2. Teaching, Living, and Improving Transitions of Care in Residency Practice: The Transitions of Care Resident David A. Baltierra, MD STFM/AAFP Conference on Practice Improvement December 1-4, 2011

3. TWEET IT!!! Join the conversation! Our Twitter hashtag is #CPI2011

4. Where are we? 4 2011-12-2 DB,WL

5. Who are we? WVU Rural Family Medicine Residency History  Founded 1996  4:4:4 (now 5:5:5)  Rural Health Clinic (>35k visit/year)  Women’s Health & Maternity Center  25 bed Critical Access Hospital  P4 Residency Program  Rural Scholar Program Stats  ~ 50K county population  15 residents  14 FM Faculty (FT/PT)  2 Pediatric Faculty  1 CNM, 1 PA  Geriatric Fellowship  Hospitalist Fellowships 5 2011-12-2 DB,WL

6. Objectives  1. Identify challenges that exist in delivering care in the modern Patient Centered Medical Home as they relate to transitions in care 6 2011-12-2 DB,WL

7. Objectives  2. Learn to address challenges and pitfalls in transition in care proactively for better care of patients, reduce medical errors and costs, and improve outcomes. 7 2011-12-2 DB,WL

8. Objectives  3. Describe Transitions of Care Resident model for coordination of care in the hospital, nursing home, primary care office, and patient home. 8 2011-12-2 DB,WL

9. Objectives  1. Identify challenges that exist in delivering care in the modern Patient Centered Medical Home as they relate to transitions in care  2. Learn to address challenges and pitfalls in transition in care proactively for better care of patients, reduce medical errors and costs, and improve outcomes.  3. Describe Transitions of Care Resident model for coordination of care in the hospital, nursing home, primary care office, and patient home. 9 2011-12-2 DB,WL

10. Background  Transitions of Care are HOT !!!!  Great hope to reduce costs  Improve care 10 2011-12-2 DB,WL

11. Figure 1. Rates of Rehospitalization within 30 Days after Hospital Discharge. 2011-12-2 DB,WL 11

12. Get on the bandwagon  AHRQ  IHI  IOM  ACGME  ACOs  WVU GMEC  My Mom & Dad 2011-12-2 DB,WL 12

13. ACGME  VI.B.1-4.: Transitions of Care  “Programs must design clinical assignments to minimize the number of transitions in patient care. Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety. Programs must ensure that residents are competent in communicating with team members in the hand-over process. The sponsoring institution must ensure the availability of schedules that inform all members of the health care team of attending physicians and residents currently responsible for each patient’s care. 2011-12-2 DB,WL 13

14. ACGME FAQ’s  What are the ACGME’s expectations regarding transitions of care, and how should programs and institutions monitor effective transitions of care and minimize the number of such transitions? 2011-12-2 DB,WL 14

15. ACGME FAQ’s  Transitions of care are critical elements in patient safety and must be organized such that complete and accurate clinical information on all involved patients is transmitted between the outgoing and incoming individuals and/or teams responsible for that specific patient or group of patients. Programs and institutions are expected to have a documented process in place for ensuring the effectiveness of transitions. This can be accomplished in many different ways. For example, the program or institution can review and document on a regular basis a sample of a transition, to include review of a sample patient’s chart and interview of the incoming responsible individual and/or team to ensure key elements in the patient care continuum for that patient have been transmitted and are clearly understood. Pertinent elements evaluated should include exam findings, laboratory data, any clinical changes, family contacts, and any change in responsible attending physician. Scheduling of on-call shifts should be optimized to ensure a minimum number of transitions, and there should be documentation of the process involved in arriving at the final schedule. The specifics of these schedules will depend upon various factors, including the size of the program, the acuity and quantity of the workload, and the level of resident education. 2011-12-2 DB,WL 15

16.  Office of Graduate Medical Education  West Virginia University School of Medicine  RESIDENT PROFESSIONALISM STANDARD FOR INTERRUPTION OF PATIENT CARE  I. Rationale  To assure continuity of care and patient safety, ACGME requires a minimum number of patient care transitions and readily available schedules listing residents and attending physicians responsible for each patient’s care. In addition to resident-to-resident patient transitions, residents must care for patients in an environment that maximizes effective communication among all individuals or teams with responsibility for patient care in the healthcare setting.  To assure that residents are well-equipped to accept responsibility for the health and safety of future patients, and to assist with a seamless transition from observing to providing quality patient care, every resident must be accountable for the treatment of any patient he/she encounters as though he/she were the sole provider of care and must treat all patients as the resident’s own patients.  II. Policy  A. If a resident is aware of any conflict that may arise during the course of any upcoming procedure or patient care activity, whether such a procedure or activity is scheduled or emergent, that resident must inform the attending physician and/or Residency Program Director in advance to allow the physician or service to determine whether patient safety will allow for reasonable accommodations. It may be necessary to alter a resident’s rotation schedule if breaks cannot be reasonably accommodated.  B. In surgical settings and other patient care activities, residents may not scrub out of surgical procedures, leave the operatory or any patient care setting for any non-emergent reason (e.g. medical conditions, breast feeding, or child or adult care). While emergencies will sometimes arise, in the event of an unforeseen emergency, residents must appropriately notify the attending physician of the emergency and seek the necessary permission to be excused only when and if the circumstances warrant. In absolutely no instance should a resident scrub out of surgery or leave the operatory without first informing the attending physician and obtaining permission to exit. Residents are expected to be compliant with current duty hour standards and program duty hour policies and procedures.  Consequences for failure to comply will be at the discretion of the Residency Program Director.  GMEC Taskforce approved: 11-3-11  GMEC approved: 11-11-11 2011-12-2 DB,WL 16

17. WVU GMEC  Transfer of Care SDOT Evaluation Emergency Medicine  “.edcheckout”  RESIDENT PROFESSIONALISM STANDARD FOR INTERRUPTION OF PATIENT CARE  HANDOFFS AND TRANSITIONS OF CARE 2011-12-2 DB,WL 17

18. WVU GMEC 2011-12-2 DB,WL 18

19. WVU GMEC 2011-12-2 DB,WL 19

20. WVU GMEC 2011-12-2 DB,WL 20

21. WVU GMEC 2011-12-2 DB,WL 21

22. WVU GMEC 2011-12-2 DB,WL 22

23. WVU GMEC 2011-12-2 DB,WL 23

24. WVUH-East 2011-12-2 DB,WL 24

25. WVUH-East 2011-12-2 DB,WL 25

26. WVUH-East 2011-12-2 DB,WL 26

27. Figure 2. Patients for Whom There Was No Bill for an Outpatient Physician Visit between Discharge and Rehospitalization. 2011-12-2 DB,WL 27

28. Grants  HRSA Equipment Grant  HRSA Residency Equipment Grant 2011-12-2 DB,WL 28

29. The Model  One resident, PGY2 or 3  4 week block  Duties Communicate with Wards Team Round with Wards Team Home Visits Office Visits Nursing Home Visits Hospice 2011-12-2 DB,WL 29

30. The Model  Portable Equipment USN Laptop Video EKG iStat Xray machine ICU Monitor 2011-12-2 DB,WL 30

31. Future Enhancements  PharmD student, others  Electronic visits  Electronic Health record integration  Enhanced scheduling  Video precepting  Video visits  Patient home monitoring equipment 2011-12-2 DB,WL 31

32. THE CURRICULUM 2011-12-2 DB,WL 32

33. Creating an Ideal Transition Home  1. Enhanced Admission Assessment for Post-Discharge Needs Include family caregivers and community providers (e.g., home health nurses, primary care physicians, HF clinic nurses, etc.) as full partners in standardized assessment, discharge planning, and predicting home-going needs. Reconcile medications upon admission. Initiate a standard plan of care based on the results of the assessment. 2011-12-2 DB,WL 33

34. Creating an Ideal Transition Home  2. Enhanced Teaching and Learning Identify the learner(s) on admission (i.e., the patient and family caregivers). Redesign the patient education process to improve patient and family caregiver understanding of self-care. Use Teach Back daily in the hospital and during follow-up calls to assess the patient’s and family caregivers’ understanding of discharge instructions and ability to do self- care. 2011-12-2 DB,WL 34

35. Creating an Ideal Transition Home  3. Patient and Family-Centered Handoff Communication Reconcile medications for discharge. Provide customized, real-time critical information to the next care provider(s) that: (a) accompanies the patient to the next institution; and/or (b) is transmitted to the receiving physician and/or home health agency or other care providers at time of discharge. 2011-12-2 DB,WL 35

36. Creating an Ideal Transition Home  4. Post-Acute Care Follow-Up High-risk patients: Prior to discharge, schedule a face-to-face follow-up visit (home care visit, care coordination visit, or physician office visit) to occur within 48 hours after discharge. Moderate risk patients: Prior to discharge, schedule a follow-up phone call within 48 hours and schedule a physician office visit within 5 days. 2011-12-2 DB,WL 36

37. Other Points  EHR  Problem List Documentation  Scheduling  Billing  Precepting  Future Technology  Team-based  Develop curriculum Medical School 2011-12-2 DB,WL 37

38. Resident Experience 2011-12-2 DB,WL 38

39. Patient Experience 2011-12-2 DB,WL 39

40. Successes  Being measured  Resident learning 2011-12-2 DB,WL 40

41. Challenges  Scheduling  Outcomes  Billing  Equipment  Inertia 2011-12-2 DB,WL 41

42. Future Areas to Explore  UHC Patient Safety Net https://www.uhc.edu/11851.htm Measure outcomes 2011-12-2 DB,WL 42

43. Resources  IHI  AHRQ  FMDRL  MedEdPortal 43 2011-12-2 DB,WL

44. References  ACGME | program directors & coordinators Retrieved 12/3/2011, 2011, from http://www.acgme.org/acWebsite/navPages/nav_PDcoord.asp http://www.acgme.org/acWebsite/navPages/nav_PDcoord.asp  Institute for healthcare improvement: How-to guide: Improving transitions from the hospital to post-acute care settings to reduce avoidable rehospitalizations Retrieved 12/3/2011, 2011, from http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImproving TransitionstoReduceAvoidableRehospitalizations.aspx http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImproving TransitionstoReduceAvoidableRehospitalizations.aspx  Institute for healthcare improvement: Effective interventions to reduce rehospitalizations: A survey of the published evidence Retrieved 12/3/2011, 2011, from http://www.ihi.org/knowledge/Pages/Publications/EffectiveInterve ntionsReduceRehospitalizationsASurveyPublishedEvidence.aspx http://www.ihi.org/knowledge/Pages/Publications/EffectiveInterve ntionsReduceRehospitalizationsASurveyPublishedEvidence.aspx 44 2011-12-2 DB,WL

45. References  Boutwell, A. jencks, S. nielsen, GA. rutherford, P. STate action on avoidable rehospitalizations (STAAR) initiative: Applying early evidence and experience in front-line process improvements to develop a state-based strategy. cambridge, MA: Institute for healthcare improvement; 2009.  Institute for healthcare improvement: Effective interventions to reduce rehospitalizations: A compendium of 15 promising interventions Retrieved 12/3/2011, 2011, from http://www.ihi.org/knowledge/Pages/Changes/EffectiveInterventi onstoReduceRehospitalizationsCompendium15PromisingInterventi ons.aspx http://www.ihi.org/knowledge/Pages/Changes/EffectiveInterventi onstoReduceRehospitalizationsCompendium15PromisingInterventi ons.aspx  Arora, V., Farnan, J., Paro, J., Vidyarthi, A., Johnson, J., Teaching Video:"Handoffs: A Typical Day on the Wards." MedEdPORTAL; Available from:www.mededportal.org ID 8331 45 2011-12-2 DB,WL

46. References  Institute for healthcare improvement: How-to guide: Improving transitions from the hospital to skilled nursing facilities to reduce avoidable rehospitalizations Retrieved 12/3/2011, 2011, from http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImproving TransitionHospitalSNFstoReduceRehospitalizations.aspx http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImproving TransitionHospitalSNFstoReduceRehospitalizations.aspx  Institute for healthcare improvement: How-to guide: Improving transitions from the hospital to the clinical office practice to reduce avoidable rehospitalizations Retrieved 12/3/2011, 2011, from http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImproving TransitionsHospitaltoOfficePracticeReduceRehospitalizations.aspx http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImproving TransitionsHospitaltoOfficePracticeReduceRehospitalizations.aspx  Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the medicare fee-for-service program. N Engl J Med, 360(14), 1418-1428. doi:10.1056/NEJMsa0803563 46 2011-12-2 DB,WL

47. Contact Information WVU Rural Family Medicine Residency 171 Taylor St Harpers Ferry, WV 25425 (304) 535-6343 www.wvuhffm.com baltierrada@wvuhealthcare.com 2011-12-2 DB,WL 47