1. Care Coordination Damien Doyle MD/CMD/FAAFP Medical Director
Optum HealthCare of MidAtantic
Staff Physician
Charles E. Smith Life Communities

2. “The single biggest problem with communication is the illusion that it has taken place”
George Bernard Shaw

3. System vs. Patient – An inherent Conflict
Care delivered by specialized practitioners with narrow focus
Organizations deliver care along product lines and specialties and are site specific
Patients are increasingly complex with a greater variety of co-morbidities managed in a growing variety of settings

4. Too many cooks….
Typical Medicare beneficiary sees an average of 2 PCPs and 5 specialists annually
Who coordinates this care?

5. Care Coordination Definition
Many definitions exist and this is part of the confusion
“The term ‘care coordination’ has no well-established definition. Rather, it is generally understood to mean a process of improving communication among the various medical professionals with whom patients come in contact and between these professionals and the patients themselves (and their families).” Brown 2004

6. Care Coordination Definition
From the National Library of Medicine, Closing the Quality Gap Vol. 7 “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services.”

7. Care Coordination Goals
(1) identify the full range of medical, functional, social, and emotional problems that increase patients' risk of adverse health events
(2) address those needs through education in self-care, optimization of medical treatment, and integration of care fragmented by setting or provider
(3) monitor patients for progress and early signs of problems
Such programs hold the promise of raising the quality of health care, improving health outcomes, and reducing the need for costly hospitalizations and medical care.”
Chen 2000

8. Transition of Care Definition
Movement of patients between health care locations, providers or different levels as their care needs change
Within settings
PCP to specialist
ICU -> ward
Between settings
Hospital -> Subacute or Home
Across health states
Curative -> Palliative
AMDA Transitions of Care Practice Guideline 2010

9. Care Transitions: Definition
“Care Transitions” refers to the movement patients make between health care practitioners and settings as their conditions and care needs change during the course of a chronic or acute illness 9

10. Transition of Care are critically and inherently linked
Care Coordination and
Transition of Care are critically and inherently linked

11. Charles E. Smith Life Communities21
Charles E. Smith Life Communities
OUR SPECTRUM OF SERVICES
Most Acute
Most Restrictive
Medical
Model
Least Acute
Least
Restrictive
Social
Subacute
Home Living
Support
Independent
Living
CARE MANAGEMENT
Hebrew Home
70 Bed Unit
Hirsh Health Center 1991
Ring 1989 (
250 Apts.)
Revitz 1978
(250 Apts.)
451 Beds
Wasserman
1969
Smith -
Kogod
1981
Landow House 2005
60 Units
Outpatient
Diagnostic &
Treatment
Assisted
Nursing Home
Home Care Solutions, LLC
Joint Ownership Augustine Home Health
2000
37 Total Acres

12. Is This Really a Problem?
~ 10% of all NH residents had an ED visit in past 90 days (Caffrey, US Dept HHS 2004)
Of these, 40% have a potentially preventable cause
Of Patients who are hospitalized,
19% re-hospitalized within 30 days
42% re-hospitalized within 24 months
Hard to define what is the appropriate/expected number

15. What illustrates bad Care Coordination
Medication Errors
Increased Health Care Utilization
Inefficient/Duplicative Care
Inadequate patient/caregiver preparation
Inadequate follow-up care
Dissatisfaction
Litigation/Bad publicity
Eric Coleman, MD/MPH
University of Colorado, Denver

16. High Risk for Transition Problems
Multiple Medical Problems
Dementia
Depression or other Mental Health issues
Isolated – lack of caregivers
Poverty
Non-English speaking
Minorities
Recent immigrants and refugees
IE, most of our patients!

17. What are the Common Factors?
Most transitions are unplanned and due to acute illness
Patients are vulnerable – functional loss, delirium, pain and anxiety are all common
Only true common factor is the patient themselves

18. What Can We Do?
Move?
Give up?

19. Safer Coordination Communication Medication Reconciliation
Patient Centered Care
End of Life Care – Patient driven plan of care

20. Safer Coordination - Communication
Discharge Instructions – Expectations
Shift the concept of “discharge” to “transfer with continuous management”
Begin transfer planning upon admission
Incorporate patient/caregiver preferences
Identify social support and function
Collaborate with practitioners across the spectrum

21. Safer Coordination – Communication
Expectations for the Transferring Team
Patient is Stable
Patient and caregiver understand the purpose of the transfer
Patient and caregiver understand their coverage
Receiving institution is capable and prepared
Care plan, orders, and clinical summary precede the patient’s arrival
Timely follow-up is arranged

22. Safer Coordination – Communication
Expectations for the Receiving Team
Review the transfer forms, clinical summary and orders
Incorporate the patient/caregiver goals and preferences
Clarify any discrepancies regarding the care plan, patient’s status or medications

23. Care Coordination Models
Key national models
Care Transitions Program
Transitional Care Model
Transforming the Care at the Bedside
Project RED (Re-Engineer Discharge)
Project Better Outcomes for Older adults through Safe Transitions (BOOST) 23

24. Care Transitions: Four Pillars Coleman, Univ. of Colorado www
Care Transitions: Four Pillars Coleman, Univ. of Colorado
Celtic Healthcare 24

25. Transitional Care Model Naylor, Univ. of Pennsylvania
Celtic Healthcare 25

26. Transforming The Care at the Bedside Model Institute of Healthcare Improvement
Celtic Healthcare 26

27. Project RED Boston University
Celtic Healthcare 27

28. Home Healthcare Role Transition Coach” (Nurse or MSW)
Prepares patient for what to expect and to speak up
Educated on use of a Personal Health Record
Educates the care team in home of patient’s needs
Follows patient to the home
Reconcile pre- and post-hospital medications
Practice or “role-play” next encounter or visit
Phone calls after discharge
Single point of contact; reinforce, ensure follow up
Does not replace hospital discharge planning!
Celtic Healthcare

29. Specialized Care Models
ISNP (Institutional Special Needs Population) – Medicare Advantage Programs
Home Care Management Programs
NORC (Naturally Occurring Retirement Communities)

30. Resources and References
Home Health Quality Improvement Campaign
Original Campaign Transitional Care Coordination Best Practice Package and resources
Current Campaign
Care Transitions Program
Coleman, E., et. Al. (2006). ARCH INTERN MED., Vol. 166. 30

31. Care Transition Tools and Resources (cont.)
Medication Management Tools
Collaboration for Homecare Advances in Management and Practice (CHAMP) Program
Barriers to Medication Adherence, Medication Management Evidence Brief, Reducing Adverse Drug Events
Beers Criteria, ARMOR Polypharmacy Tool, How to Write a Pill Card, Medication Reconciliation Process, Risk Assessment for Non-adherence, Script for Adherence Counseling, Speak Up Brochure – Help Avoid Mistakes with Your Medicines, Tips for Preventing Problems When Taking Multiple Medications, Your Medications – What to ask 31

32. “There was an important job to be done and Everybody was sure that Somebody would do it. Anybody could have done it, but Nobody did it… Everybody blamed Somebody when Nobody did what Anybody could have done”
Anonymous