Download Nancy Skinner PPT

Transitions of Care and Reducing Readmissions
Nancy Skinner, RN-BC, CCM
[email protected]
NTOCC is a 501c4 organization
US.NMH.12.03.001
TODAY’S HEALTHCARE
ENVIRONMENT
“It's about better care: care that is safe, timely, effective,
efficient, equitable and patient-centered.”
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Source: http://www.ama-assn.org/amednews/2010/12/20/prse1221.htm
Thoughts For Today!
Transitional and community-based care is often
disorganized and haphazard with patients shuffled
from one post-acute environment or provider to
another with little advocacy, no established
transitional care plan, and absolutely no idea that it
should not be that way.
Patients often move from door to door; episode of
care to episode of care without a champion to
coordinate that care.
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More Thoughts!
This starts a downward trajectory of their health
status that not only can prompt readmissions to
an acute care facility but also cause physical,
emotional, and financial compromise that may
interfere with the patient’s quality of life.
Patients are confused. Families are in crisis. And,
your intervention may be the one action that
decreases anxiety and prevents negative
outcomes!
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Some Words from Secretary Kathleen Sebelius
“Americans go the hospital to get well,
but millions of patients are injured
because of preventable complications
and accidents. Working closely with
hospitals, doctors, nurses, patients,
families and employers, we will
support efforts to help keep patients
safe, improve care, and reduce costs.
Working together, we can help
eliminate preventable harm to
patients.”
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Source: http://www.hhs.gov/news/press/2011pres/04/20110412a.html
Establishing the Goals
On March 22, 2011, the U.S. Department of
Health and Human Services released its National
Strategy for Quality Improvement in Health Care
(National Quality Strategy).
The Affordable Care Act required the Secretary of
HHS to establish a national strategy to improve
the delivery of health care services, patient health
outcomes, and population health. This strategy is
designed to guide federal, state, and local health
initiatives.
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Source: http://www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdf
Three Broad Aims of the National Quality Strategy:
Better Care, Healthy People/Healthy Communities, and Affordable Care.
Six Strategies to Advance these Aims include:
1
Prevention and Treatment of Leading Causes of Mortality
2
Supporting Better Health in Communities
3
Making Care More Affordable
4
Making care safer by reducing harm caused in the delivery of care
5
Ensuring that each person and family members are engaged as partners in
their care
6
Promoting effective communication and coordination of care
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Source: http://www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdf
What is “Transition of Care” ?
 The movement of patients from one health care practitioner or setting to
another as their condition and care needs change
 Occurs at multiple levels
 Within Settings
 Primary Care
 ICU
Specialty Care
Ward
 Between Settings
 Hospital
Sub-acute facility
 Ambulatory clinic
 Hospital
Senior center
Skilled nursing
Home
 Across Health States
 Curative care
 Personal residence
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Palliative care/Hospice
Assisted living
Source: Coleman E. http://www.caretransitions.org/definitions.asp
Hospital
Transition Issues Dramatically Impact
Patients & Their Caregivers
Patient &
Caregiver
ER
ICU
OUTPATIENT:
• Home
• Home Care
• PCP
• Specialty
• Pharmacy
• Case Mgr.
• Caregiver
• Hospice
In-Patient
SNF
Patient &
Caregiver
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ALF
Transition Issues Dramatically Impact
Patients & Their Caregivers
NO
Discharge
Care Plan
Patient &
Caregiver
ER
NO
Medication
Reconciliation
OUTPATIENT:
• Home
•
•
•
•
•
•
•
ICU
Home Care
PCP
Specialty
Pharmacy
Case Mgr.
Caregiver
Hospice
NO
Care Plan
NO Medication
Reconciliation
NO Personal
Medicine List
In-Patient
SNF
ALF
Patient &
NO
Personal
Medicine List
NO
Coordinated
Care Plan
Caregiver
NO
Care Plan
NO Medication
Reconciliation
NO Personal
Medicine List
To Date We Have Not Had
Consistent and Accepted Transition Tools
 Medication Reconciliation Elements
 Comprehensive Care Plan
 Health or Clinical Status
 Transition Summary
 Patient & Caregiver Tools & Resources
 Consistent Performance Measures That Apply to All Health Care Settings
 Accountability for Sending & Receiving Information
 Aligned Payment Incentives
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Source: National Transitions of Care Coalition. http://www.ntocc.org
Rehospitalizations: Medicare Fee-for-Service
• Analysis of Medicare Claims data from 2003-2004
• Includes the 11,855,702 Medicare beneficiaries discharged from the hospital
Summary Analysis
 19.6% (nearly 1/5) were
rehospitalized within 30 days
 34% were rehospitalized
within 90 days
 50.2% of those rehospitalized within
30 days after a medical discharge
there was no bill for a visit to a
physician office
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Source: Jencks FS et al. N Engl J Med 2009;360:1418-28.
“The Billion Dollar U-Turn”
• Frequent - 17.6% of all Medicare hospitalizations are 30-day
rehospitalizations
• Costly - $12B in Medicare spending; est. $25B across all
payers annually
• Actionable for improvement
• 76% potentially avoidable
• Heart failure, pneumonia, COPD, acute MI lead the medical conditions
• CABG, PTCA, other vascular procedures lead the surgical conditions
• Performance highly variable
• Medicare 30-day rehospitalization rate varies 13-24% across states
• Variation greater within states
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MedPAC Report to Congress, Promoting Greater Efficiency in Medicare. June 2007
Mark Taylor, The Billion Dollar U-Turn, Hospitals and Health Networks, May 2008
Commonwealth Fund State Scorecard on Health System Performance. June 2007
Transparency
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Transparency
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Transparency
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Transparency
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Transparency
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Transparency
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Quality
How do Quality Measures impact
care coordination?
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Adherence and Persistency – A Component of
Transitional Care
"Keep watch also on the faults of the patients
which often make them lie about the taking of
things prescribed.”
 “Life is short, and Art long; the crisis fleeting; experience perilous, and
decision difficult. The physician must not only be prepared to do what is
right himself, but also to make the patient, the attendants, and externals
cooperate.”
"Drugs don't work in patients who don't take
them."
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Source: National Transitions of Care Coalition. http://www.ntocc.org
Adherence and Persistency – A Component of
Transitional Care
 One in three patients fail to fill their prescriptions.
 Approximately three of four Americans report they do not consistently
take their medications as directed.
 Sixty percent of patients cannot correctly name their medications and up
to 20% of patients take other people’s medications.
 Between 33 and 69 percent of medication-related hospital admissions in
the U.S. are due to poor adherence.
 Approximately one fourth of all nursing home admissions are related to
improper self-administration of medications.
 In common chronic conditions such as diabetes and hypertension,
adherence rates average between 50-65 percent.
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Source: National Transitions of Care Coalition. http://www.ntocc.org
Adherence and Persistency – A Component of
Transitional Care
 The overall impact of non-adherence to prescribed treatment
plans is staggering with a resultant mortality rate of over
125,000 deaths per year in the United States alone.
 “Poor adherence to treatment regimens is exacting a heavy
toll on the American health care system in the form of
unnecessary illness, disability and premature mortality,
particularly among the burgeoning number of chronically ill
patients. Nonadherence in all its manifestations costs $290
billion per year in unnecessary health care spending.”
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Source: National Transitions of Care Coalition. http://www.ntocc.org
Our healthcare system operates in
“silos” and information queues
– incapable of reciprocal operation with other related
management systems & different departments of organizations
© Eric A. Coleman, MD, MPH
WORKING TO
ADDRESS THE ISSUES
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Diverse Organizations and Professionals
Advise and Support NTOCC
These groups represent over 200,000 health care professionals, 11,000 employers
and 30,000,000 consumers throughout the United States.
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Patient and Family Caregiver Tool Development
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NTOCC Provides Tools & Resource Development
for Patient and Family Caregivers
Tool Highlights
 Guidelines for a
Hospital Stay with
Helpful Definitions
For Patient, Family, &
Caregiver
 Taking Care of MY
Health Care
Français & Español
 My Medicine List
Français & Español
Additional NTOCC Tools & Resources
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Additional NTOCC Resources
 Health Information Technology Position Paper
 Updated Public Policy Concept Paper
 Electronic Compendium – Collection of Transitions of Care Models
 Elements of Excellence for Safe Transitions of Care – Cross Walk of
Common Interventions
 Patient and Family Caregivers Bill of Rights
 Transition of Care Web-Based Evaluation Tool
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NTOCC Considerations
 Improve communication during transitions with providers, patients, and
caregivers
 Support the implementation of electronic medical records that include
standardized data elements
 Increase the use of case management and professional care coordination
 Expand the role of the pharmacist in transitions of care
 Establish points of accountability for sending & receiving
 Implement a payment system that aligns incentives
 Develop performance measures to encourage better transitions of care
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NTOCC. Improving Transitions of Care.
The Vision of the National Transitions of Care Coalition. May 2008.
TOC Compendium
The TOC Compendium is a
collection of resources such
as white papers, journal
articles, and websites that a
"Transitions of Care"
professional or interested
consumer might find useful
in their practice or medical
situation.
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Explore the
TOC Compendium at:
www.NTOCC.org/Compendium
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TOC Compendium: Browsing
 Allows a search based on a predetermined
Care Strategy or Setting
 Based on the category selected, the resulting list will
display to the right and the category on the left under
the "Narrow your results" section. Additional categories
will also appear in this section, as selected.
 The resulting search list will be an aggregate of all the resources that fall
into one or more of the selected categories.
 To remove a category from the search, click "Remove" located next the
category name and the results page will update accordingly. To quickly
reset your search, click "Clear All".
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TOC Compendium: Searching
 Keyword Search allows you to enter your
own specific words such as "Aging" or
"Nursing Home"
 Searches across the full title, description, and
list of predetermined key words for each resource.
 If the word is referenced, the resource will be displayed.
 Allows for author searching
 Type the last name of the author to view a list of resources where that specific
last name is referenced
 Please remember that this key word search feature is based upon a
simple search algorithm with an "OR" search only.
 For example, using the keywords "Elder" and "Cancer" will pull any resource
containing one or both of the specified words.
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Compendium: Suggest a Resource and
Provide Feedback
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Compendium: Feedback
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Seven Essential Intervention Categories
1
Medications Management
2
Transition Planning
3
Patient and Family Engagement / Education
4
Information Transfer
5
Follow-Up Care
6
Healthcare Providers Engagement
7
Shared Accountability across Providers and Organizations
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Source: http://www.NTOCC.org/compendium (2011)
Improving Communication
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Source: National Transitions of Care Coalition (NTOCC) Measures Workgroup.
Transitions of care measures. 2008.
The Integrated Team
 Physicians
 Pharmacists
 Wellness or Health Coaches
 Specialists
 Lab and Radiology Professionals
 Hospitalists
 Rehab personnel
 Nurses
 Skilled Case Managers
 Therapists
 Patient
 Behavioral Health
 Family Caregivers
 Social Workers
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Transition Connector
 Collaborative Team
 Community Team
 PCP
 Patient
 Specialist
 Physician
 Pharmacist
 Nurse
 Social Worker
 Case Manager
 Skilled Nursing Facility
WHO
IS
THE
CONNECTOR?
 Allied Health
– Respiratory Therapist
 LTC Services
 Pharmacy
 Community Clinic
 Home Care
 GCM/CM
 Rehabilitation
 Hospice
– Dietitian
 Community Resources
– Physical Therapist
 Health Plan
– Educator
 Medical Home
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Improving Communication
Will Improve Transition Issues
Medication
Reconciliation
Data Elements
+
Care / Case
Transition Process
My
Med List
ER
ICU
In-Patient
OUTPATIENT:
• Home
• Home Care
• PCP
• Specialty
• Pharmacy
• Case Mgr.
• Care Giver
• Hospice
Patient
SNF
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ALF
Care Models, Policy, Advocacy, & Performance
Measures
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Transition of Care Models
 Care Transitions Intervention: Dr. Eric Coleman - Transition Coaching
http://www.caretransitions.org
 Transitional Care Model: Dr. Mary Naylor – Advanced Nurse Practitioners
http://www.nursing.upenn.edu/media/transitionalcare/Pages/default.aspx
 Guided Care: Dr. Chad Boult - Guided Care Nurse
http://www.guidedcare.org
 Project RED: Dr. Brian Jack, Boston University Medical Center,
Re-engineering Discharges
http://www.bu.edu/fammed/projectred/
 Project BOOST: Society of Hospital Medicine
http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/
CT_Home.cfm
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Transition of Care Models
Care
Transitions
Intervention
: Eric
Dr.Transitional
Eric
Coleman
- Transition
Coaching
 Care
Transitions
Intervention:
Dr.one
Coleman
- Transition
Coaching
The
anticipated
cost
savings of
Coach
(responsible
for
http://www.caretransitions.org
http://www.caretransitions.org
350
chronicallyill adults) after an initial hospitalization, over a period of
twelve months, is $330,00
Transitional
Care
Model:
Mary
Naylor
- control
Advanced
Nurse
 Transitional
Care
Model:
Dr.Dr.
Mary
Naylor
-vs.
Advanced
Nurse
Practitioners
Total
health care
savings
for
intervention
patients
at 24 weeks
Practitioners
http://www.nursing.upenn.edu/media/transitionalcare/Pages/default.asp
were$300/patient. In patients with heart failure, the mean savings at 52
xhttp://www.nursing.upenn.edu/media/transitionalcare/Pages/default.as
weeks
was $5000 per patient
px
 Guided Care: Dr. Chad Boult - Guided Care Nurse
 http://www.guidedcare.org
Guided
Dr. Chad
Boult - per
Guided
Care
Nurse
An
annual Care:
net savings
of $75,000
nurse
or $1364/patient
http://www.guidedcare.org
 Project RED: Dr. Brian Jack - Boston University Medical Center, Re engineering
Project
RED
: Dr. Brian
Jack - Boston
Medical
Center
- ReDischarges
http://www.bu.edu/fammed/projectred/
Patients
who
received
intervention
had a University
33.9% lower
cost than
those
engineering
Discharges
http://www.bu.edu/fammed/projectred/
who
did not receive
intervention,
translating into a savings of $412 per
patient
 Project BOOST: Society of Hospital Medicine
 http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTra
Project BOOST:
Society
of Hospital
Medicinehospital lead to a reduction
Implementation
of the
program
at one Georgia
http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTra
in nsitions/CT_Home.cfm
30
day readmission rates in those under age 75 from 25.5% to 8.5%
nsitions/CT_Home.cfm
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Emerging Care Models
 Transition of Care Clinic - Tallahassee Memorial Hospital
Dr. Dean Watson
Chief Medical Officer
 Rush Enhanced Discharge Planning Program,
University Medical Center
Robyn Golden, MA
Director of Older Adult Programs
Email: [email protected]
Cost analysis within Rush’s fee-for-service environment
 Showed a $1,293 savings per patient
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Additional Resources
 NFCA - National Family Caregiver Association – Family Caregiving Resources
www.thefamilycaregiver.org
 CAPS - Consumers Advancing Patient Safety – Toolkits
www.patientsafety.org
 NTOCC - National Transitions of Care Coalition – Provider & Consumer Tools
www.ntocc.org
 CMSA - Case Management Society of America – CM Medication Adherence
Guidelines & Disease Specific Adherence Guidelines
www.cmsa.org
 AMDA’s (Dedicated to Long Term Care Medicine™) Transitions of Care in the
Long Term Care Continuum practice guideline http://www.amda.com/tools/clinical/TOCCPG/index.html
 ACC and IHI – Hospital to Home – Reducing Readmissions, Improving Transitions
http://www.h2hquality.org/
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The Pharmacy Opportunity
 Leadership role in interdisciplinary efforts to
establish accurate and complete medication
lists
 Hospital admission and discharge
 Any change in level of care
 Encourage community-based providers and
health care systems to collaborate in
medication reconciliation efforts
 Educating patients and their caregivers on
their role in retaining a current list of
medications
 Assisting patients and caregivers through the
provision of a personal medication list
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ASHP. Medication Therapy and Patient Care: Organization and Delivery of Services–Positions. 2009.
AFFORDABLE CARE ACT
We Are Perched at the Beginning of the Middle!
Patient Protection and
Affordable Care Act
 Improving Quality & Efficiency of
Care
 Reduction of Hospital
Readmissions
 Provisions for Medical Home
 Provisions for Medication Therapy
Management
 Access to Care
 Provisions for Care Coordination
 Community-Based Care
Transition programs
 Chronic Care Disease
Management
 Transitional Care Provisions
 Wellness Programs
 Shared Decision Making
 Bundled Payments
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The Patient Protection and Affordable Care Act. 42 USC 18001 (2010).
Case Manager will be the "linchpin“
of Accountable Care Success
Many "naive policymakers, out-of-touch regulators, inflexible legal
experts and physician-leader apparatchiks" contend primary care
physicians can manage all the elements of an ACO. Jaan Sidorov, MD,
publisher of ACO Watch and The Disease Management Care Blog,
disagrees. "Docs don't mind being ultimately responsible, but they have
little interest in reviewing, recruiting or educating lists of patients. They
are happy to delegate such tasks to case managers.” In other words, the
case managers will be the linchpin to assuming ACO success. Where the
rubber hits the road. Where the light shines. Where the action is. Where
the return on investment will be achieved." (ACO Watch)
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http://acowatch.wordpress.com/2011/06/20/the-5-imperatives-of-accountable-care/
What Causes Hospital Readmissions?
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Determinants of Preventable Readmissions
 Patients with generally worse health and greater frailty are more
likely to be readmitted
 Identifying determinants does not provide a single intervention
or clear direction for how to reduce their occurrence
 There is a need to address the tremendous complexity of
variables contributing to preventable readmissions
 Importance of identifying modifiable risk factors (patient
characteristics and health care system opportunities)
 Preventable hospital readmissions possess the hallmark
characteristics of healthcare events prime for intervention and
reform > leading topic in healthcare policy reform
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Case Study
Mrs. Johnston is an 87 year old woman in good
health. She has GERD, minor urinary incontinence,
and severe arthritis in her right knee. She has
prescription medication to treat these ailments. She is
relying more on pain medications for her knee. Her
leg is beginning to turn outwards and has given way
on several occasions. She is a widow and lives by
herself in her own home in a Midwest suburb. She
swims five days a week, eats healthy balanced meals,
volunteers at her church, plays bridge, quilts, and
keeps up with current events and politics. She has
four adult children, three who live in the city and one
in a neighboring state. Mrs. Johnston is scheduled for
a right knee replacement.
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Case Study 1 – Making A Difference?
 PCP sent medical information to the Surgeon for 1st visit
 Patient had a Medicine List and FAQ for 1st visit
 Surgeon provided written instructions or office health coaching
 Admission medication reconciliation & transition medication reconciliation
were completed with patient and family caregiver health coaching
 Health coaching about urinary incontinence issues and care plan options
 Timely transition summary, care plan, and transition medication
reconciliation were available to the PCP, home health agency and
Physical therapist on transition from hospital
 Follow transition call with patient & family scheduled 24-48 hours after
transition with possible home visit at day 4 or 5
 Scheduled follow up transition set prior to transition home
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Case Study: Hospital to LTC
“Elise”
 82-yer-old woman with T2DM admitted from LTC to the hospital for a
stroke and complicated UTI
 T2DM for 15 years, body mass index 31. History of CVD, lower extremity
edema, limited ability to perform ADL
 Elise was taking metformin for her diabetes
 A1C at admission of 8.6%. Metformin discontinued and basal/bolus
insulin regimen was initiated to manage hyperglycemia during hospital
stay
 Elise will be discharged to LTC facility on basal insulin
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Case Study: Hospital to LTC
“Elise”
What is the role of the
case manager in the transition of care
relating to Elise’s diabetes
treatment and monitoring in LTC?
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Case Study: Hospital to LTC
“Elise”
 Standardized “TOC” discharge order set is completed and a
comprehensive medication reconciliation is performed
 T2DM medications
 Metformin (per outpatient dose)
 Basal insulin 16 units SQ once daily at bedtime
 Medium dose correctional insulin
 Monitoring of BG at meals and bedtime (4 × per day)
 Follow up consult scheduled with endocrinologist within 1 week of
patient’s return to LTC
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Case Study: Hospital to LTC
“Elise”
Back at the LTC facility, Elise’s care is being
discussed and optimized based on the TOC discharge
recommendation and the subsequent endocrinology
consultation…
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Communication
“Doctors and patients alike say that when they
communicate well, healing goes better, and it can even
make the difference between life and death.” But a
national survey of doctors and hospitalized patients
found that, in reality, effective communication often is
sorely lacking.
Only 48% of patients said they were always involved in
decisions about their treatment, and 29% of patients
didn't know who was in charge of their case while they
were in the hospital.
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http://www.usatoday.com/yourlife/health/healthcare/studies/2010-12-06-1Adoctalks06_ST_N.htm
Communication
When physicians have more personalized
discussions with their patients and encourage
them to take a more active role in their health,
both doctor and patient have more confidence
that they reached a correct diagnosis and a
good strategy to improve the patient's health.
That approach can help eliminate or reduce
unnecessary and costly testing and referrals to
specialists.
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Source: Bertakis KD et al. J Amer Board Fam Med 2011;24:229 –39.
Facilitating A Safe Transition
Medication reconciliation at discharge
Transitional
planning
Comprehensive discharge
planning
Post-discharge support (e.g. Pharmacist call,
home care.) in specific conditions is essential!
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Transitioning The Continuum of Care
with Bi-Directional Communication
PCP/Medical
Home
Home Care
LTC
Advocate
Motivational
Interventions
Community Health
Center
Hospital
Patient
TOC Manager
Health
Promotion
Health Plan
Increase
Productivity
Pharmacy
Hospice
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Employer
Specialist
Providers & Patients with Tools Working Together &
Improved Communication…Means Better Transitions of Care
Questions?
Contact Information:
Cheri A. Lattimer, RN, BSN
[email protected]
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References
 O’Reilly, K. Health Reform Law Will Boost Care Quality. Amednews.com.
 DHHS. Partnership for patients to improve care and lower costs for Americans .
http://www.hhs.gov/news/press/2011pres/04/20110412a.html April 2011.
 DHHS. National Strategy for Quality Improvement in Health care.
http://www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdf
March 2011.
 Coleman E. http://www.caretransitions.org/definitions.asp
 Jencks SF, Williams MV, Coleman EA. Rehospitalization among patients in the
Medicare fee-for-service program. N Engl J Med 2009;360:1418-28.
 MedPAC Report to Congress, Promoting Greater Effeciency in Medicare. June
2007.
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