Download TouchPointCare - Care Transitions

TouchPointCare
Managing Care Transitions to
Reduce Unplanned
Readmissions for patients with
Heart Failure, MI &
Pneumonia
Typical Recipients for Discharge
1. Home – patients benefit from calls, texts, emails or other
“touches” to monitor their condition and provide education.
2. Other providers:
A. Home with Home Health – if agencies wish to
remain recipients of ongoing referrals, they must
regularly share timely patient information back to the
hospital
B. SNF – if facilities wish to remain recipients of
ongoing referrals, they must regularly share timely
patient information back to the hospital
1. Home-based Care Transition
Program (non Home health)…
…combines telephone contacts with automated interactions,
(IVR, texts, emails, video, etc.). Ongoing and more frequent
contact and patient education reinforce behavior associated
with a healthy future.
Home-based Health Coaching Call
Within 24-48 hours of discharge, all patients are called for an initial
coaching call. This call can be performed by the hospital staff or
outsourced and coordinated by TouchPointCare. During this call, the
clinician will review patient care and cover the following key issues:
Medication Reconciliation (review and reconcile medications, answer medication
questions)
Dynamic Patient –Centered Health Record (review discharge summary,
understand plan of care)
Physician Appointments (follow up visits)
“Red Flags” (signs and symptoms patients need to be aware of for improved self
care/self management)
Home-based Patient Monitoring
Based on the initial coaching call, patients are divided into two groups, “Tech-Abled”
and “Tech-Un-Abled”
“Tech-Abled” Patients are asked to call into an automated (IVR) system on a daily or
regular basis. They can also choose to respond to monitoring questions directly via the
internet, (PC, Mac, smartphone, etc). In addition, these patients receive a series of
educational texts as well as educational emails which have embedded educational
videos personalized for their use. The combination of IVR calls, texts, emails and videos
help the patient improve their self-care/self-management abilities and help them
manage their chronic care condition.
“Tech-Un-Abled” Patients receive calls from staff members or other call agents who are
able to walk through approved “scripts” and allow the patient to share concerns, ask
questions and relay important signs and symptoms.
With both groups of patients, if any patient response “triggers” an alert, an clinical staff
are automatically notified. In addition, all reports allow clinicians to “manage by
exception” and view only triggered alerts for the patient population being monitored.
Alerts
•
The TouchPointCare system allows “thresholds” to be established for all types of
questions, (such as the examples above). When a response is outside the
prescribed thresholds, an alert is “triggered” and the question and given response will
appear in all reports in red. In addition, if desired, the system can out an email to
caregivers or others notifying them of the patient’s responses.
•
In addition to this traditional type of alert process, TouchPointCare also offers an
additional alert feature allowing question responses to initiate another “touchpoint”.or
action. As an example, if a patient is responding to a question, the response to this
question can initiate another action or event, such as:
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–
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If on a routine IVR monitoring call, a patient responds that they haven’t taken their medications, they might
be prompted, via a text or an outbound IVR call, to remind them to take their medications 15 or 30 minutes
later.
A patient is asked if they would like to speak to a nurse, a “yes” response automatically schedules this call
A patient’s response indicates they need more frequent contact, and thus are automatically scheduled for
additional calls
Sample Scripts
Compared to how you felt when you left the hospital, do you feel just as good or better today?
Are you taking your medications as prescribed at discharge?
If no, Why not?
Have you had any elevation of temperature above 99 degrees or felt like you might have temperature
elevation?
Has your breathing been more difficult today than over the past day or two?
Have you had any new symptoms in the last day or two, such as,
Chest tightness, or
Unclear thinking, or
Severe fatigue, or
Swelling and/or pain in your calf, or
Pain on urination .
If yes to any of these, answer YES, and someone will contact you.
If no go to next series…
2. Home Health & SNF
While many patients are discharged directly to home, the hospital is still “at risk” for
patients discharged to either a SNF or home health agency. Hospitals need to be assured
by SNF or HH staff that patients under their care are receiving the proper care.
Since research strongly advocates for follow up using “the 4 Pillars” of care transitions,
hospitals need to be assured that these issues have been addressed with each patient
admitted to their care:
Medication Reconciliation
Physician Follow up
Red Flags or signs/symptoms to watch
Patient centered documentation/record
Hospitals can mandate HH & SNF staff comply and respond to a series of questions
regarding discharged patients, (if they want to keep receiving referrals that is). They
can do so via IVR, or they can do so via the computer/browser.
In addition, hospitals can provide targeted and ongoing online staff education to SNF &
HH staff to better prepare staff for dealing with re-hospitalization issues.