Lee Memorial Health System Our Journey Through Transitions of Care Joan Carroll RN, BA, CDMS, CCM Director Care Transitions

Lee Memorial Health System

Lee Memorial Health System 1,423 Acute Care Operational Beds Not For Profit Public Hospital System with 10 Member Elected Board of Directors 10,000 Employees, 4,300 Volunteers & 1,200 Staff Physicians, 85 Employed Physicians 6 Hospitals, Sub Acute, Physician Group, Convenient Cares, Home Health, Skilled Nursing Facility, Rehabilitation, Regional Cancer Center, LPG united Way House 81,531 Admissions Annually

Care Transition Coaching CT is a 4 week program to help patients transition from hospital to home, while learning how to manage their chronic condition The LMHS model for Care Transition Coaching is a combination of the Coleman Model, Project RED, BOOST 5 basic areas of our coaching program include Patient self management assessment Medication Management Personal Health Record Diagnosis / Red Flags / Actions Communicating with health care professionals

Discoveries Didn’t know their diagnosis Had no idea what it was No understanding of acute or chronic Believed the hospital cured them Recovery is a rest period No knowledge of their role No knowledge of red flags Reverted to meds they already paid for No medication management system Couldn’t remember 3 of their meds and their purpose or side effects

Discoveries Patient had prescription meds that were not on the discharge instructions Patient had no prescriptions for new meds on the discharge instructions Patient had no idea of their limitations DME had not been delivered BIPAP not delivered / patient in trouble Patient extremely SOB 1days post discharge/ ankles still showing extreme edema / Poor discharge Home not safe Patient depressed or lonely

Discoveries Couldn’t find their discharge instructions Didn’t remember anyone going over them Had not filled their new prescriptions Taking OTC meds unapproved Believed the salt shaker (which they didn’t use) was the only source of sodium Had not scheduled their PCP appointment Drank 10-15 glasses of water a day (per Dr. Oz) Used their inhalers incorrectly Couldn’t read and/ or follow direction Were unstable on their feet

Even More discoveries Had 50 feet of Oxygen tubing Nebulizer was filthy Alcoholics? No money for meds or groceries No transportation to the doctor No caregiver assistance Couldn’t get an appointment for 1 month Caregiver was worse than the patient Depression Electricity had been turned off No food

AHA. Could these possibly be the root causes for re-admissions AHA! Could these possibly be the root causes for re-admissions? Where do we begin?

Next step/ collect data Patient Activation Assessment Discharge Evaluation Medication Discrepancies Readmissions

Results Patient Activation Assessment showed patients prior to discharge– Scores 1-3/10 Discharge Evaluations March 2011 -60% Med Discrepancies – 92% in January of 2011

What Next? Communicate and Collaborate Hospitalists and Specialists Case management VP of Nursing Discharge Nurses Staff Nurses Nursing Education Pharmacists Respiratory Therapists Physical Therapists Nutritionists

What did we do in Acute Care? Discharge order sets for CHF and COPD/ simplified / disease specific CHF Unit opened and certification completed Physicians include specific discharge orders for screening for balance/ medication review Improved cognitive assessment Palliative Care Training Increased Home Health Referrals Teach Back education Standardized Handouts Caregivers are identified in the EMR

LMHS System Initiatives Acute Care System Wide Risk Stratification Tool Tracking Readmission reasons Care Transitions Care Management Website – Community Resources Teach Back and F/U appointment Pharmacy Collaboration on Medication Discrepancies CHF Unit / Cardiac Decision Unit for Obs patients Readmission work groups- Pulmonary & CHF

System Accomplishments CHF Unit opened / Certification completed/ readmissions reduced at HP Pharmacy providing Medication prior to discharge EPIC update of Discharge orders improved Rounding initiated at ¾ facilities COPD Management Program GC Reduce LOS/ Readmissions Committee CCH Readmissions Committee Home Health protocols for diuresis in home completed Home Health Telehealth using 400 units in the community Home Health frontloading Nutrition Assessment with Food Bank Vouchers

Home Health Agencies/ Coalition Work Group SNF Administrator and DON Case Management & Medical Social Workers Hospitalist ED Physician SNF Medical Directors ED Nurses Care Transitions Director Infection Control Educator Palliative Care

SNF Coalition and workgroup/ Quarterly meetings Review Lee County readmission data Discuss 2 facilities Readmissions initiatives Create Readmission Task Force Developed a tool to collect transfer data for SNF on CHF, COPD and MI Root Cause Analysis completed Action Plan completed Completed INTERACT Training Training 13 facilities

Readmission Root Cause Analysis

Small Tests of Change Discharge Summary faxed to SNF 24- 48 hr Updating the automated referral near discharge INTERACT II utilized at a few SNFs Include Transition of Care with all new physician Orientation Nurse to Nurse Hand off communication Epic transfer information printed and sent to SNFs Standardized PT / OT post acute recommendations Pharmacy completes Medication Reconciliation all SNF transfers

System Wide High Risk Assessment Age 70 or greater Chronic Conditions (CHF, AMI, Pneumonia, Diabetes, etc.) Polypharmacy Takes Anticoagulants, ASA, Plavix, Insulin, Digoxin Previous Admissions within last 3, 6 or 12 months Living Situation Health Literacy & Language Cognitive Impairment Patient Self-Health Rating Fall Risk Palliative Care Psych/Social- Depression

Chronic Disease Self-Management Program An evidence-based health promotion program for persons with chronic diseases Teaches participants self-management techniques Brings community agencies together to tackle chronic illness in a unified manner; thus, maximizing utilization of resources and minimizing overlap of initiatives Train-the-trainer format to improve self-management and build self-confidence Generic enough to cover a variety of different conditions

CDMP Program Overview Six weekly 2.5 hour sessions Each class is led by two trained lay leaders Focusing on: - Nutrition and exercise - Using community resources - Learning about medication use - Relaxation techniques - Solving health-related problems

Care Transitions Update The Personal Health Record and handouts are available in Spanish Expansion to all the hospitals (7 coaches, 2 RT, 1 MSW) HPC+RC / PT CT Coach Provided Teach back education for several HHA / acute care units CHF handouts available in Spanish See patients twice, at discharge and 15 days May add Grand Aides Developing a Caregiver Assessment tool Nutritional assessment program with supplementation

What is a successful transition? Discharge education begins on admission Providers are alert to all the possible care needs after discharge Compassionate teach back is provided by all disciplines Literacy and health literacy are assessed and education is provided at the patient‘s level of understanding Appropriate caregivers are included in the discharge education

What is a successful transition? Care Transitions coaches follow the patient for 30 days Patients are referred to appropriate agencies for additional services The patient has transportation to the PCPs office within 8 days of discharge The patient has food and has obtained his medications The patient has knowledge of his medications and self management details The Patient’s primary caregiver knows about the hospitalization

Finally DONE!! Thank you for your attention. Transition home safely!