The New World of Healthcare for the Elderly: Care Transitions

1. The New World of Healthcare for the Elderly: Care Transitions

2. Hamster Healthcare

3. Rates of Rehospitalization within 30 Days after Hospital Discharge Jencks SF et al. N Engl J Med 2009;360:1418-1428

4. Chronic Illness Epidemic Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update

5. The Boomers are Coming to Medicare

6. Transitional Care (TC) Defined Transitional care – range of time limited services and environments designed to ensure health care continuity and avoid preventable poor outcomes among at risk populations as they move from one level of care to another, among multiple providers and/or across settings.

7. The Billion Dollar U-Turn

8. Quality is Awful!

9. Transitional Care Programs “The transitional period between sites of care is an especially vulnerable time for patients, often characterized by conflicting medical advice, medication errors, and a lack of additional treatments that might have been avoided. Care transitions interventions are designed to target these problems and ease the transition between sites.”Dr. Eric Coleman, MD

10. Dangers of Discharge • ¼ of hospitalized patients need further work up • >1/3 are not done • Missing discharge summary • Family not ready to take patient • Lack of understanding • Hazards in the home • Info transfer is missing

11. Transitions are Dangerous… • To… • From… • Within…

12. "If you think that you can run an organization in the next 10 years as you've run it in the past 10 years you're out of your mind." CEO, Coca Cola

13. . . . That Culminated in Complex Legislation March 30, 2010 REFORM Public Law No. 111-148: Patient Protection and Affordable Care Act: March 23, 2010 Public Law No. 111-152: Health Care and Education Reconciliation Act of 2010: March 30, 2010 13

14. Began Jan. 11, 2010 …. 5 years

15. 14 QIOs with 14 Target Communities Whatcom County Upper Capital Region Greater Lansing Area SW NJ Providence RI Western PA Omaha NW Denver Evansville Metro Atlanta East Tuscaloosa HRR Baton Rouge Miami Harlingen HRR 15

16. The Four Pillars of Care Transitions Medication management Patient-centered record (PHR) Follow-up with PCP/Specialist Knowledge of “Red Flags” or warning signs/symptoms and how to respond Stoplight Tools Dr. Eric Coleman http://www.caretransitions.org/

17. Transition Coaches • The ability to shift from doing things for a given patient to encouraging them to do as much as possible for themselves • Competence in medication review and reconciliation, and • Experience in activating patients to communicate their needs to a variety of health care professionals.

18. Acute Care Hospitalization and ED:The Number One Target in Healthcare Reform !

19. The Beers List

20. Care Transitions Tools: Medication Discrepancy

21. Before I leave the hospital…. • I have the instructions I need to keep my health condition from becoming worse. • I know what symptoms to watch out for. • I know the name and phone number of who to call if I see any of these symptoms. • My family or someone close to me knows what I will need once I leave the hospital. • I know what medications to take, how to take them, and possible side effects. • I will schedule a follow up appointment with my primary care doctor. • I will have a clear and complete copy of my discharge instructions. • After I leave the hospital… • 1. I will write down questions I have about my condition. • 2. I will take all bottles of medicine I am using to each doctor visit. • 3. I will call _________________ • immediately at (XXX) XXX-XXX if I experience any of the following: • • Temperature above 101° F • • Uncontrollable pain • • Increased confusion • • Increased redness or d • drainage around wound • • Questions about which • medications to take The Personal Health Record of: Josephine Patient Personal Information: Address: Home Phone#: Birth Date: Patient ID# PCP Name: Advanced Directives?: Hospitalization Information: Admitted: _/_/_ Discharged: _/_/_ Reason for Hospitalization: ___________________________________________ Caregiver Information: Name: Phone #: Relation to Patient: Personal History Please check any illnesses or health problems listed below that you have ever experienced. • Arthritis • Abnormal Heart Rhythm • Cancer • Diabetes • Hardening of the Arteries • Heart Disease • Heart Failure • High Blood Pressure • Hip Fracture • Lung Disease • Medical/Surgical Back conditions • Pneumonia • Stroke • Other: ____________________ Personal Health Record Remember to take this Record with you to all of your doctor visits My Medications are: Medication Dose ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ Allergies: _____________________ Reason Side Effects ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________