Improving Transitions: A Community Approach Part II Cheri Lattimer Executive Director Case Management Society of America (CMSA) Executive Director National Transitions of Care Coalition (NTOCC) Tennessee Hospital Association

Waves of Change New models of health care delivery and reimbursement are quickly evolving Their success is contingent on effective care coordination This in turn requires interprofessional and transdisciplinary collaboration

Key Driver: The National Quality Agenda The National Quality Strategy is available at 1.Better Care 2.Healthy People 3.Affordable Care Making care safer Ensuring person- and family-centered care Promoting effective communication/coordination of care Promoting prevention/treatment of top mortality causes Working with communities to enable healthy living Making quality care more affordable 6 Priorities:3 Aims:

Goals Of These New Models Minimize fragmentation & improve transitions of careFocus on patient safety and quality of careImprove the patient’s experience with careExpand access to careReduce the cost of effective carePayment that recognizes value of patient-centered care

Processes to promote evidence-based medicine, patient engagement, and care coordination, including: Patient-centered philosophy and operations Coordinated and integrated care Use of evidence-informed medicine Use of health information technology for data sharing/reporting capabilities Continuous quality improvement processes What These New Models Require

Collaboration “HEN’s work is a collaborative process...” Hospital Engagement Networks Without collaboration, there is little hope for positive change or successful outcomes Lies At The Heart Of Successful Partnership of Patients “To work together with others to achieve a common goal”

Moving Towards A Collaborative Care Model Source: Robert Wood Johnson Foundation (November 2011). Implementing the IOM Future of Nursing Report—Part II: The Potential of Interprofessional Collaborative Care to Improve Safety and Quality. Accessed at

Core Competencies for Interprofessional Collaborative Practice Values/Ethics for Interprofessional Practice Work with individuals of other professions to create/maintain climate of mutual respect and shared values. Roles/Responsibilities for Collaborative Practice Use knowledge of one’s own role and those of other professions to appropriately assess/address care needs. Interprofessional Communication Communicate in a responsive and responsible manner that supports team approach to care. Interprofessional Teamwork and Team-Based Care Apply relationship-building values and principles of team dynamics to perform effectively in different team roles. Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.

Patient Physicians Wellness or Health Coaches Lab and Radiology Professionals Rehab Front Office Staff Case Managers Medical Assistant Pharmacist Specialists Hospitalist Nurses Therapists Social Workers The Integrated Team

Collaborative Team  Patient/Care Partner  Physician  Pharmacist  Nurse  Social Worker  Case Manager  Lab Technician  Allied Health  Respiratory Therapist  Dietitian  Physical Therapist  Educator Community Team  Patient/Care Partner  PCP  Specialist  Skilled Nursing Facility  LTC Services  Pharmacy  Community Clinic  Home Care  GCM/CM  Rehabilitation  Hospice  Community Resources  Health Plan  Medical Home  DME Who Is The Connector? Transition Connector

Characteristics of High-Performing Collaborative Teams Shared Goals Everybody is working toward the same goals. Promoting patient- and family-centered care is paramount. Clear Roles Team members are clear on how to work together and how to accomplish tasks. No individual members are more important than the team. Mutual Trust People have solid and deep trust in each other and in the team’s purpose. Each team member respects the team processes and other members. Effective Communicatio n Everyone understands goals and knows what is expected. Criticism is constructive and is oriented toward problem-solving and removing obstacles Measurable Processes/ Outcomes Documenting processes and outcomes as well as sharing successes; for example, improved clinical outcomes or patient satisfaction. Effective Communication Measurable Processes/Outcomes

Strategies To Create Patient-Centered, Collaborative Care Teams Sevin, C; Moore, G; Shepherd, J; Jacobs, T; & Hupke, C (2009). Transforming care teams to provide the best possible patient-centered, collaborative care. Journal of Ambulatory Care Management, 32(1), Promote team communication through conducting daily or twice daily care team huddles (5-20 min). Optimize each person’s role on the team based on the scope of practice, experience, skills, and abilities. Provide regular feedback on process and outcome measures to the care team. Invite patient and family representatives to participate in the care team to provide feedback/advice on care processes. Collaborate with community resources to improve the health of people in that community. Use the clinical information system (CIS) to query, manage, and plan for both individual patient and the population of patients

Promoting Collaboration—Key Points Collaboration results in high-functioning interprofessional care teams Requires a culture of trust, respect, and professional interdependence Promoting understanding of case manager’s role is key Requires putting standards of practice into everyday practice.

Primary Care is Key Component of Care Coordination Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family & community. Institute of Medicine, 1996

Knowledge and experience with care coordination Focus on patient-centered processes Assessment, planning, facilitation across care continuum Knowledge of population-based care management strategies Meaningful communication with patient, family, care team Case Manager Skills Are Required For Success in These New Models!

The Pharmacy Opportunity Leadership role in interdisciplinary efforts to establish accurate and complete medication lists – Hospital admission and at transition – 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 ASHP. Medication Therapy and Patient Care: Organization and Delivery of Services–Positions

Care Coordination Activities (AHRQ) Care coordination includes six specific activities: 1.Determine care coordination needs 2.Create/update a proactive plan of care 3.Communicate – Between health care professionals & patients/families – Within teams of health care professionals – Across health care teams or settings 4.Facilitate transitions 5.Connect with community resources 6.Align resources with population needs Meyers D, Peikes D, Genevro J, Peterson Greg, Taylor EF, Tim Lake T, Smith K,Grumbach K. The Roles of Patient-Centered Medical Homes and Accountable Care Organizations in Coordinating Patient Care. AHRQ Publication No. 11-M005-EF. Rockville, MD: Agency for Healthcare Research and Quality. December Accessed 08/23/2012 at

Reimbursement for Care Coordination Revised CPT book for 2013 includes new codes for care coordination Codes added for care coordination of patients with complicated, ongoing health issues within a PCMH, ACO, or other novel medical service delivery model Allows billing for time that is not necessarily face-to-face but spent connecting patients to community services, transitioning them from inpatient to other settings and preventing readmissions

AHRQ – Comparative Effectiveness Research for Care Coordination Care Coordination Measures for Primary Care Practice NQF – Performance Measures for Care Coordination CMS – 10th SOW for QIOs Supports Care Transitions TJC – Patient Safety Standard Medication Reconciliation URAC – Incorporated Transition of Care in Revised CM Standards NCQA – Complex Case Management Standards AMA – PCPI Transitions of Care Development of Care Coordination Measures

Care coordination “Care coordination is not a stand- alone service that ends at the practice’s property line. Rather, it is a bridge to connect services across the greater care community, cementing the medical home’s foundation as the central hub of patient care and accountability. Likewise, it includes not only the patient, but the patient’s family and community.” Katherine H. Capps President, Health2 Resources “Care coordination is not a stand- alone service that ends at the practice’s property line. Rather, it is a bridge to connect services across the greater care community, cementing the medical home’s foundation as the central hub of patient care and accountability. Likewise, it includes not only the patient, but the patient’s family and community.” Katherine H. Capps President, Health2 Resources Patient-Centered Primary Care Collaborative (2011) Core Value, Community Connections: Care Coordination In The Medical Home. Accessed 08/23/2012 at

Effective Care Transitions Are Key Providers need to be aware of successful strategies from evidence-based models of care transitions Implementing effective care coordination strategies will achieve the National Quality Strategy goals Focusing on effective care transitions will help new models of care delivery and reimbursement be successful Coordination is Key to Promoting Quality, Safety, and Effectiveness of Care

Working together “We’ve medicalized so many things, but transitions are not medical events. It’s about the team working together. It’s a person event.” Jennifer Fels, RN, MS, Director, Southwestern Vermont Medical Center

Improving Transitions of Care: Elements of Best Practice Defined Medication ManagementTransition Planning ToolsPatient and Family Engagement/EducationTools For Information TransferFollow-up Visit – PCP/SpecialistPost-Transition Call or VisitAccountability For Sending & Receiving Safe, effective, efficient transitions of care =

Put Best Practice Into Standard Practice! Common Themes Across Evidence-Based Care Transitions Models Include: Identification of a specific staff person to provide transitional care support Interdisciplinary communication/coordination Patient engagement/activation Enhanced post-discharge follow up

Primary care accountabilities include addressing health care needs, developing partnerships with patients, families, and the community. Effective care coordination is critical to achieve optimal outcomes in primary care settings. Be aware of measures used to evaluate outcomes and effectiveness of care coordination. Be accountable to the profession– put the Standards of Practice into everyday practice. Promoting Accountability—Key Points

Comprehensive Primary Care Functions 1.Risk-stratified care management 2.Access and continuity 3.Planned care for chronic conditions and preventive care 4.Patient and caregiver engagement 5.Coordination of care across the medical neighborhood Reference: CMS Center for Medicare and Medicaid Innovation Comprehensive Primary Care (CPC) Initiative

Current Focus in The New Health Care Landscape Better Health Value for Mone y Best Care

Better Health Value for Money Patie nt Best Care And What Will Get Us There! Better care triforce

How Is Patient-Centered Care Defined? Care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions. Institute of Medicine (IOM), Crossing the Quality Chasm: A New Health System for the 21st Century. Relationship-based primary care that meets the individual patient and family’s needs, preferences, and priorities. AHRQ PCMH Resource Center Accessed 08/23/

... Yet some still just don’t get it ! Some responses from a 2011 survey of PCMH practices: Patient-Centered Primary Care Collaborative (2011) Core Value, Community Connections: Care Coordination In The Medical Home. Accessed 08/23/2012 at Q: Do you involve patients in your care coordination program in care decision-making, feedback and planning? If yes, please briefly list the ways in which you do this. Yes. They have to be in final agreement with the treatment plan. Yes. Focus groups. Yes. In the office I try to involve patients in their care plan as much as possible. Q: Does your practice/organization use a team approach to care coordination? If yes, please briefly describe the process. Yes. The front office assistant will begin the process by handing the patient a sheet to verify their medications, insurance, etc. The medical assistant will take the patient back and provide (by protocols) any health maintenance needs that exist and also address any chronic issues that are due. Then the physician will see the patient.

Think Broadly About Patient Engagement! Engagement in patient’s own care Communication and information sharing Self-care management Decision making Quality improvement (QI) within the primary care practice Development and implementation of public policy and research. Peikes D, Genevro J, Scholle SH, Torda P. The Patient-Centered Medical Home: Strategies to Put Patients at the Center of Primary Care. AHRQ Publication No Rockville, MD: Agency for Healthcare Research and Quality. February Accessed - 8/24/2012 at Patient engagement can take place on various levels :

Case in point...

Effective Communication = Effective Engagement Open and honest conversations are critical to promote interprofessional approach to patient care Bring active listening skills into everyday conversations Need to be fully in the moment for meaningful communication to occur Connect on a personal level to build trusting relationships

Patient and family engagement is core function of primary care and care coordination. Engagement can take place at multiple levels— at patient level, at organization level, and at public policy level. There are many opportunities for healthcare providers to raise awareness of patient- centered care within their organizations and communities. Promoting Engagement—Key Points

Medicare Transitional Care Act Copyright 2011 National Transitions of Care Coalition 5 The Medicare Transitional Care Act would provide Medicare beneficiaries that are at highest risk for hospital readmissions access to evidence based transitional care services that are provided by an eligible transitional care entity, such as hospitals, skilled nursing facilities and community based- organizations. The bill would also provide incentives for the use of technology and other tools to improve care transitions.

Medicare Transitional Care Act Copyright 2011 National Transitions of Care Coalition 5 NTOCC Recommended changes incorporated into bill: “Findings” which include multiple care transition models and references NTOCC’s work on care transitions issues An expanded definition of “eligible entities and providers” (ensures case managers, pharmacists, social workers etc. are eligible to provide services) Broadens the definition of “Transitional Care Services” to support evidence-based care transition models which align with NTOCC’s seven essential elements. Includes language to require the documentation of a family caregiver during the plan-of-care process. Requires the development of measures to address and hold accountable both the sending and receiving side of the transition.

Medicare Transitional Care Act ***For Immediate Release******Media Contact*** September 14, 2012 Lindsay Punzenberger at (202) Legislation Introduced that Seeks to Fill Care Transition Gaps Medicare Transitional Care Act of 2012 designed to improve transitions of care for high risk Medicare beneficiaries WASHINGTON, D.C.— Today, Representatives Earl Blumenauer (D-OR), Thomas Petri (R-WI), Allyson Schwartz (D-PA) and Jan Schakowsky (D-IL) introduced the bipartisan Medicare Transitional Care Act of 2012, legislation that seeks to improve transitions of care for Medicare beneficiaries at highest risk for readmission as they move from the hospital setting to their home, skilled nursing facility or next point of care. The National Transitions of Care Coalition (NTOCC) believes the bill is an important step forward to improving patient outcomes and reducing unnecessary health-related expenses.NTOCC

Waves of Change Changing is like Breathing – And we all know what Happens when we stop Breathing Questions Cheri Lattimer RN, BSN