Download P.A.V.E. Project Status Report

PAVE Project
Status Report
November 16, 2011
Care
Transitions
Workgroup
Medication
Management
Workgroup
Personal
Health
Record
Workgroup
Innovative Regional Solutions
PAVE Project Participants

Forty-six (46) participating organizations







Hospital/Healthcare Systems
Specialty Hospitals
Home Care
Payers
Primary Care Practices
Others
Over 140 individual participants on the Project’s Workgroups
Representing Nursing, Physicians, Pharmacists, Administrators, and
Executives
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Medication Management Workgroup
Key Deliverable:


Medication Passport, a set of
standards for all medication
reconciliation/ transfer forms
 Endorsed
by workgroup
participants
 Shared with all PAVE Project
participants
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PATIENT ID LABEL
FACILITY NAME
MEDICATION PASSPORT
Main Reason for Admission:
Allergies:
Patient reports no known medication allergies
No documented medication allergies
Medication to Avoid
Reaction if taken
Active Medications For
After Hospital Discharge
New
Today’s Date:
Dose change
MEDICATION
BRAND NAME
Medication to Avoid
No
abbreviations
MEDICATION
GENERIC NAME
DOSE
Continuation
Continuation
Indicate
changes
New
Dose change
New
Dose change
Continuation
New
Dose change
Continuation
New
Dose change
Continuation
Use both
generic and
brand names
HOW TO
TAKE
Reaction if taken
TAKE NEXT
DOSE AT
COMMENTS/
SPECIAL
INSTRUCTIONS
Indicate when
next dose is due
REASON
FOR USE
Use plain
language
(Add more lines as needed)
Medications that should no longer be taken:
MEDICATION
COMMENTS
Discontinued
medications
Discharging Physician’s Name (please print):
Provider’s
information
Phone #: ___________________
Primary Care Provider’s Name (please print):
Phone #: ___________________
Pharmacy: _ ___________________________________________
Phone #:
Page
of
Care Transitions Workgroup
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
Five sub-groups created
based on identified gaps





Risk Assessment
Communication &
Coordination with the
Primary Care Providers
Coordination with Insurers
Issues Related to the
Discharge Process
Patient Education/Health
Literacy
Care Transitions Workgroup

Key Deliverables:




Teach Back Session (Jan 2011)
Payor Passport
Patient Activation MeasureTM (PAMTM) Pilot Project
Evaluation (to be completed December 2011)
Care Transitions Passport



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In development
To include contact information of key care transitions
departments and description of the care transitions process at
each hospital
Set of standards identifying the critical components of an
effective care transition at hospital discharge
PAVE Payor Passport
Prior Authorization
After Hours & Weekend
Contacts for hospital admissions
and UM staff
Case Management Services
Disease Management
Programs
Home Care Department
Nurse Advice
Line/Call Line
Payor
888-xxx-xxxx and follow 888-xxx-xxxx and follow prompts 888-xxx-xxxx and follow
prompts for the services for the services you are looking prompts for the services
you are looking for
for
you are looking for
888-xxx-xxxx and follow 888-xxx-xxxx and follow
prompts for the services prompts for the services
you are looking for
you are looking for
888-xxx-xxxx and
follow prompts for
the services you are
looking for
Payor
1-800-xxx-xxxx
1-800-xxx-xxxx
1-800-xxx-xxxx
Payor
888-xxx-xxxx and follow 888-xxx-xxxx and follow prompts 888-xxx-xxxx and follow
prompts for the services for the services you are looking prompts for the services
you are looking for
for
you are looking for
888-xxx-xxxx and follow 888-xxx-xxxx and follow
prompts for the services prompts for the services
you are looking for
you are looking for
888-xxx-xxxx and
follow prompts for
the services you are
looking for
Payor
1-800-xxx-xxxx
1-800-xxx-xxxx
1-800-xxx-xxxx
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1-800-xxx-xxxx
1-800-xxx-xxxx
1-800-xxx-xxxx
1-800-xxx-xxxx
1-800-xxx-xxxx
1-800-xxx-xxxx
Personal Health Record Workgroup

Key Deliverable:
Personal Health Tracking Form
One sign or symptom (e.g., daily
weight, blood sugars, etc.)
One behavior (e.g., walk a
specific number of steps per day,
eat more fish/less meat, etc.)
 Being finalized for dissemination

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Project Measurement


Baseline measurement conducted in August and
September 2010
 Transitions of Care Survey
 Retrospective chart reviews of readmitted
patients
 CTM-3 Survey of readmitted patients
 Tracking of readmission rates
Transitions of Care Survey repeated recently
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Transitions of Care Survey



Inventory of strategies/
interventions
32 questions in total
Four sections

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

During hospitalization
At discharge
Post-discharge
Measurement
Pre- and post-project
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Sample Questions
Transitions of Care Survey Results




Improved coordination of care among care providers and
across settings
More formalized approaches around care transitions
within hospitals – care teams, transitions coaches
More coordination with patients and their families –
follow-up appointments, testing, etc.
More focus on appropriate patient education at discharge
– Teach Back, discharge checklists, red flags
Re-survey conducted in October 2011
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Readmission Rates for PAVE Hospitals
PAVE Readmission Rate
Baseline (12.2%)
Goal 10% decrease (11.0%)
Readmission Rate
13.0
12.5
12.0
11.5
11.0
10.5
Source: Delaware Valley Healthcare Council
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Mar-11
Feb-11
Jan-11
Dec-10
Nov-10
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
May-10
Apr-10
Mar-10
Feb-10
Jan-10
10.0
What Worked?







Learning from other hospitals/organizations
Discussion of best practice
Networking, brainstorming and sharing of ideas
Ability to collaborative across institutions and settings
Gained a broader perspective of the care transitions
issues
Teach Back session
PAM Pilot
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Lessons Learned


Willingness to share among participants was key to
success of the project.
Scope needs to be clearly defined and reasonable.



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Not a lot of literature identifying best practice at project start
Workgroups and sub-groups need to be manageable in
size and with reasonable expectations.
Sharing of progress among the workgroups was a
challenge.
The momentum and desire to collaborate will extend
beyond the “formal” end of the project.
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High-Level Project Timeline
Activity
1Q10
2Q10
Kick-Off: Regional Symposium
May
Expert Panel Convened
May
Participant Recruitment
June
Baseline Data Collection
Kick-Off Meetings for Workgroups
Strategy Development Period
Re-Measure and Share Successes
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3Q10
4Q10
1Q11
2Q11
3Q11
4Q11
July
Aug Sep
Oct
Sep
Oct
Oct
Sep
Oct-Dec
Contact:
Patricia Yurchick
Phone: 215-575-3742
Email: [email protected]
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