Home Health Quality Improvement (HHQI) National Campaign Transitional Care Coordination February 6, 2008

1. Home Health Quality Improvement (HHQI) National CampaignTransitional Care CoordinationFebruary 6, 2008

2. New York State Local Area Network of Excellence (LANE)

3. HHQI National Campaign Update • Final Intervention Package • Opportunity for clinician CEU’s will end February 29, 2008 • Web site – location of intervention packages • The campaign is coming to a close, but not the initiative to reduce ACH • HHQI ACH Reports continue to July 2008

4. Available for download from the HHQI Campaign Web site at http://www.homehealthquality.org

5. Third in the Building Upon The Basics Series • December: Patient Self-Management • January: Disease Management • February: Transitional Care Coordination

6. Objectives • Define Transitional Care Coordination • Describe the “care transitions” model and the “transitional care” model • Provide the agency the “next steps” to assess and implement a plan to begin addressing “care transitions” within your home health agency.

7. Definition • Care Transition – refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness (Dr. Eric Coleman) • Care Coordination – targets the chronically ill who are at risk for increased use of health care services and assists in filling the gaps in our traditional reactive system

8. Definition • Transitional Care Coordination • Combines the concepts ofcare transitions and care coordination • SendingReceiving

9. Industry Experts: Care Transitions • Dr. Eric Colman – University of Colorado • “Transitional Coach” model • Care Transitions Intervention • Dr. Mary Naylor – University of Pennsylvania • “Transitional Care” model

10. Care Transitions Model – Dr. Eric Coleman • Personal Health Record • Physician follow-up • Discharge Preparation Checklist • Patient Self-Activation and Management • Coaching • Knowledge of medications • Knowledge of “Red Flags” www.caretransitions.org

12. Transitional Care Model – Dr. Naylor • Advance Practice Nurse • Identifies high risk, vulnerable patients • Specific protocol based patient care needs • Collaboration with the patient’s physician • Intervention lasts until six (6) weeks after patient discharge from the acute care facility www.nursing.upenn.edu/centers/hcgne/science_TRIP.html

14. Commonalities between the transition models • Continuity of care • Reduces the number of “handoffs” • Early recognition of deterioration in condition • Stress medication management • Early collaboration with the physician • Appointment within first 5-10 days post acute care episode.

15. Transitional Care Coordination • Occurs daily • Home health agency is both receiver and sender of information • Includes the “handover” of information • Transfer of information • Professional responsibility

16. Role of Handovers • Exchange vital information • Consistent, detailed, appropriate • Communicate patient status • Provide an opportunity for asking questions to ensure complete understanding of the patient related information • Pass on responsibility • Support patient safety

17. Handovers • Think “Transitions • NOT • “Discharges”!

18. Connections To: • Reducing ACH rate • Home Health • Physician

19. Reducing ACH rate • Increased patient self-management • Personal Health Record • Medication reconciliation • Medication Discrepancy Tool • Handover of patient information to other care provider(s)

23. Home Health • Communication with discharge planners & social workers • Schedule an session to discuss common patient transition challenges within both the hospital and agency • Provide feedback with patient’s outcome post-acute discharge • Arrange for care team meetings for high-risk patients • Provide an educational session to discuss and exchange policies, procedures, tools, admission criteria, and expectations • Discharge criteria and face sheet

24. Physician • Key player • Expected release of a consensus statement to address the physician’s role in transitional care coordination • National Attention • American College of Physicians, Society of General Internal Medicine • Society of Hospital Medicine • National Transitions of Care Coalition

26. Agency Self Assessment • Implementation of previous best practices • Standardized communication methods • Referral process • Transfer/discharge process • Sharing agency patient education materials • Standardized communication of patient related information • Physician • Family/significant other • Community service providers Pg. 21&22

27. Agency Action Items • Create a care coordination team • Review • Agency processes, protocols, and forms • Tools in previous BPIP • Educate • Agency staff • Patient/families Pg. 23&24

28. BPIP Pg. 20

30. Clinician educational tracks • Nursing, therapy, MSW, home health aide • Example of personal health record is on the MSW track. • Overview with examples of tools • Patient story • Podcast • Home health agency story • Post test-continuing education credits

31. Website Resources • HHQI Campaign Web site– www.homehealthquality.org • MedQICWeb site – www.medqic.org • IPROWeb site – www.ipro.org • Joint Effort New York (JENY) - http://jeny.ipro.org

32. CONGRATULATIONS !!! St. Peter’s Hospital Home Care ProgramAlbany, New York • Featured in Success Story Section of Transitional Care Coordination Package: • “St Peter’s Home Care Improves Communication, Resulting in More Efficient Transitional Care Coordination”

33. Overall HHQI Campaign success • 67% registered because QIO recommended • 93% reported the monthly BPIP keep them motivated • 89% identified the Hospital risk assessment BPIP as most helpful • 86% found the Nurses Track the most helpful section • 65% utilized the CDs mailed quarterly • 94% used the monthly HHQI reports

34. Questions and Comments

35. Kelly Donohue Coordinator of CommunicationsContinuing Care Leadership Coalition555 West 57th - Suite1500 New York, New York 10019 Phone: 212-506-5424Fax: 212-258-5331donohue@cclcny.org State Association Contact Information • Alexis SilverDirector of Development and Special ProjectsHome Care Association of New York State, Inc.194 Washington Avenue, Suite 400Albany, NY 12210Phone: 518-810-0658Fax: 518-426-8788asilver@hcanys.org • Rose DuhanSenior AnalystHome and Community Based ServicesHealthcare Association of New York StateOne Empire DriveEastRensselaer, NY 12144Phone:  518-431-7620Fax: 518-431-7915rduhan@hanys.org • Margaret ClarkAssistant Director of Public PolicyNew York State Association of Healthcare Providers, Inc. 99 Troy Road, Suite 200East Greenbush, New York 12061Phone: 518-463-1118 ext. 811Fax: 518-463-1606clark@nyshcp.org

36. Sara ButterfieldProject Leader IPRO20 Corporate Woods BoulevardAlbany, New York 12211Phone: 518-426-3300 ext. 104Fax: 518-426-3418sbutterfield@nyqio.sdps.org IPRO Contact Information • Christine StegelPerformance Improvement CoordinatorIPRO20 Corporate Woods BoulevardAlbany, New York 12211Phone: 518-426-3300 ext. 113Fax: 518-426-3418cstegel@nyqio.sdps.org • Victoria AgramontePerformance Improvement CoordinatorIPRO20 Corporate Woods BoulevardAlbany, New York 12211Phone: 518-426-3300 ext. 115Fax: 518-426-3418vagramonte@nyqio.sdps.org