Destination Safe Care Transitions – Staying on Track Hiloni Bhavsar, MD Assistant Professor, General Internal Medicine UH Quality Institute Liaison Physician Informaticist, UHCare Elizabeth Ingram BS Clinical Application Analyst UHCare Ambulatory EMR Jonathan S. Lever, MPH, NREMT-P Senior Clinical Data Analyst Institute for Healthcare Quality & Innovation University Hospitals Case Medical Center Chrissie Blackburn, MHA Principal Advisor, Patient and Family Engagement University Hospitals & UHCMC Institute for Healthcare Quality and Innovation Edmundo Mandac, MD Department of Emergency Medicine Interim Chair - UHCMC Nancy DeSantis Manager, Patient Access Services Khaliah Fisher-Grace, MSN, RN, CPHQ, PCCN Senior Quality Improvement Nurse Institute for Healthcare Quality & Innovation University Hospitals Case Medical Center Lee Manning Schoeppler, RN, MSN, MBA, NEA-BC Agency Administrator, Director of Clinical Integration University Hospitals Home Care & Hospice George V. Topalsky MD, F.A.C.P. UH Internal Medicine Center Co medical director Southwest Region Site director UH Independance health center Mary Ann Gravenstein, MD Stefan Gravenstein, MD, MPH Professor of Medicine Interim Chief, Division of Geriatrics and Palliative Care Center for Geriatrics and Palliative Care Case Medical Center Laura Wilson, BSN, RN Clinical System Liaison, Electronic Medical Records (EMR)/ UHCare UH Conneaut Medical Center Corinne Hurley, RN, MSN Director, Institute for HealthCare Quality and Innovation Physician Office Based Care Cynthia B.R.Zelis, MD, MBA Vice President Clinical Integration University Hospitals Cleveland Faisal A. Khan, Esq. Assistant General Counsel

Disclosures Speakers in this presentation have no disclosures.

Objectives Identify and describe national and local best practices in transitions of care through experts and patient perspective Understand the resources available within the UH system today Understand the implications of poor transitions of care on patient experience, readmissions, and reimbursement Attendees will write an “I will…” statement at the end of the presentation to apply one transition of care best practice to their current workflow

Overview Background information on transitions of care Best practices Case: Dr. Mary Ann Gravenstein Workshop Large group discussion Background 2 minutes Best practice presentation 5 minutes Case presentation 5 minutes (3-4 slides) Workshop/Large Group Discussion

Clinical Integration “The Key to Health Care Reform” -American Hospital Association, Feb 2010 “Clinical Integration is the extent to which patient care services are coordinated across people, functions, activities, and sites over time so as to maximize the value of services delivered to the patient.” S Shortell, R Gilles, D. Anderson Remaking Health Care in America, 2000

Clinical Integration is a TEAM Effort WHY CLINICAL INTEGRATION? Patient Primary Care Provider Laboratory Specialty Providers Radiology Post Acute Care Therapy Home Health Care Acute Care Hospitals Emergency Dept. Clinical Integration is a TEAM Effort WHY CLINICAL INTEGRATION? Quality Communication Patient Experience Work Flow Efficiency Lower Litigation Risk Cost Reduction System Revenue

Transitions of Care: Potential Consequences Quality Communication Patient Experience Work Flow Efficiency Litigation Risk Readmission Prolonged Length of Stay Duplication of tests Inaccurate treatment Poor Patient Satisfaction Decreased patient loyalty Increased work for staff Incomplete documentation Risk of Joint Defense

ED/Urgent Care Best Practices: RECIPROCITY Communication of Key Info (Based on Evidence and local input) ED/UC/ SNF/Hospital Community Physician’s Office Visit Timeline ED/UC/SNF/Hospital Best Practice Community Physician At intake Notify PCP about hospital utilization Provide clinical info when referring patients for ED/UC evaluation During visit Invite PCP to participate in EOL discussions Provide patient with effective education Provide patient with written d/c instructions Provide patient with f/u phone # Perform medication reconciliation Schedule outpatient f/u appointment Provide ED/UC/Hospital with phone access to outpatient staff who can answer clinical questions Provide ED/hospital with access to outpatient clinical info At discharge Provide PCP with hospital contact info Provide PCP with summary clinical info Confirm receipt of hospital d/c info After discharge F/U with high risk pts via phone Conduct outpatient f/u Perform outpatient med reconciliation

48-Hour Readmission Review Pilot (UH Case) 136 patient readmitted within 48 hours, November 2014 – March 2015 39 reviews completed Measure % Yes All-or-none and standard of care met 2.6 Notify community MD office about observation/admission 74.6 Provide receiving MDs with hospital clinicians contact info 58.5 Patient education prior to discharge 92.4 Written discharge instructions prior to discharge 87.9 Follow-up phone number prior to discharge 72.3 Medication reconciliation 95.4 Schedule follow-up appt 87.7 Provide PCP office with patient summary 75.4 PCP participated EOL discussions during visit 96.8 EOL=end of life

Practices and Policy Best Practice UH Policy (Hiloni) Notify community physician office about hospital admission N/A Provide receiving clinician’s with hospital clinicians contact information prior to discharge GM-68 Provide patient with effective education prior to discharge CP 24, G 846 (Nursing Practice Manual) Provide patient with written discharge instructions prior to discharge CP 24, GM 68, G 846 (Nursing Practice Manual) Provide patient with follow up phone number prior to discharge G 846 (Nursing Practice Manual) Perform medication reconciliation prior to discharge CP 24, CP 112 Schedule outpatient follow up appointment prior to discharge Provide community physician office with summary clinical information at discharge Invite primary care physician to participate in end-of-life discussions during hospital visit (Hiloni) What is the standard definition , What is the policy, What are best practices Resident education

Best Practices In an ideal world…. Presenting diads Think about the practices during the case presented Use the practices at your table to apply them to the case

THEME then best practices by setting 1 Notify of PCP of encounter and disposition Hospital to PCP Notify community MD office about outpatient observation and hospital admission Hospital to SNF Notify community MD office about encounter and disposition SNF to ED/Hospital PCP to ED/Hospital N/A ED/UC to PCP ED/UC to Hospital Coaching Patient/caregiver write contact information in PHR of each provider through care transitions

Introduction

Case Presentation Patient falls at home Arrives in ED X-ray shows comminuted fx Ortho MD attempts closed reduction without pain meds Admitted inpatient Patient gets long-leg cast Admit med rec is not correct Discharged to acute rehab Pain control inadequate Discharged to home with home health Home health monitors INRs PCP appt. made Scheduling amb = can’t go to PCP office No appt. = no opiates or INR management Rehab doc fills opiates 84 y/o female falls at home Patient values and beliefs around osteoporosis Arrives in the ED X-ray Comminuted distal tibial fracture Ortho – MD in the ED straightens leg without medications/analgesia Patient in severe amount of pain Admitted as an inpatient for 1-2 days Didn’t know patient could have gone directly to acute rehab – could go directly there b/c they can still participate in 3 hrs of rehab Admission med recc wrong From last hospital stay – from last hospital stay was 8 months prior for hip replaced/bowel perf complication ?Discharge med rec correct? Discharged to acute rehab Pain medications were not sufficient Took a long time to get the right pain med on board Night shift nurses dropped leg when doing transfers Got a full-leg cast was to protect knee for future knee placement Made it difficult for transfers due to the cast Discharged to home with home health Home health couldn’t get PCP to sign-off on Dilaudid, INR, Warfarin Rx Can’t go to appointment for PCP office Office doesn’t accommodate gurney Couldn’t get dilaudid because she hadn’t been seen – can’t be seen b/c no gurneys allowed Eventually the acute rehab doc was able to fill Rx for pain management Ortho doc was not willing to prescribe until visit completed Eventually filled to get her to office appt. Discharged by home health = who will manage INR’s Warfarin management couldn’t be done because the INR was being done at home by home care PCP wanted Coumadin clinic follow up but this would cost $1000 PER VISIT for ambulance ride due to long-leg cast and need for transport Ultimately patient had to get POCT for self-INR monitoring Payment for INR management for results that are called in vs. checked through the office Eventually gets to PCP appointment Gradually things were able to get back to baseline. Follow up with ortho Eventually gets PCP follow up

Workshop Tables to be set up in Diads of transitions rather than individual components = pair facilitators accordingly. May lead to larger groups this way Facilitators can encourage participation Ideal size is 5 but likely will be more people than that. POSSIBLE MIND MAPPING EXERCISE Sheets of paper, post-it’s and pens And easel 10 minutes to put the ideas on post-it’s 10 minutes to organize the post –it’s in the categories 10 minutes to do the driver mapping – DISCUSSION IS THE VECTORS - THIS WOULD LARGE GROUP EXERCISE for everyone to contribute

Group Discussion