Transitions of Care: Helping Patients Cross the Great Divide

1. Transitions of Care: Helping Patients Cross the Great Divide Maryanna Arsenault Mary Harkins Becker, MD Elaine McMahon Michelle Tarr, RN MHLC PRISM 2 May 3, 2007

2. Session Overview • Outline transition of care issues • Panelist presentations • HomeHealth Visiting Nurses of Southern Maine, Maryanna Arsenault • MMC PHO Care Management Team, Michelle Tarr, RN • MH Elder Care Services, Elaine McMahon • Time for questions/discussion

3. The story of my uncle • Uncle Dixon lives in EL Paso, Texas and had a heart attack on 1/15/07 • He was in the hospital for 7 days • He was discharged to home where he lives alone • At discharge he was started on 11 new medications

5. When I arrived we had lots of questions: • Who did he need to follow up with? • Who was managing his PT/INRs? • Who was managing his blood sugars? • Who wanted to know about the side effects from the new meds? • What scripts needed filling? • How could he keep track of all of the medications? • Why did he have two scripts for some medications, but not for all? • What about the medications he was on before his heart attack?

6. Lots of questions, con’t. • Did he need homehealth services? • If so what could they offer him? • What about his BPH? (The cardiologist stopped the medication the urologist put him on for this.) • What level of activity was he to do until cardiac rehab started?

7. Transition of Care Issues • Lack of communication between providers discharging and providers assuming care • Medication errors • Duplication of services • Neglected patient care issues • Patient and caregiver confusion and distress • Lack of follow up care

8. MMC PHO Care Management Program Growth December 2005 15 RN Care Managers 46 Practices 149 Physicians 1,244 Patients Served 13,880 Encounters December 2006 20 RN Care Managers 67 Practices 219 Physicians 2,588 Patients Served 27,095 Encounters

9. CIR Adult Diabetes Outcomes Care Excluding Care Managed Patients Percent of Patients TestedConcurrent Annual Test Result At Increased Risk: At least 1 of the following BP ≥ 140/90, HbA1c ≥ 8, LDL ≥ 130 Intermediate: All of the following BP < 140/90, HbA1c < 8, LDL < 130 Optimal: All of the following BP < 130/80, HbA1c < 7, LDL < 100 2005 - 2006 382 additional patients documented at optimal level (n=4,660) (n=6,349) (n=6,988)

10. Care Managed Adult Diabetes Outcomes CarePercent of Patients Tested Concurrent Annual Test Result At Increased Risk: At least 1 of the following BP ≥ 140/90, HbA1c ≥ 8, LDL ≥ 130 Controlled: All of the following BP < 140/90, HbA1c < 8, LDL < 130 Optimal: All of the following BP < 130/80, HbA1c < 7, LDL < 100 (n=191) (n=738) (n=1,521) 2005 - 2006 182 additional patients documented at optimal level

11. PHO CM Patient Satisfaction Scale: : 5= Excellent; 4=Very Good; 3=Good; 2=Fair; 1= Poor N= 46

12. HomeHealth Visiting Nurses • Member of MaineHealth • Medicare certified home health agency • Serving Cumberland and York Counties and surrounding communities • Patient census of 1100 • Nursing, Therapy, Social Work

13. Telehealth Program • Interactive video nursing visits • Admission diagnoses: • COPD 491-496 (includes asthma and chronic Bronchitis) • Heart Disease • Hypertension 401-405 • Ischemic Heart Disease 410-418 • Other cardiac disease 420-427, 429 • Heart Failure 428.xx • Diabetes Mellitus 250.xx

14. Telehealth Program • Patient census of 30 (soon to be expanded to 60) • Reduced re-hospitalization • Reduced urgent, unplanned medical care