Community-Based Transitions of Care Marsha Thorson, MSPH Jane Brock, MD, MSPH Colorado Foundation for Medical Care QualityNET Conference: Baltimore, MD October 25, 2007

What we’ll cover… Background Care Transitions Intervention (CTI) Framework Models we are testing Data Measurement strategy Summary

Background 18-month special study Initial design was to work with two communities to implement the CTI and decrease 14- and 30-day hospital readmission rates Because of VALUE special study, now working with 3rd community Framework developed to describe how QIOs can work with communities to implement the CTI and support decreased hospital readmission rates

Fundamental Disconnect… SNF Hospital Skilled Nursing Facility Home Ambulatory Care Clinic Hospice Rehabilitation Facility Hospice **Dr. Eric Coleman’s slide, printed here with permission.

Care Transitions Intervention Dr. Eric Coleman, University of Colorado Well proven Increase quality of care Cost-effective 4 pillars medication management; patient-centered record; follow-up; red flags 5 encounters Hospital/SNF Visit; Home Visit; 3 Follow-Up Calls Care Transitions Measure (CTM) http://www.caretransitions.org Patient Centered Coaching

CTM-3 Items The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. When I left the hospital, I clearly understood the purpose for taking each of my medications.

Framework Background on care coordination and the CTI Test models for implementation Describe a measurement strategy Implications for future work Methods Workflow and process observation by CFMC staff Site exchange visitation among involved staff from different settings CTI Training Group structuring of improved transitional care Provision of readmission rate data feedback to the hospital http://www.medqic.org

My Medications are: Personal History Personal Health Record Medication Dose ______________________________ Allergies: _____________________ Reason Side Effects Remember to take this Record with you to all of your doctor visits Personal Health Record The Personal Health Record of: Josephine Patient Personal Information: Address: Home Phone#: Birth Date: Patient ID# PCP Name: Advanced Directives?: Hospitalization Information: Admitted: _/_/_ Discharged: _/_/_ Reason for Hospitalization: ___________________________________________ Caregiver Information: Name: Phone #: Relation to Patient: Personal History Please check any illnesses or health problems listed below that you have ever experienced. Arthritis Abnormal Heart Rhythm Cancer Diabetes Hardening of the Arteries Heart Disease Heart Failure High Blood Pressure Hip Fracture Lung Disease Medical/Surgical Back conditions Pneumonia Stroke Other: ____________________ After I leave the hospital… 1. I will write down questions I have about my condition. 2. I will take all bottles of medicine I am using to each doctor visit. 3. I will call _________________ immediately at (XXX) XXX-XXX if I experience any of the following: • Temperature above 101° F • Uncontrollable pain • Increased confusion • Increased redness or d drainage around wound • Questions about which medications to take Before I leave the hospital…. I have the instructions I need to keep my health condition from becoming worse. I know what symptoms to watch out for. I know the name and phone number of who to call if I see any of these symptoms. My family or someone close to me knows what I will need once I leave the hospital. I know what medications to take, how to take them, and possible side effects. I will schedule a follow up appointment with my primary care doctor. I will have a clear and complete copy of my discharge instructions. **Dr. Eric Coleman’s slide, printed here with permission.

Models we are testing Community 1* Community 2* Community 3 Implemented modification of the CTI Community 2* Implemented CTI in true form Community 3 ??

Data Community 1 Community 2 Community 3* Quantitative & qualitative Qualitative, AI interviews

Community 1 Hospital Discharge

Community 1 SNF Discharge Flowchart

Community 1 Home Health Intake

Community 1 Outpatient Intake

Community 2 Hospital Discharge

Community 2 SNF Admission

Community 2 Home Health Start of Care

Community 2 Physician Office Patient Tracking

Community 3 Hospital Discharge

Community 3 SNF Admission

Community 3 Home Health Start of Care Visit

Community 3 Physician Office Intake To be observed.

Measurement strategy

Measurement strategy

Summary Transitional care and coordination of care Issues Providers are ready Issues Patient centric Self management Patient activation Provider centric Information transfer Handover management

Summary PCP capture Community building Commitment

Call to action QIOs working on transitional care and coordination of care studies Discussion Wikipedia Invite providers to be involved QIO panel presentation/discussion

Acknowledgements University of Colorado CFMC Eric Coleman, MD, MPH Carly Parry, PhD Sandy Chalmers, MPH Amita Chugh, BA Heidi Kramer, RN, ND CFMC Jane Brock, MD, MSPH Marsha Thorson, MSPH Risa Hayes, CPC Alicia Goroski, MPH Jason Mitchell, BS Christina Underwood, MPH Participants in each community Other QIOs

Resources http://www.cfmc.org/value/ http://www.caretransitions.org http://www.cfmc.org/providers/providers_pcc.htm http://en.wikipedia.org/wiki/Transitional_care http://www.ntocc.org/ And many others!

More information Marsha Thorson, MSPH Project Manager, Transitions of Care Program mthorson@cfmc.org 303.668.4690 Jane Brock, MD, MSPH Medical Officer Clinical Lead, Transitions of Care Program and VALUE jbrock@cfmc.org 303.695.3300 ext. 3050

Disclaimer: “This material was prepared by CFMC (PM-415-146 CO 2007), the Medicare Quality Improvement Organization for Colorado, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.”