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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 3 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 4 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 6 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 7 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 8 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 9 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 10 Transitions of Care Survey Inventory of strategies/ interventions 32 questions in total Four sections During hospitalization At discharge Post-discharge Measurement Pre- and post-project 11 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 12 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 13 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 14 Lessons Learned Willingness to share among participants was key to success of the project. Scope needs to be clearly defined and reasonable. 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. 15 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 16 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] 17