1. Transitions of Care A Team Based Approach Care Transformation Collaborative of R.I.
Donna Soares RN, CDE, CDOE, CVDOE
Nurse care manager
University Family Medicine

2. Definition of Transitions of Care
Patient movement from one facility to another
Hospital to home, SNF to home, Hospital to rehab etc.

3. Currently in Rhode Island
Realization of high re-admission rates in our state
Many missing pieces in TOC process
eg. Don’t always receive reports from hospitals re: patient updates etc.

4. Before we Started Where do we begin? What do we want to accomplish?
Assess entire process – admission, pre- discharge, discharge, accessing medical records
Assess current internal TOC process flow, then turn to external areas

5. What We Did:
Analyzed existing TOC process via process mapping sessions
Involved entire team in workflow development and implementation
Made NCM aware of all inpatient admissions
Attempt to streamline TOC reports from multiple payers and CurrentCare (Direct Alerts)
MAs are starting point- They notify the NCM as they track faxes, Current care. They inform NCM of where the patient was. NCM gets payer reports, but don’t always find them helpful. We know our patients.
Provider notified of patient discharge by NCM
Med secretaries do follow up appointments. Calls from families informing them of patient admission. Process developed to inform entire team of this.
Need to gather all info in advance of patient appointment.

6. What We Did: Review payer reports – not always reliable
Fine tuned entire process through messaging in the EHR
Analyzed communication process amongst team (Secretaries and Medical Assistants) for TOC
Identified and implemented opportunities via process mapping

7. Things to Consider Available resources Health care resources
Patient discharge needs
Available resources
Health care resources
Community resources
Continuity of care needs
Behavioral health
All these are handled by hospital d/c planner prior to hospital d/c.

8. Patient Example
41 y/o male with muscular dystrophy fell at home on 3/24/ Went to KCMH ER. DX – distal clavicle fracture.
83 y/o grandmother is patient’s caretaker. She called our office on 3/25/2015 to schedule follow-up for him here. She was given an appointment for him for 3/30/2015.
With our process, I was notified of the upcoming appointment before I had notification of ER visit. I contacted patient’s grandmother and was able to facilitate an appointment with orthopedic for 3/27/2015.

9. Results: NCM is not a solo sport
Team involvement is key with the TOC process
PCP needs to be coordinator for TOC
Developed at a glance identification of high risk patients in EHR
Eliminated much of paper trail

10. Results: Dynamic and fluid process Smoother TOC for our patients
Efficiencies gained with workflow redesign
Re-evaluate our re-admission rates

11. Moving Forward Seamless TOC for the patient, for practice staff
Improved communication with all players in the state
Foster partnerships with hospital discharge planning staff and NCM
Involve specialists
Ongoing meetings with Healthcentric Advisors – involving representation from all healthcare arenas (hospitals, SNF’s, home care)
Improved data from payors (timely and actionable)
Triple Aim
lower healthcare costs,
improved satisfaction / experience of care,
improved care across the population)

12. Questions? Thank you! Resources:
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