1. Transitions of Care Debbie Ashworth, BSN, MSHA, ACM
Executive Director, Care Management / Documentation Improvement
Audrey Trammell, BSN, RN
Transitions of Care Coordinator

2. Transitions of care Objectives
Discuss ways to strengthen and expand provider support as a way to improve care transitions
Discuss initiatives to decrease hospital readmissions and how PCP’s and Post acute providers can assist with initiatives
Discuss ways to promote improved health outcomes through improved provider communication

3. Transitions of care

4. Transitions of Care
Every Patient should have a Patient-Centered Medical Home and Personal Provider
Provide Appropriate Quality Personal Care to each patient during your time of responsibility
Provide Accurate, Appropriate and Real-time data to the next care team at time of transition
Follow up after transfer to confirm transition has occurred

5. Patient Centered Medical
Transitions of Care
Patient Centered Medical
Home
Hospital
Rehab
Skilled Care
Health information
Demographics
Personal Healthcare Information
Care Plan
Follow up

6. The Right Healthcare Provider
Transitions of care
Do It Right
The Right Patient
The Right Service
The Right Time
The Right Place
The Right Healthcare Provider

7. Transitions of Care Passing the Baton
Demographics (Name, Birthdate, SS #, Health insurance)
Patient-Centered Medical Home (Personal Provider)
Medical diagnosis
Medications
Allergies
Advanced Directives
Recent Surgeries and Procedures
Appropriate Diagnostic and Lab Reports
Brief Summary of Care Provided
Treatment Plan

8. Patient Centered Medical Home NEEDS TO KNOW WHAT’S GOING ON
Transitions of care
Patient Centered Medical Home NEEDS TO KNOW WHAT’S GOING ON
Hospital system needs accurate contact information for every Patient Centered Medical Home/Primary Care Providers
Notification system in place that inform PCMH of Emergency Room Visits, Admissions and Discharges of all designated patients within 24 hours of the event
Computer Access to all PCMH for medical records of Patient’s Assigned to Medical Home/Personal Provider
Ability to schedule follow up appointments with PCMH within 7 days of discharge from Hospital
Data transfer to PCMH of Transition Data within 1 business day

9. Direct Messaging
Direct is a standards-based transportation mechanism that can help healthcare professionals securely send messages to other providers, patients, or other authorized entities such as hospitals, pharmacies and laboratories from their EMR (electronic medical record).
Direct is similar to but includes special security requirements to encrypt health data to be sent out of the EMR and ensure the receiver has been authenticated.

10. How providers benefit from direct messaging
Direct offers secure delivery of health information for immediate use by healthcare providers, enabling physicians and hospitals to increase efficiency and lower costs
Exchange of paper records is slow, expensive and inadequate for quality care
Too often, PCPs seeing patients following hospitalization are forced to ask patients “What happened in the hospital?”

11. How providers benefit from direct messaging
Computer processing of information received through fax or US mail is not possible.
Traditional and phone call exchanges may violate HIPPA requirements

12. Direct messaging
HEALTH INFORMATION MANAGEMENT DEPARTMENT PAT HARWELL – TRACY HICKEY –

13. Transitions of care – Measures
Readmissions within 30 days
Return visits to Emergency department within 30 days
Number of Emergency department visits in a 6 month period
Number of discharges that have a scheduled transition/follow up visit within 7-14 days of discharge
Number of transfers from Skilled Care/Rehab to hospital and readmissions
Percent of patients presenting to Emergency Department with a known PCP/PMCH

14. Transitions of care

16. Disease Management Program- LIFT
Teach patients how to manage chronic diseases to reduce morbidity and mortality (and improve quality of life)
Reduce unnecessary ED visits and hospitalizations, especially for safety net population
Improve coordination of care after hospital discharge, especially between primary care, specialists
Decrease readmission rates in CHF, Diabetes, and COPD
Expand access to primary care and behavioral health
Address social determinants of health by assisting with social needs (transportation, affordable meds, etc.)

17. Disease Management Program- LIFT
Disease Management receives a list of all patients discharged from one of our hospitals with one of 4 diagnoses:
COPD, CHF, Diabetes and Asthma
Automated Referrals based on Labs:
A1C
Blood Sugar
NP/Doctor/Cardiologist Referral
Self Referrals

18. Disease Management Program- LIFT
Multi-Disciplinary Approach
Registered Nurse
Pharmacist
Dietitian
Social Worker
Respiratory Therapist
Nurse Practitioner
Behavioral Health Counselor

19. Disease Management Program- LIFT
Quarterly themed food demonstrations to teach how to cook more healthy
Focus on specific months with an emphasis on
Heart
Stroke
Diabetes

20. Disease Management Program- LIFT
How to make a referral? Call

21. Cardiac rehab Cardiac Rehab Jackson Dyersburg Martin
Bolivar – Coming Fall 2019
Increasing Access to Quality Cardiac Rehabilitation Care Act of 2019, H.R , was introduced by U.S. Representatives John Lewis (D-GA) and Adrian Smith (R-NE). The bill enables qualified nurse practitioners, physician assistants, and clinical nurse specialists to order and refer for these services) . ( expanded-access-to-cardiovascular-rehab- services?utm_campaign=advocate&utm_medium= _newsletter&utm_source=advocate&utm_content= )

22. Heart Camp / Joint Camp
New process to help streamline the Preadmission process by being proactive and teaching the patients before the procedures
Developing a plan of care to help decrease length of stay and planning for discharge upon admission
Developing a teaching booklet that is used by multi disciplines that will be utilized in the boot camp.

23. Transitions of care – Initiatives
Developing Care Pathways for patients with CHF and COPD
Multiple initiatives being worked on regarding transitions of care:
COPD
CHF
Behavioral Health Pilot with Post Acute Providers
CHF / COPD Pilot with Post Acute Providers
Reducing UTI’s Pilot with Skilled Nursing Facilities
Integrated Care Processes
Transitions Team working on processes of transitioning patients between all levels of care
Readmission group with all providers in West Tennessee (except Shelby Co)
Transitions of Care processes

24. Debbie Ashworth, BSN, MSHA, ACM
Audrey Trammell, BSN, RN