Transitions of Care Debbie Ashworth, BSN, MSHA, ACM Executive Director, Care Management / Documentation Improvement Audrey Trammell, BSN, RN Transitions of Care Coordinator

Transitions of care Objectives Discuss ways to strengthen and expand provider support as a way to improve care transitions Discuss initiatives to decrease hospital readmissions and how PCP’s and Post acute providers can assist with initiatives Discuss ways to promote improved health outcomes through improved provider communication

Transitions of care

Transitions of Care Every Patient should have a Patient-Centered Medical Home and Personal Provider Provide Appropriate Quality Personal Care to each patient during your time of responsibility Provide Accurate, Appropriate and Real-time data to the next care team at time of transition Follow up after transfer to confirm transition has occurred

Patient Centered Medical Transitions of Care Patient Centered Medical Home Hospital Rehab Skilled Care Health information Demographics Personal Healthcare Information Care Plan Follow up

The Right Healthcare Provider Transitions of care Do It Right The Right Patient The Right Service The Right Time The Right Place The Right Healthcare Provider

Transitions of Care Passing the Baton Demographics (Name, Birthdate, SS #, Health insurance) Patient-Centered Medical Home (Personal Provider) Medical diagnosis Medications Allergies Advanced Directives Recent Surgeries and Procedures Appropriate Diagnostic and Lab Reports Brief Summary of Care Provided Treatment Plan

Patient Centered Medical Home NEEDS TO KNOW WHAT’S GOING ON Transitions of care Patient Centered Medical Home NEEDS TO KNOW WHAT’S GOING ON Hospital system needs accurate contact information for every Patient Centered Medical Home/Primary Care Providers Notification system in place that inform PCMH of Emergency Room Visits, Admissions and Discharges of all designated patients within 24 hours of the event Computer Access to all PCMH for medical records of Patient’s Assigned to Medical Home/Personal Provider Ability to schedule follow up appointments with PCMH within 7 days of discharge from Hospital Data transfer to PCMH of Transition Data within 1 business day

Direct Messaging Direct is a standards-based transportation mechanism that can help healthcare professionals securely send messages to other providers, patients, or other authorized entities such as hospitals, pharmacies and laboratories from their EMR (electronic medical record). Direct is similar to e-mail but includes special security requirements to encrypt health data to be sent out of the EMR and ensure the receiver has been authenticated.

How providers benefit from direct messaging Direct offers secure delivery of health information for immediate use by healthcare providers, enabling physicians and hospitals to increase efficiency and lower costs Exchange of paper records is slow, expensive and inadequate for quality care Too often, PCPs seeing patients following hospitalization are forced to ask patients “What happened in the hospital?”

How providers benefit from direct messaging Computer processing of information received through fax or US mail is not possible. Traditional email and phone call exchanges may violate HIPPA requirements

Direct messaging HEALTH INFORMATION MANAGEMENT DEPARTMENT PAT HARWELL – 541-7807 TRACY HICKEY – 541-7801

Transitions of care – Measures Readmissions within 30 days Return visits to Emergency department within 30 days Number of Emergency department visits in a 6 month period Number of discharges that have a scheduled transition/follow up visit within 7-14 days of discharge Number of transfers from Skilled Care/Rehab to hospital and readmissions Percent of patients presenting to Emergency Department with a known PCP/PMCH

Transitions of care

Disease Management Program- LIFT Teach patients how to manage chronic diseases to reduce morbidity and mortality (and improve quality of life) Reduce unnecessary ED visits and hospitalizations, especially for safety net population Improve coordination of care after hospital discharge, especially between primary care, specialists Decrease readmission rates in CHF, Diabetes, and COPD Expand access to primary care and behavioral health Address social determinants of health by assisting with social needs (transportation, affordable meds, etc.)

Disease Management Program- LIFT Disease Management receives a list of all patients discharged from one of our hospitals with one of 4 diagnoses: COPD, CHF, Diabetes and Asthma Automated Referrals based on Labs: A1C Blood Sugar NP/Doctor/Cardiologist Referral Self Referrals

Disease Management Program- LIFT Multi-Disciplinary Approach Registered Nurse Pharmacist Dietitian Social Worker Respiratory Therapist Nurse Practitioner Behavioral Health Counselor

Disease Management Program- LIFT Quarterly themed food demonstrations to teach how to cook more healthy Focus on specific months with an emphasis on Heart Stroke Diabetes

Disease Management Program- LIFT How to make a referral? Call 731-425-6956

Cardiac rehab Cardiac Rehab Jackson Dyersburg Martin Bolivar – Coming Fall 2019 Increasing Access to Quality Cardiac Rehabilitation Care Act of 2019, H.R. 3911, was introduced by U.S. Representatives John Lewis (D-GA) and Adrian Smith (R-NE). The bill enables qualified nurse practitioners, physician assistants, and clinical nurse specialists to order and refer for these services) . (https://www.acc.org/latest-in-cardiology/articles/2019/07/23/17/32/new-legislation-proposes- expanded-access-to-cardiovascular-rehab- services?utm_campaign=advocate&utm_medium=email_newsletter&utm_source=advocate&utm_content=20190725)

Heart Camp / Joint Camp New process to help streamline the Preadmission process by being proactive and teaching the patients before the procedures Developing a plan of care to help decrease length of stay and planning for discharge upon admission Developing a teaching booklet that is used by multi disciplines that will be utilized in the boot camp.

Transitions of care – Initiatives Developing Care Pathways for patients with CHF and COPD Multiple initiatives being worked on regarding transitions of care: COPD CHF Behavioral Health Pilot with Post Acute Providers CHF / COPD Pilot with Post Acute Providers Reducing UTI’s Pilot with Skilled Nursing Facilities Integrated Care Processes Transitions Team working on processes of transitioning patients between all levels of care Readmission group with all providers in West Tennessee (except Shelby Co) Transitions of Care processes

Debbie Ashworth, BSN, MSHA, ACM Debbie.Ashworth@WTH.org Audrey Trammell, BSN, RN Audrey.Trammell@WTH.org