1. For the Healthcare Provider
Transitions of Care
Atrial Fibrillation

2. Table of Contents What is Transitions of Care?
Efficacy of Transitions of Care Approach
Project Scope
The Role of the Provider
The Role of the Patient
Resources
Action Requested and Timeline
Feedback Survey

3. Background and CHallenges
Most commonly diagnosed arrhythmia disorder
2.3 million people in U.S. living with AF
- 160,000 new cases annually
Patients with multiple chronic conditions can visit ~16 physicians annually
AF is responsible for 88,000 deaths per year
- $16 billion in healthcare costs
Challenge of coordinating basic information (e.g., test results, prescription medications, diagnosis)
Poor coordination often leads to adverse clinical outcomes, increased re-admissions, over-utilization of health care services, and untimely follow-up

4. Transitions of Care Definition
Transitions of Care refer to the movement of patients between health care locations, providers, or different levels of care within the same location as their conditions and care needs change.
Specifically, they can occur:
Within settings
Between settings
Across health states
Between providers

5. Care coordination definition
Care coordination is a function that helps ensure the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time. Coordination maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and high-quality patient experiences and improved healthcare outcomes.

6. Principles Care coordination is important for everyone
Some populations are particularly vulnerable
Care coordination measures may be appropriate at the clinician-level; others may be appropriate at the group, practice or organizational-level
Patient/family surveys are essential to measure care coordination; performed within close proximity to the healthcare event

7. Elements of transitions of care
Medication reconciliation
Follow-up tests and services
Changes in plan of care
Involvement of team during hospitalization, discharge, follow-up, etc.
Communication
Transfer of all information when site of care changes
Education of the patient and family

8. National care coordination goals
Healthcare organizations and their staff will continually strive to improve care by soliciting and carefully considering feedback from all patients and their families regarding coordination of their care during transitions.
Medication information will be clearly communicated to patients, family members, and the next healthcare professional and/or organization of care, and medications will be reconfirmed at each transition.
All healthcare organizations and their staff will work collaboratively with patients to reduce 30­-day readmission rates.
All healthcare organizations and their staff will work collaboratively with patients to reduce preventable emergency department visits.

9. Efficacy of transitions of care
Hospital to Home – ACC & IHI national quality improvement initiative to reduce cardiovascular-related hospital readmissions and improve the transition from inpatient to outpatient status for individuals hospitalized with cardiovascular disease (e.g., heart failure)
Medication management
Follow-up
Symptom management

10. Transitions of Care AND Provider Payment
Provider payments are shifting toward the key elements of Care Quality and Care Coordination
By 2015, providers will be required to document quality improvement indicators or face decreases in reimbursement
By 2017, Medicare reimbursement will be adjusted based on documented quality outcomes for all physicians
Capturing those indicator data will aid in either enhancing existing care protocols or developing new ones

11. Afib transitions of care goal
Project Goal:
To develop practical resources to encourage best practices in clinical decision-making, patient-provider communication, and patient self-management.

12. role of the Care provider
Engaging Mended Hearts Volunteers
Making a referral to post-ablation patients
Review Patient Care Pathway
Patient Care Plan
Review Patient Discharge Checklist (provided in patient kits)
Review AF Educational Resources (provided in the patient kits)

13. Role of the Mended hearts volunteer
Understand the Patient Care Pathway
Peer-to-peer patient support
Patient Care Plan (No interpretation of orders/prescriptions)
And what is it and why is this important?
Patient Discharge Checklist (General)
Atrial Fibrillation Educational Resources

14. role of the patient and caregiver
Understand the Patient Care Pathway
Patient Care Plan
And what is it and why is this important?
Patient Discharge Checklist
Atrial Fibrillation Educational Resources

15. Provider/patient Kit resources
Provider Resource Kit
Best practices
Patient care plan
elements
Discharge checklist
Transition record checklist
Mended Hearts Info
Patient Resource Kit
Elements of a care plan
Patient discharge checklist
Role of the caregiver
Guide to AFib brochure
AFib Patient DVD
Mended Hearts Info

16. Feedback surveys Healthcare Provider Mended Hearts Volunteer Patients
Web-based / monthly survey - 4 questions
Mended Hearts Volunteer
Telephone / Web-based surveys – Monthly/Quarterly
Patients
Postcard / Received during visit – 4 questions for 30 days post event

17. Questions?
Thank You!