1. 1 A Collaborative Approach to Transition Management

2. Manage the Discharge from One Care Setting to Another Transition: Movement of a member/patient from one care setting to another as the member’s/ patient’s health status changes. 2

3. Care Transition Management Objectives: By the end of this presentation you should: Understand the care coordinator’s role and accountability with transition support 3

4. Care Transition Management Objectives: Be familiar with Transition of Care (TOC) Collaborative Improvement Project List the Four Pillars of Optimal Transition management than can impact avoidable readmissions 4

5. Care coordinators Who are they? Licensed Registered Nurse or Social Worker What do they do? Communicate with members/patients and their health care providers Coordinate services 5

6. Care coordinator’s role Communicate, support, educate, arrange services Provide effective transition support Communicate with individuals involved in the discharge process 6

7. Care coordinator’s role Identify and note current services and needed changes Assess issues known to impact readmissions Update care plan 7

8. Improving Transitions of Care (TOC) After Hospitalizations Goal: To reduce hospital readmissions by improving member/patient support for the transition from hospital to home or a health care setting 8

9. Improving Transitions After Hospitalizations Health plans want to reduce: Fragmented care Unsafe care Readmissions 9

10. Improving Transitions After Hospitalizations Three year improvement project Train care coordinators Promote member/patient and family involvement 10

11. Key Interventions: Improve Transition of Care (TOC) Log Train care coordinators in use of TOC Log Annual audits of TOC Logs 11

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13. TOC Log Tool care coordinators use as a process to: Prompt communication Educate member/patient and family Manage the transition process 13

14. TOC Log Tool care coordinators use as a process to: Prevent or reduce unplanned or avoidable transitions Meet regulatory requirements for managing care transitions 14

15. Improving the TOC Log Revision Process: Gather care coordinator’s input Focus Groups 15

16. Improving the TOC Log Revised the TOC Log to: Incorporate care coordinators’ requests for value-added tool Use as a standardized communication tool with prompts for the Four Pillars for Optimal Transition Auditable tool for CMS and Project 16

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19. Questions and Answers 19

20. New to TOC Log Four Pillars for Optimal Transition: Timely follow-up visit Medication self-management Knowledge of red flags Use of personal health record 20

21. Timely Follow-up Appointment Did the member/patient schedule the appointment (appt)? Assist with making the appt, as needed How will they get to the appt? Stress the importance of keeping the appt 21

22. Medication Self-management Determine whether member/patient/ responsible party have an understanding of current medication regimen. Does the member/patient: Have medications (meds) changes? 22

23. Medication Self-management Have their meds? Remember to take their meds? Need help with med set-up or taking them? Questions/Concerns about their meds? 23

24. Knowledge of Red Flags Indicate whether the member/patient/ responsible party are aware of symptoms that indicate problems with healing or recovery. Does the member know: What are the warning signs/symptoms? 24

25. Knowledge of Red Flags What action should they take if symptoms appear? Who and when to call with questions or concerns? Do they have phone numbers available? 25

26. Use of a Personal Health Record Indicate whether member/patient/responsible party uses a personal health care record for tracking health history and current medication regimens. 26

27. Use of a Personal Health Record An organized account of personal health information that the member/patient can self-record and bring to appointments. Use to increase member/patient engagement and self-management 27

28. Personal Health Record Typical PHR topics: Personal & caregiver contact information Healthcare providers & contact information Medical history 28

29. Personal Health Record Medications Warning signs Questions for practitioners/list of appointments Personal goals 29

30. Personal Health Record: Example 30

31. Personal Health Record: Example 31

32. New to TOC Log As a result of this transition discussion: Have you updated the member’s/patient’s care plan? ⃞ Yes ⃞ No If No, explain Services started, stopped, changed and/or refused? ⃞ Yes ⃞ No Comments 32

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34. Questions and Answers 34

35. Transition of Care Tools Fax Sheet for Provider Communication Transition of Care Toolkit 35

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38. Transition of Care Toolkit Summary of health plan projects that focus on improving transitions Importance of transitions and a list of research-based hospital discharge programs Risk Assessments and intervention links: 38

39. RARE Campaign (Reducing Avoidable Readmissions Effectively) Many regional hospitals are participating in the statewide RARE Campaign and working internally on ways to reduce Readmissions during hospitalization, and best practices to reduce avoidable readmissions with partnering agencies. 39

40. RARE Campaign (Reducing Avoidable Readmissions Effectively) Lead Partners: Institute for Clinical Systems Improvement (ICSI), Minnesota Hospital Association (MHA), Stratis Health 40

41. Transition of Care Toolkit Risk assessments/intervention resources: Health Literacy Depression Substance abuse Falls Cognitive impairment Pain 41

42. Risk Factors for Readmission Limited Health Literacy  Teach-back method Depression  Patient Health Questionnaire-9 Substance abuse  AUDIT-C (At-risk Drinking)  CAGE or CAGE-AID (Alcohol and Drug Disorders) 42

43. Other Important Risks Falls Cognitive impairment Pain 43

44. Questions and Answers 44

45. Annual Audits: Monitor and provide feedback to care coordinators on TOC communication process Monitor and meet CMS requirements for providing effective transition support 45

46. Opportunities: Hospital Connect with health plan care coordinator Notify care coordinator of discharge 46

47. Opportunities: Desired Outcomes: Optimize services Decrease confusion Reduce readmissions 47

48. Improving TOC: Summary Care coordinator’s management of transitions and member/patient/family education is key to preventing readmissions The Four Pillars of Optimal Transition are evidenced-based The TOC Log is a dual purpose document:  prompts for care coordinator  an auditable tool 48

49. Questions and Answers 49