Best Practice Intervention Package:

1. Best Practice Intervention Package: Transitional Care Coordination Welcome to the WebEx for the 12th Best Practice Intervention Package: Transitional Care Coordination.Welcome to the WebEx for the 12th Best Practice Intervention Package: Transitional Care Coordination.

2. Theme for final three Best Practice Intervention Packages: December: Patient Self-Management January: Disease Management February: Transitional Care Coordination Building Upon the Basics is the theme for the last three Best Practice Intervention Packages. They are as follows: December: Patient Self-Management January: Disease Management February: Transitional Care Coordination These packages are a little more complex than previous packages. These packages will help your agency build upon best practice interventions to reduce acute care hospitalizations that have been introduced monthly throughout the campaign, hence Building Upon The Basics! Transitional Care Coordination is the final package of this series and will build upon the work of all the previous packages, including patient self-management and disease management!Building Upon the Basics is the theme for the last three Best Practice Intervention Packages. They are as follows: December: Patient Self-Management January: Disease Management February: Transitional Care Coordination These packages are a little more complex than previous packages. These packages will help your agency build upon best practice interventions to reduce acute care hospitalizations that have been introduced monthly throughout the campaign, hence Building Upon The Basics! Transitional Care Coordination is the final package of this series and will build upon the work of all the previous packages, including patient self-management and disease management!

3. Purpose of Patient Self-Management, Disease Management and Transitional Care Coordination: Advance to a higher level of care Improve patient outcomes Improve patient satisfaction Reduce avoidable hospitalizations The purpose of the Building Upon the Basics Packages of Patient Self-Management, Disease Management and Transitional Care Coordination is to: Advance to a higher level of care Improve patient outcomes Improve patient satisfaction Reduce avoidable hospitalizations The purpose of the Building Upon the Basics Packages of Patient Self-Management, Disease Management and Transitional Care Coordination is to: Advance to a higher level of care Improve patient outcomes Improve patient satisfaction Reduce avoidable hospitalizations

4. Objectives After viewing this WebEx, the learner will be able to: Define Transitional Care Coordination Identify tools/resources available in this Best Practice Intervention Package (BPIP) Recognize components of the Best Practice Intervention Package that will be of value to your agency Now we�ll begin a review of the Transitional Care BPIP. The objectives of this educational WebEx are as follows: Define Transitional Care Coordination Identify tools/resources available in this Best Practice Intervention Package Recognize components of the Best Practice Intervention Package (BPIP) that will be of value to your agency Now we�ll begin a review of the Transitional Care BPIP. The objectives of this educational WebEx are as follows: Define Transitional Care Coordination Identify tools/resources available in this Best Practice Intervention Package Recognize components of the Best Practice Intervention Package (BPIP) that will be of value to your agency

5. Transitional Care Coordination Utilizing the following best practices can help design an effective care transitions program 1. Hospitalization Risk Assessment 2. Emergency Care Planning 3. Medication Management 4. Phone Monitoring and Frontloading Visits 5. Physician Relationships 6. Patient Self-Management 7. Disease Management Previous best practices that have already been implemented are essential in designing an effective care transitions coordination program. Interventions with special significance to transitional care include the following: 1. Hospitalization Risk Assessment 2.�Emergency Care Planning 3.�Medication Management 4.�Phone Monitoring and Frontloading Visits 5.�Physician Relationships 6.�Patient Self-Management 7.�Disease Management A crosswalk is included in the package that lists the best practice intervention packages and shows how each can support Transitional Care Coordination.Previous best practices that have already been implemented are essential in designing an effective care transitions coordination program. Interventions with special significance to transitional care include the following: 1. Hospitalization Risk Assessment 2.�Emergency Care Planning 3.�Medication Management 4.�Phone Monitoring and Frontloading Visits 5.�Physician Relationships 6.�Patient Self-Management 7.�Disease Management A crosswalk is included in the package that lists the best practice intervention packages and shows how each can support Transitional Care Coordination.

6. Transitional Care CoordinationGoes Both Ways Sending Receiving Transitional care coordination is a multidimensional best practice intervention which includes both sending and receiving patient information. One must understand the concepts of care transitions and care coordination and then synchronize the meanings to formulate this best practice, transitional care coordination, to decrease avoidable hospitalizations. We�ll take a brief look at care transitions and care coordination to better understand the evolution of transitional care coordination.Transitional care coordination is a multidimensional best practice intervention which includes both sending and receiving patient information. One must understand the concepts of care transitions and care coordination and then synchronize the meanings to formulate this best practice, transitional care coordination, to decrease avoidable hospitalizations. We�ll take a brief look at care transitions and care coordination to better understand the evolution of transitional care coordination.

7. Care Transitions Refers to the patients moving between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness (Care Transitions Program, University of Colorado). http://www.caretransitions.org First let�s look at Care Transitions. The term �care transitions� refers to patients moving between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness (Care Transitions Program, University of Colorado). http://www.caretransitions.org The findings of the ongoing research of Dr. Eric Coleman and The Care Transitions Program at the University of Colorado at Denver Health Sciences Center suggest that effective care transition intervention leads to improved self-management knowledge and skills for many patients, primarily in the areas of: (1) medication management, (2) condition management and (3) patient confidence regarding what was required during the transition and beyond (Coleman, Parry, Chalmers, & Min, 2006). First let�s look at Care Transitions. The term �care transitions� refers to patients moving between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness (Care Transitions Program, University of Colorado). http://www.caretransitions.org The findings of the ongoing research of Dr. Eric Coleman and The Care Transitions Program at the University of Colorado at Denver Health Sciences Center suggest that effective care transition intervention leads to improved self-management knowledge and skills for many patients, primarily in the areas of: (1) medication management, (2) condition management and (3) patient confidence regarding what was required during the transition and beyond (Coleman, Parry, Chalmers, & Min, 2006).

8. Care Coordination Targets the chronically ill who are at risk for elevated health care and provides services that fill the gaps in our traditional, reactive system Combines the elements to keep the chronically ill and elderly as healthy as possible and to reduce the use of costly services such as the emergency room and inpatient hospitalization (Meckes, 2005) Now we�ll discuss Care Coordination. The term �care coordination� targets the chronically ill who are at risk for elevated health care and provides services that fill the gaps in our traditional, reactive system. Care coordination combines the best elements of home health, disease management and case management to organize a personalized health care system to keep the chronically ill and elderly as healthy as possible and to reduce the use of costly services such as the emergency room and inpatient hospitalization (Meckes, 2005). Now we�ll discuss Care Coordination. The term �care coordination� targets the chronically ill who are at risk for elevated health care and provides services that fill the gaps in our traditional, reactive system. Care coordination combines the best elements of home health, disease management and case management to organize a personalized health care system to keep the chronically ill and elderly as healthy as possible and to reduce the use of costly services such as the emergency room and inpatient hospitalization (Meckes, 2005).

9. Transitional Care Coordination Transitional care has been defined as 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 and Berenson, 2004). This leads us to transitional care coordination. The formal definition of Transitional Care Coordination includes the concepts of care transitions and care coordination. Transitional care has been defined as 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 and Berenson, 2004).This leads us to transitional care coordination. The formal definition of Transitional Care Coordination includes the concepts of care transitions and care coordination. Transitional care has been defined as 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 and Berenson, 2004).

10. Transitional Care Coordination Poses challenges that distinguish it from other types of care Transitional care encompasses both the sending and receiving aspects of the transfer and is essential for those with complex care needs (AGS, 2006) Transitional care, which primarily concerns the relatively brief time interval that begins with preparing a patient to leave a setting and concludes when the patient is received in the next setting, poses challenges that distinguish it from other types of care. The American Geriatric Society (2006) stated that transitional care encompasses both the sending and receiving aspects of the transfer and is essential for those with complex care needs. Effective transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well educated in chronic care and have current information regarding the patient�s goals, preferences and clinical status. Transitional care, which primarily concerns the relatively brief time interval that begins with preparing a patient to leave a setting and concludes when the patient is received in the next setting, poses challenges that distinguish it from other types of care. The American Geriatric Society (2006) stated that transitional care encompasses both the sending and receiving aspects of the transfer and is essential for those with complex care needs. Effective transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well educated in chronic care and have current information regarding the patient�s goals, preferences and clinical status.

11. Transitional Care CoordinationHandoffs/Handovers The transfer of patient information from one setting to another has become known as �handoff� or �handover�. Both terms handoff and handover are being used in healthcare related to transitions of care. We have adopted the term handover for the Transitional Care BPIP to represent transitions of care of the patient to and from settings. A handover is a significant patient safety issue. Handovers are error-prone and variable. They are a vulnerable gap in patient care. An exchange of information does not require that the other person understands what is being transmitted by simply conveying information. Information is often acquired and transmitted without determining comprehension. A Handover implies transfer of information as well as professional responsibility to both deliver the information and assure it is understood. � The transfer of patient information from one setting to another has become known as �handoff� or �handover�. Both terms handoff and handover are being used in healthcare related to transitions of care. We have adopted the term handover for the Transitional Care BPIP to represent transitions of care of the patient to and from settings. A handover is a significant patient safety issue. Handovers are error-prone and variable. They are a vulnerable gap in patient care. An exchange of information does not require that the other person understands what is being transmitted by simply conveying information. Information is often acquired and transmitted without determining comprehension. A Handover implies transfer of information as well as professional responsibility to both deliver the information and assure it is understood. �

12. Transitional Care CoordinationHandovers The role of handovers is to: Exchange vital information Share impressions of patient status Exchange information and assume or pass on responsibility Support patient safety The role of handovers is to: Exchange vital information Share impressions of patient status Exchange information and assume or pass on responsibility Support patient safety The role of handovers is to: Exchange vital information Share impressions of patient status Exchange information and assume or pass on responsibility Support patient safety

13. Transitional Care CoordinationHandovers Care transitions are not optional and should be , occur daily and should be a standard of care. This is certainly true in home health care. Home health referrals typically come from facility based care settings such as hospitals or nursing homes and the home health agency becomes the receiver of the transferred patient. It is a known fact that many of these transitions lack the ingredients for what would be defined as an optimal transition or handover. Home health becomes the sender with a patient/caregiver transition (or handover) when the patient is transferred to the emergency room, the physician office or other care setting. Care transitions are not optional and should be , occur daily and should be a standard of care. This is certainly true in home health care. Home health referrals typically come from facility based care settings such as hospitals or nursing homes and the home health agency becomes the receiver of the transferred patient. It is a known fact that many of these transitions lack the ingredients for what would be defined as an optimal transition or handover. Home health becomes the sender with a patient/caregiver transition (or handover) when the patient is transferred to the emergency room, the physician office or other care setting.

14. Patients cross many settings for health care. Our handovers must be consistent, detailed and appropriate to each setting. Transitional care coordination is like putting pieces of the puzzle together to improve patient health care and to reduce avoidable acute care hospitalizations. Home care needs to assist patients and caregivers to connect the care provided back and forth across the settings. The care transitions intervention by Dr. Coleman�s team has been built on four pillars or conceptual domains. The illustration on the next slide adapts the four pillars concepts into the home health arena. Patients cross many settings for health care. Our handovers must be consistent, detailed and appropriate to each setting. Transitional care coordination is like putting pieces of the puzzle together to improve patient health care and to reduce avoidable acute care hospitalizations. Home care needs to assist patients and caregivers to connect the care provided back and forth across the settings. The care transitions intervention by Dr. Coleman�s team has been built on four pillars or conceptual domains. The illustration on the next slide adapts the four pillars concepts into the home health arena.

15. Here are the four pillars adapted for home health using the Care Transitions model. The four pillars is the primary tool for this package. The pillars are: 1. Assistance with medication self-management: Patient is knowledgeable about medications and has a medication management system. �2. Use of a patient-centered record: Patient understands and utilizes the Personal Health Record (PHR) to facilitate communication and ensure continuity of care planning across providers and settings. The patient or caregiver manages the PHR. �3. Timely, informed primary care/specialist follow-up: Patient schedules and completes follow-up visit with the primary care physician or specialty practitioner and is prepared to be an active participant in these interactions. �4. Knowledge of �red flags�: Patient is knowledgeable about indicators that suggest his/her condition is worsening and instructions regarding how to respond. Agencies may work on one or more pillars at a time until all of the pillars are incorporated for improved care transitions processes. � � �Here are the four pillars adapted for home health using the Care Transitions model. The four pillars is the primary tool for this package. The pillars are: 1. Assistance with medication self-management: Patient is knowledgeable about medications and has a medication management system. �2. Use of a patient-centered record: Patient understands and utilizes the Personal Health Record (PHR) to facilitate communication and ensure continuity of care planning across providers and settings. The patient or caregiver manages the PHR. �3. Timely, informed primary care/specialist follow-up: Patient schedules and completes follow-up visit with the primary care physician or specialty practitioner and is prepared to be an active participant in these interactions. �4. Knowledge of �red flags�: Patient is knowledgeable about indicators that suggest his/her condition is worsening and instructions regarding how to respond. Agencies may work on one or more pillars at a time until all of the pillars are incorporated for improved care transitions processes. � � �

16. Four Pillars Patient Centered Record (PHR) According to Parry, Coleman, Smith, Frank and Kramer (2003), the four pillars are operationalized through two mechanisms: Personal Health Record and Patient/Caregiver Coaching (self-management support). How does home health fit with the patient/caregiver-coaching model? In many cases there is not the availability of an external coach and therefore to optimize the quality and effectiveness of care transitions, the home health clinician needs to function as the patient/caregiver coach. Detailed information showing how the home health clinician can provide patient-centered coaching is in the BPIP. According to Parry, Coleman, Smith, Frank and Kramer (2003), the four pillars are operationalized through two mechanisms: Personal Health Record and Patient/Caregiver Coaching (self-management support). How does home health fit with the patient/caregiver-coaching model? In many cases there is not the availability of an external coach and therefore to optimize the quality and effectiveness of care transitions, the home health clinician needs to function as the patient/caregiver coach. Detailed information showing how the home health clinician can provide patient-centered coaching is in the BPIP.

17. The ACH Connection Effective transitional care potentially improves patient safety and reduces avoidable acute care hospitalizations. Care transition interventions are designed to encourage patients and their caregivers to assume a more active role during care transitions so that they may reduce re-hospitalization rates.Effective transitional care potentially improves patient safety and reduces avoidable acute care hospitalizations. Care transition interventions are designed to encourage patients and their caregivers to assume a more active role during care transitions so that they may reduce re-hospitalization rates.

18. Resources Some additional resources associated with this package are a sample personal health record and the Care Transitions Medication Discrepancy form. Some additional resources associated with this package are a sample personal health record and the Care Transitions Medication Discrepancy form.

19. Poster Poster Connection Pages As with every package, a poster is included for you to use as a visual reminder of this topic. There are also 2 connection pages to help your agency work with physicians and hospital discharge planners.As with every package, a poster is included for you to use as a visual reminder of this topic. There are also 2 connection pages to help your agency work with physicians and hospital discharge planners.

20. Leadership Track Agency assessment Action items Action plan Leadership should review the Leadership Track information and then complete the agency assessment, action items and develop an action plan. This follows the format of the other BPIPs. Leadership should review the Leadership Track information and then complete the agency assessment, action items and develop an action plan. This follows the format of the other BPIPs.

21. Nursing and Therapy Tracks Transitional Care Coordination: Key Points for Clinicians The Four Pillars of Care Transition Activities Care Transitions: Joe�s Story Podcast Examples of Excellence Post-test with Free CNEs for RNs or Certificate for LPN and Therapists Nursing and Therapy Tracks include � Transitional Care Coordination: Key Points for Clinicians The Four Pillars of Care Transition Activities Care Transitions: Joe�s Story�an example of optimal care transition activities or handovers Podcast Examples of Excellence Post-test with Free CNEs for RNs or Certificate for LPN and therapistsNursing and Therapy Tracks include � Transitional Care Coordination: Key Points for Clinicians The Four Pillars of Care Transition Activities Care Transitions: Joe�s Story�an example of optimal care transition activities or handovers Podcast Examples of Excellence Post-test with Free CNEs for RNs or Certificate for LPN and therapists

22. Medical Social Worker Track Transitional Care Coordination: Key Points for Social Workers Care Transitions: Joe�s Story Podcast Personal Health Record (including completion of own PHR) Examples of Excellence Post-test MSW Track includes Transitional Care Coordination: Key Points for Social Workers Care Transitions: Joe�s Story Podcast Personal Health Record (including completion of own PHR) Examples of Excellence Post-testMSW Track includes Transitional Care Coordination: Key Points for Social Workers Care Transitions: Joe�s Story Podcast Personal Health Record (including completion of own PHR) Examples of Excellence Post-test

23. Home Health Aide Track Transitional Care Coordination: Key Points for Home Health Aides Podcast Personal Health Record (including completion of own PHR) Post-test The HHA Track includes: Transitional Care Coordination: Key Points for Home Health Aides Podcast Personal Health Record (including completion of own PHR) Post-testThe HHA Track includes: Transitional Care Coordination: Key Points for Home Health Aides Podcast Personal Health Record (including completion of own PHR) Post-test

24. This is the final BPIP Educational WebEx for the HHQI National Campaign. Congratulations on your commitment to the HHQI National Campaign!! The Final Best Practice Intervention Package: Transitional Care Coordination. As always �Congratulations on your commitment to the HHQI National Campaign!!!The Final Best Practice Intervention Package: Transitional Care Coordination. As always �Congratulations on your commitment to the HHQI National Campaign!!!