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Care Transitions: A Demonstration Project Tim Young, LCSW Piedmont Hospital Sixty Plus Older Adult Services The Journey 2006 - Eric Coleman article Summer 2007 – Geriatric Work Session Fall 2007 - Awarded an 18 Month CMS/HHS demonstration grant (July ’08 through December ’09) January 2008 - Hosted Transitions training with Eric Coleman July 2008 - Transitions Demonstration Project launched Fall 2008 – Project BOOST Pilot Project Launched Strategic Work Team Areas of Opportunity Identified Discharge Planning End of Life Issues Focus on Geriatric Care in ED Medication Reconciliation Communication Flow Eric Coleman’s Model 4 Pillars Personal Health Record Medication Reconciliation Red Flags Medical Follow up Desire to Expand Transitions Concept Challenge Selling community partners on concept Barriers Overworked staff Resistance to taking on more work Transitions Work Team Hospitalists Services Sixty Plus Older Adult Services Patient Care Coordination Nursing Services Emergency Department Pharmacy NICHE (Nurses Improving Care for Hospitalized Elderly) Palliative Care Cardiovascular Services Visiting Nurse Health Systems (VNHS) Piedmont’s Transitions Model The Must Haves Sustainability Communication and Collaboration are key Multidisciplinary teams who are accountable, will take risks and will not accept status quo Strong executive staff and physician advocates Ability to initially adapt project to support the existing culture, processes and work flow of your organization Lessons Learned Realistic timelines Expectations Data and outcomes Process improvement and/or research Utilize “teachback” technique with patients to gauge their understanding of discharge plan Teach Back Using simple language Ask patient/family to repeat her understanding of concept Identify and correct misunderstandings Ask patient/family to demonstrate understanding again Repeat above until convinced of comprehension or inability to do so Phase I – Exploring the Process Hospital-based transitions coach Provide Personal Health Record Begin educational process Community-based transitions coach Review medications Continue educational process Phase I - Success Discovered barriers Home Health Companies Difficult to train multiple “teams” Patients often not receiving skilled nursing Medication Reconciliation Belief was that medications were “100% reconciled” Reviewed internal and external Partnership with VNHS Why hospital and home health agency partnership? We are truly in this together! No duplication of effort/contact – a natural fit On-going contact with patient/family/physician Processes in place to “catch” bouncebacks and clinically determine reason for readmission – swat team approach Improve processes when problem identified Phase II – Implementation Hospital Discharge Planners Limited to 4 units to reduce staff (2 BOOST) Limited to Medicare primary patients 3 Counties most served by hospital Appropriate for home health services Home Health Provider - VNHS Committed 2 SW’ers as coaches Phase II - Barriers Under utilization of home health Medication reconciliation Discrepancies noted by pharmacy Phase II - Success Increased education about home health “homebound status” Order for “RN to eval and treat” Identified more psychosocial issues affecting ability to manage post discharge Higher visibility of SW’ers for home health has led to increase in referrals Criteria Medicare as primary coverage Age 70 or over Inpatient stay on 6 Center, 6 North, 6 South or 5 Center Patient is identified for project by IMS Team, Patient Care Coordinator – physician orders home health Meets criteria for home health Lives within designated geographic area (3 counties) Patient or POA choose to participate and signs consent Project Goals Reduce 30 day readmission rate Reduce ED visits Increase patient/family satisfaction Develop/implement a sustainable model Address process improvement opportunities Build broad base of community partners Align with the Piedmont’s leadership’s strategic plan (cost reduction, quality, etc.) For BOOST patients, IMS indicates CT appropriate. PCTC reviews patient list for nonBOOST CT appropriate (70 +, on designated units, Medicare primary, lives at home) PCC checks Quest for CT orders PCTC consents patient to CT program with VNHS as HH provider; PCTC gives patient CT portfolio PCC Logistics receives HH referral from physician and writes orders; VCTL meets with CT patient to answer questions, explain HH program, verify payment source CT Patient HH Non-admit; VNHS to notify PCTC via email of non-admit; SOC clinician to notify PCP of non-admit Legend CT Patient under Piedmont Care CT Patient under VNHS Care CT Patient refuses Coach Visit; Coach notifies VTM; VTM to notify PCTC of coach refuse by email CT Patient HH Non-Admit CT Patient BB High Risk BOOST - Piedmont's better outcomes for older adults through safe transitions program BB - Bounceback CNS - Clinical Nurse Specialist If patient did not CT - Care Transitions attend MD CTBS - Care transitions bounceback survey appointment, notify CVS - Coach visit survey HHTM ED - Emergency Department GCM - Geriatric Case Manager HH - Home Health IMS - Internal Medicine Service IP - In-Patient OBV - Observation PCC - Patient Care Coordinator PCP - Primary Care Physician PCTC - Piedmont CT Coordinator PDFC - Post-discharge follow-up call CT HH Discharge; VNHS notify POC - Plan of care PCTC of any unmet patient needs SOC - Start of care VCTL - VNHS CT Liaison VTM - VNHS Team Manager BB clinical review by CNS. Huddle meeting BB case review; identify as avoidable or unavoidable. If avoidable, interventions identified with plan. CT Patient Discharged VNHS Intake Coordinator sends email to VNHS CT team; HH SOC visit scheduled within 24 hours PCTC identifies BB based on daily report and notifies BB team via email. VNHS RN/PT completes SOC visit within 48 hours Piedmont BB (ED/OBV or IP) within 30 days/90 days Coach Visit within 48 hours of SOC visit.: 4 pillars; completes CVS; faxes CVS to PCTC; refers to Sixty Plus GCM for complex cases PDFC within 48 hours. For BOOST CT patients, IMS nurse calls. For non-BOOST CT patients, PCTC calls. CT HH Resumption of Care CT BB VNHS PDFC Completes CTBS VNHS follow-up call to confirm patient attended MD appointment at 14 days postdischarge Continue POC HH Clinical Visits 60 day services CT HH 60-day recert For BOOST patients, IMS indicates CT appropriate. PCTC reviews patient list for non-BOOST CT appropriate (70 +, on designated units, Medicare primary, lives at home) PCC checks Quest for CT orders PCTC consents patient to CT program with VNHS as HH provider; PCTC gives patient CT portfolio PCC Logistics receives HH referral from physician and writes orders; VCTL meets with CT patient to answer questions, explain HH program, verify payment source CT Patient Discharged Care Transitions in Hospital Identify as appropriate Screen for cognition and depression Educate on intervention and obtain signed consent Home health liaison provides additional education Follow up appointments scheduled prior to discharge CT Patient Discharged VNHS Intake Coordinator sends email to VNHS CT team; HH SOC visit scheduled within 24 hours CT Patient HH Non-admit; VNHS to notify PCTC via email of non-admit; SOC clinician to notify PCP of non-admit CT Patient refuses Coach Visit; Coach notifies VTM; VTM to notify PCTC of coach refuse by email VNHS RN/PT completes SOC visit within 48 hours Coach Visit within 48 hours of SOC visit.: 4 pillars; completes CVS; faxes CVS to PCTC; refers to Sixty Plus GCM for complex cases PDFC within 48 hours. For BOOST CT patients, IMS nurse calls. For non-BOOST CT patients, PCTC calls. If patient did not attend MD appointment, notify HHTM VNHS follow-up call to confirm patient attended MD appointment at 14 days post-discharge Continue POC HH Clinical Visits 60 day services CT HH Discharge; VNHS notify PCTC of any unmet patient needs CT HH 60-day recert Care Transitions in Home Health Start of care (SOC) within 48 hours Hospital notified of non-admissions Coach visit made by social worker within 48 hours of SOC For on-going psychosocial issues, referral may be made for GCM Confirm that patient kept the follow up appointment with MD BB clinical review by CNS. Huddle meeting BB case review; identify as avoidable or unavoidable. If avoidable, interventions identified with plan. PCTC identifies BB based on daily report and notifies BB team via email. Piedmont BB (ED/OBV or IP) within 30 days/90 days CT HH Resumption of Care CT BB VNHS PDFC Completes CTBS Bounceback Protocol Receive notice of bounceback within 60 days Alert team members of reencounter Notify discharge planner of need for resumption of home health orders Meet weekly to discuss these cases Implement strategies to address avoidable reencounters Case Study - Mrs. H 88-year-old female Admitted with pancreatitis, s/p cholecystectomy, and a pseudocyst History of HTN, DM, afib, upper GI bleed, pulmonary HTN, CHF, breast cancer, and UTI Widowed, lives with daughter Ambulatory with cane/walker Dependent in ADL’s (bathing, meals, transportation, meds) Hospitalizations 12/22 through 12/24 4th IP stay in 2 months Seen in ED Started on TPN at discharge with home health 2/7 through 2/18 Bounceback discussion Discharged on home hospice Care Transitions Group Differences Research Design Patient Universe – 70 +, Medicare primary insurance, in-patient or observation, any presenting diagnosis, possible discharge to home (HH orders), SNF or assisted living Patient Sample – 70 +, Medicare primary insurance, in-patient or observation, discharged to home Treatment Group 1 Demographics – 70 + and Medicare primary insurance Non-BOOST in-patient or OBV Discharged to home Receives HH via VNHS (coaching visit, clinical, possible telemonitoring); PCTC follow-up call Treatment Group 2 Demographics – 70 + and Medicare primary insurance BOOST in-patient or OBV Discharged to home Receives HH via VNHS (coaching visit, clinical, possible telemonitoring); BOOST follow-up phone call Control Group 3 Demographics – 70 + and Medicare primary insurance Either BOOST or non-BOOST inpatient or OBV Discharged to home May/may not receive HH; may /may not receive BOOST follow-up phone call Non-CT patients Group Differences Measurable Outcomes 1. Group differences in 30-day In-Patient Readmit Rates 2. Group differences in 30-day ED/obv Rates 3. Group Differences in Avoidable 30-day Piedmont Reencounter (ED, OBV, IP) Rates 4. Group differences in Average Length of Stay during readmit 5. Group differences in Average Number of Days from Discharge to Readmit 6. Group differences in Average Number of Days from Discharge to Next ED Visit 7. Group differences in HH admit/HH non-admit patients 30-day Piedmont Re-encounter Rates (ED, OBV, IP) Age Ranges of Patients in CT Program 120% 100% 90 + 80% 80 - 89 60% 90 + 80 - 89 70 - 79 40% 20% 0% 70 - 79 CT Average Age = 80 Years Gender of Patients in CT Program 43% Male Female 57% Total CT Consented Patients by BOOST Status 39% Non-BOOST BOOST 61% CT Diagnosis Categories Evaluated Cardiac and CHF Syncope COPD Clotting (DVT,PE) Pneumonia Cellulitis Renal Failure Altered Mental State Procedure Infection Stroke (CVA) GI Issues Urinary Track Infection Other CT Patients Chief Complaints Upon Admission Cardiac/CHF Other Pneumonia COPD Infection 0 5 10 15 20 Medicare 30-Day Readmit Rates 25% 20% 15% 10% 18% 17% 13% 5% 0% National (65+) Piedmont (65+) CT Consented (70+ & Homebound Care Transition Patients with Home Health Care 100% 100% 72% 70% PT with HH PT without HH Total 28% 30% Total Care Transitions PTs Bounceback PTs Patient Reasons for Bouncebacks Self-management Issues 60% 54% 50% Inadequate Support System 39% 40% Medication Issues 31% 30% 20% 25% Unaddressed Co-morbid Conditions 18% 11% 10% 7% 8% Procedure 8% 0% 0% Unavoidable Avoidable Transitions in the ED Transitions Care Coordinator in ED Priority Patients: Those already enrolled in Transitions Frequent flyers Previously seen by Sixty Plus Identified high risk Dementia Limited social support Transitions in the ED - Process Receive notification of repeat encounter Screen for cognition and depression Ask if patient talked with health care provider before coming to the ED Begin education on Care Transitions pillars from the ED Follow up post discharge Transitions in the ED - Success Developed electronic tool to highlight repeat encounters Increased screening for cognitive issues and/or depression Started education about discharge planning while in the ED Increased referrals to home health services from the ED