’s participation in their care management • Staff from “receiving” facility visits the patient in hospital and initiates the transition • Extended Care Pathways • Program for All-Inclusive Care of the Elderly (PACE) • www.SFGetCare.com • www.sfgov.org/daas (Dept of Aging and Adult Services)

39. In Summary • Problems related to transitional care are common • There is evidence that enhanced focus on transitional care improves outcomes • Multiple tools are available that can help us improve our transitional care

40. In Summary: High Quality Transitional Care • Reliable information on transfer • Clear instructions about pending tests, follow up visits, follow up tasks, and medications • Preparation of patient, family, and caregiver • Empowerment of patient to assert preferences

41. References • Coleman EA. (2003). Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society. 51: 549-555 • Coleman et al. (2004). Preparing patients and caregivers to participate in care delivered across settings: the care transitions intervention. Journal of the American Geriatrics Society. 52: 1817-1825