1. Why are we involved? Transitions of Care: What We Need to Know www.ntocc.org

2. Current State of Healthcare Care is complex Care is complex Care is uncoordinated Care is uncoordinated Information is often not available to those who need it when they need it Information is often not available to those who need it when they need it As a result patients often do not get care they need or do get care they dont need As a result patients often do not get care they need or do get care they dont need IOM, Crossing the Quality Chasm

3. What is Transition of Care The movement of patients from one health care practitioner or setting to another as their condition and care needs change The movement of patients from one health care practitioner or setting to another as their condition and care needs change Occurs at multiple levels Occurs at multiple levels – Within Settings Primary care Specialty care Primary care Specialty care ICU Ward ICU Ward – Between Settings Hospital Sub-acute facility Hospital Sub-acute facility Ambulatory clinic Senior center Ambulatory clinic Senior center Hospital Home Hospital Home – Across health states Curative care Palliative care/Hospice Curative care Palliative care/Hospice Personal residence Assisted living Personal residence Assisted living (c) Eric A. Coleman, MD, MPH

4. What is Transitional Care? A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location Based on a comprehensive care plan and availability of well- trained practitioners that have current information about the patient's goals, preferences, and clinical status. Based on a comprehensive care plan and availability of well- trained practitioners that have current information about the patient's goals, preferences, and clinical status. Includes: Includes: – Logistical arrangements – Education of the patient and family – Coordination among the health professionals involved in the transition Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.

5. Ineffective Transitions Lead to Poor Outcomes Wrong treatment Wrong treatment Delay in diagnosis Delay in diagnosis Severe adverse events Severe adverse events Patient complaints Patient complaints Increased healthcare costs Increased healthcare costs Increased length of stay Increased length of stay Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature Review Report. March 2005. Available www.safetyandquality.org/internet/safety/publishing.nsf/Content/ AA1369AD4AC5FC2ACA2571BF0081CD95/$File/clinhovrlitrev.pdf

6. PatientPatient ERERICUICU In-PatientIn-Patient PatientPatient OUTPATIENT: Home Home PCP PCP Specialty Specialty Pharmacy Pharmacy Case Mgr. Case Mgr. Care Giver Care GiverOUTPATIENT: Home Home PCP PCP Specialty Specialty Pharmacy Pharmacy Case Mgr. Case Mgr. Care Giver Care Giver SNFSNFALFALF Transition Issues Dramatically Impact Patient Care

7. Patient ERICU In-Patient Patient OUTPATIENT: Home PCP Specialty Pharmacy Case Mgr. Care Giver SNFALF NO Medication Reconciliation NO Personal Medicine List NO Coordinated Care Plan NO Discharge Care Plan NO Care Plan NO Medication Reconciliation NO Personal Medicine List NO Care Plan NO Medication Reconciliation NO Personal Medicine List

8. What Can We Do …

9. Keep A Medication List Develop your My Medicine List Develop your My Medicine List You can get started with a simple tool by NTOCC You can get started with a simple tool by NTOCC Download the tool from the website Download the tool from the website Complete the tool with your personal medications Complete the tool with your personal medications Share that information with each clinician you see whether in the ER, hospital, doctors office, clinic or pharmacy Share that information with each clinician you see whether in the ER, hospital, doctors office, clinic or pharmacy

12. SNFSNFALFALF ERERICUICUIn-PatientIn-Patient The NTOCC Tools Make it Possible to Address the Transition Issues OUTPATIENT: Home Home PCP PCP Specialty Specialty Pharmacy Pharmacy Case Mgr. Case Mgr. Care Giver Care GiverOUTPATIENT: Home Home PCP PCP Specialty Specialty Pharmacy Pharmacy Case Mgr. Case Mgr. Care Giver Care Giver PatientPatient My Med List Medication Reconciliation Data Elements + Care / Case Transition Process

13. www.ntocc.org Watch for New Patient Tools Over the Next Few Months