Transitional Care

1. Transitional Care CareOne-RWJUH Adrianna Luzzo, ANP-BC Care Navigator Nurse practitioner Transitional care program

2. Transitional Care Concept • Goal to establish a single seamless system to manage the patient care from admission, through diagnosis, modalities of treatment, patient assessment for discharge, and treatment modalities employed post discharge

3. What are the Transitions? • Hospital to home • Hospital to sub acute to home • Sub acute to home • Home with health care services to home without health care services

4. Transitional Care Focus • Elderly patients with multiple chronic conditions who require continuing monitoring and assessment by the healthcare system

5. Critical Issues that Transitional Care Addresses • Lack of primary care management continuity (Hospitals and sub acute facilities have their own physicians) • Does the primary care physician responsibility shift to a specialist at a certain time? • Operations and executions within each institution/office/system • Problems resulting from inefficiencies within each institution • Management effectiveness/efficiency-do staff performing functions have sufficient resources, plan, and support to meet outcomes and objectives to be proficient and successful

6. Why Transitional Care? • The driving force of transitional care is to avoid Medicare penalties • To ensure continuity of care for patients post hospital discharge • To avoid potentially preventable readmissions to hospitals • Lack of coordination between institutions, modalities, and providers for post discharge care • Improve patient satisfaction and clinical patient outcomes • Enhance patient/caregiver/family engagement • Empower patients and families to self manage their health to maximum capability • Integration, partnership and coordination across all healthcare systems

7. Key Transitional Care Projects/Programs • Coleman and Naylor Models-focus on improving patient self health management • Project BOOST and Project RED-programs focused on several elements to implement efficient health institutions and post discharge care plans

8. Coleman Model Implementation • Model focus is to improve patient self management of health utilizing professionals (nurses, social workers, case managers, life coaches, etc.) • “The model has been adopted by 750 organizations, 20 percent of which are hospitals. And out of the 47 communities under the Centers for Medicare & Medicaid Services' Community-Based Care Transitions Program, 34 are using Care Transitions Intervention, Coleman said.The Care Transitions Intervention has been shown to cut 30-day readmissions by 20 to 50 percent--even six months down the line, according to Coleman.” Care Transitions Intervention - FierceHealthcarehttp://www.fiercehealthcare.com/special-reports/care-transitions-intervention#ixzz28x1v6K1w

9. Naylor Model Implementation • Model focus is to improve patient self management of health utilizing nurses • “U Penn's model, which partners with Aetna and Kaiser Permanente, cut readmissions by 28 percent within the first 24 weeks and by 13 percent within a year. It also has cut costs by 39 percent per patient, or nearly $5,000, within the year after hospitalization.” Transitional Care Model - FierceHealthcarehttp://www.fiercehealthcare.com/special-reports/transitional-care-model#ixzz28x2Ds9xo

10. Project BOOST Implementation • Project BOOST-a training program that utilizes mentors and experts to do site visits at institutions to transform existing processes and place new interventions to help decrease readmissions • “Nearly 3,900 sites have downloaded the BOOST toolkit, as of February, and the mentoring program has been implemented at more than 100 sites, according to an SHM fact sheet. Project BOOST has resulted in a 21 percent drop in all-cause readmission rates, although Maynard noted updated data will be published soon. Project BOOST also collaborates with Blue Cross Blue Shield Association of Michigan and the California Health Care Foundation.” Project BOOST - FierceHealthcarehttp://www.fiercehealthcare.com/special-reports/project-boost#ixzz28x3sjpSM

11. Project RED Implementation • Project RED-Project Re-engineered Discharge-improve discharge process with emphasis on effective language during discharge process and encourage follow up appointments, medication management and post discharge plan with telephonic intervention if necessary • “The model, supported by the Agency for Healthcare Research and Quality, the Blue Cross Blue Shield Foundation and the Patient-Centered Outcomes Research Institute, among others, has proven successful, lowering hospital utilization by 30 percent and saving nearly 34 percent in costs ($412) per patient who received intervention, according to a Project RED fact sheet.” • Project RED - FierceHealthcarehttp://www.fiercehealthcare.com/special-reports/project-red#ixzz28x3YO6kv

12. CareOne Transitional Care Program • Hospitals and sub acute facilities are increasing allocation of resources/staff to implement transitional care program • Hybrid of Coleman and Naylor models-utilizing nurse practitioner • Focuses on medication management, red flag signs and symptoms, follow up appointments, personal health record • Utilizes visits during hospitalization, sub acute stay, house calls, and telephone conferences • Utilizes variety of patient education material

13. Transitional Care Process • Initial identification of patient for transitional care at admission • A total care plan including post discharge developed at time of diagnosis to facilitate the identification of the appropriate facilities and resources • A continuous assessment of the patient to modify the program as patient condition progresses • Identification of critical parameters that need to be managed and assessment of capabilities to execute the plan including patient compliance, caregiver capabilities, etc. • Establish management capability to follow and respond to evolving patient condition from admission to 30 days post discharge

14. Target Population • Pneumonia • CHF • AMI • Patients who have been admitted to RWJUH within the past 30 days • Patients who are identified as high risk for readmission • Patients who need sub acute rehab at CareOne • Patients with Medicare as primary insurance

15. Care Navigator Role • Help coordinate care from the enrollment in transitional care program to 30 days post discharge • Personal health record used as a key tool to manage care

16. Care Navigator Role • Engage the patient, caregivers, and family to ensure that all aspects of the care program are implemented • Directly engaged in the hospital, CareOne sub acute facilities, and the home

17. Referral • Patients are referred to CareOne by RWJUH case management • CareOne nurse liaison can identify transitional care program candidates • CareOne nurse liaison contacts care navigator and transitional care process initiated • RWJUH transitional care team referral

18. Hospital • The care navigator will meet with patient/caregiver/family in hospital • Introduce care navigator role, transitional care, the personal health record and answer questions and concerns

19. CareOne Sub acute Facility • The care navigator will meet with patient/caregiver/family in sub acute rehab facility within 24-72 hours post discharge from the hospital and help facilitate care, discharge planning, and education • Personal health record • Collaboration of disciplines • Walgreens

20. Home • The care navigator will meet the patient/caregiver/family in the home/assisted living facility/CareOne long term care facility, 24-72 hours post discharge from the sub acute rehab facility • Review of previous health/hospitalization episode • Medication reconciliation • Follow up care and facilitating scheduling if necessary • Preparation for follow up care • Assist understanding the importance of taking an active role in managing health conditions, establishing health goals • Educating patient/caregiver/family with self care skills

21. Telephone • The care navigator will call the patient/caregiver/family a minimum of 2 times after initial home visit within the 30 days post hospitalization discharge • During telephone follow up, the care navigator will assess patient status related to established goals and home visit interaction • Care Navigator will use custom created script during telephone interaction

22. Documentation • The care navigator will record all interactions with patient/caregiver/family on paper tools established for each visit and telephone conference • The care navigator will track and record each patient status on 30 days post discharge from hospital

23. Evaluation Parameters • Evaluation of transitional care program will be determined using the readmission rate of patients enrolled in the RWJUH/CareOne transitional care program vs. readmission rates of patients discharged from RWJUH to other sub acute facilities with similar diagnoses • Evaluation of transitional care program will be determined using the readmission rate of patients with CHF, pneumonia, and AMI enrolled in the RWJUH/CareOne transitional care program vs. readmission rates of patients discharged from CareOne last year with diagnoses of CHF, pneumonia and AMI

24. Continuing Connection and Evolution • Biweekly transitional care team meeting with RWJUH internal transitional care team-(CMO, NP transitional care coordinator, 2 physician advisors, IT, Case management, Nursing, Physiatrist, VNA, Social Work, Biomedical statistics, Palliative care) • Discussion of enrollment, progress, challenges, solutions, plans

25. Challenges • Human condition is volatile-physically, emotionally, psychologically, socially • Healthcare culture of “doing for the patient” • Alignment of all healthcare providers’ goals and values • Time constraints • Patient and family motivation level, education level • Healthcare provider responsiveness and timeliness to patient questions and status with limited response and explanation to the patient and family

26. Challenges • Healthcare provider office accommodation for follow up appointments • Patient and family ability to manage their own healthcare in current living situation, physical condition, emotional state, financial state, mobility state • Recognizing, implementing and executing palliative and hospice care consults • Insurance constraints and boundaries • Unforeseen circumstances including co morbid condition deterioration and patient non compliance

27. Challenges • Established discharge procedure and execution • Lack of electronic medical records at current CareOne facilities and transparent connectivity between all healthcare institutions and offices • Communication between physicians/healthcare providers across care settings • Under utilization of resources: pharmacists, insurance programs, students, media • Dietary educational deficits that require ongoing follow up

28. Challenges for Transitional Care Process • Accurate identification of target population • Referral procedure to program • Current discharge protocol and procedure • Effective execution of transitional care process

29. CareOne Working Solutions • Interact II-nursing education, including palliative care • Next Step Home-clinical processes starting at patient admission-walking rounds, concurrent review, medication reconciliation • CHF and COPD program implementation • Stop and Watch Program • Ambassador Program • Partnership with cardiology group-cardiac assessment tool

30. CareOne Working Solutions • Walgreens bedside medication delivery • OT activities-include medication management-pill in putty, pill boxes, calling pharmacies for refills • New discharge medication reconciliation process-all physicians write medications • Pilot of electronic medical records occurring • NJ Relay • Relationships established with home physicians and social workers

31. CareOne Working Solutions • Utilization of pharmacy resources • Utilization of insurance resources • Scheduling healthcare provider appointments prior to leaving rehab facility • Fax discharge medications to community primary care physician

32. STATS • Total patients enrolled: 116 • Total admissions into program: 132 • Total Readmissions: 31 • Total Medicare Readmissions: 26 • Total Medicare Readmission Penalty Diagnosis of CHF, MI, pneumonia: 19 • Total House calls: 60 • Total Medication Discrepancies: 85

33. Case Reviews RWJUH-CAREONE JOINT PROGRAM FOR TRANSITIONAL CARE ADRIANNA LUZZO, ANP-BC

34. Patient #1 • A.C. 84 year old male • PMH: CHF, AFIB, CRI, CAD, HTN, Anemia, PVD, BPH, NIDDM, hypothyroidism, hyperlipidemia, psoriasis, h/o colitis • PSH: PPM/AICD, h/o AAA with stent 4/7/06, CABG 2005, SBO-lyses of adhesions 4/2002 • Pneumonia vaccine: 3/2011 • Family history: non contributory • Social history: h/o tobacco use; lives at home with wife, patient wife recently diagnosed with mild dementia, 2 daughters involved in patient care • Community PCP: Dr. Bobby Malik

35. Timeline • RWJUH admission 1/20/12-1/31/12-Pneumonia, hemoptysis, hypoxia • CareOne at East Brunswick 1/31/12-2/23/12-S/P pneumonia • -On 2/23/12 patient had fever and dyspnea with O2 sat down to 60% (CT of chest performed within the week before readmission to RWJUH showed improvement in overall infiltrates) • RWJUH admission 2/23/12-3/3/12-Respiratory distress and hypoxia, R/O pneumonia, hypotension, CHF exacerbation, persistent infiltrates • CareOne at East Brunswick 3/3/12-4/12/12-S/P CHF exacerbation, bronchitis, hypotension, persistent infiltrates • Discharged home on 4/12/12-with wife and help of daughters • Moved into assisted living facility with his wife 4/16/12

36. Transitional Care • Enrolled in RWJUH-CareOne transitional care program on 3/2/12 • Date of 30 days post hospital discharge: 4/2/12 • Discharged from RWJUH-CareOne transitional care program 4/13/12 without readmission

37. Interventions • 1. Attentive physician • 2. Constant communication • 3. Daily to 3x weekly encounters-patient status required frequent visits • 4. Frequent chart review • 5. Earlier intervention with URI • 6. Medication catch-discrepancy at home care setting

38. Patient #2 • S.S. 87 year old male • PMH: CHF, COPD, h/o MI, CAD, h/o recurrent pneumonia, aortic stenosis, HTN, AFIB, BPH, MUGA scan showed LF=45% • PSH: CABG, AICD 2009, AAA repair 2004, cardiac stents x 3, angioplasty 2007 • Pneumonia vaccine: as per RWJUH records-within the past 5 years • Family history: Patient unable to recall. Mother deceased gastric CA • Social history: Patient lives alone and has a son who comes by his house about 2x daily to give him his medications and provide him with meals. • Community PCP: Dr. Evangelista (cardiology) and VA

39. Timeline • RWJUH admission 3/15/12-3/26/12-respiratory distress, COPD exacerbation, CHF exacerbation, pneumonia • CareOne East Brunswick Admission 3/26/12-4/17/12-s/p CHF exacerbation, COPD exacerbation, pneumonia

40. Transitional Care • Enrolled in RWJUH-CareOne transitional care program on 3/26/12 • Date of 30 days post hospital discharge: 4/25/12 • Discharged from RWJUH-CareOne transitional care program 5/4/12 without readmission

41. Interventions • 1. Constant communication • 2. Daily to 3x weekly encounters-patient status required frequent visits • 3. Frequent chart review • 4. Earlier intervention with cellulitis • 5. Medication catch-discrepancies at home care setting • 6. Facilitate timely PCP follow up • 7. Recognition of inadequate nebulizer equipment • 8. Caregiver support and education

42. My Contact Information • Adrianna Luzzo, ANP-BC • Care Navigator-Nurse Practitioner • Transitional Care Program • 732-675-8478 • aluzzo@care-one.com

43. Helpful Websites • http://www.caretransitions.org/ • http://www.caretransitions.org/provider_tools.asp • http://www.transitionalcare.info/index.html • http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&TEMPLATE=/CM/HTMLDisplay.cfm&CONTENTID=27659 • http://www.projectred.org/