1. Transitions of Care : Implications for Inter-Professional Clinical Education

2. The Message from CMS Current Health Care Costs are Unsustainable Triple Aim – Better Health – Better Healthcare – Lower Costs 2

3. Multiple Chronic Conditions Target of New CMS Strategy More than ¼ of Americans have multiple chronic conditions 2 out of 3 older Americans Treatment for them accounts for 66% of health care budget

4. Coming Readmission Penalties  Almost 1 out of every 5 Medicare FFS discharges (19.5%) are readmitted within 30 days  34% of discharges were readmitted within 90 days  Estimated annual cost to CMS = $17.4 Billion Jenks, S et al. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. NEnglJMed 2009: 360:1418-28

5. Readmissions are a Symptom It’s not about readmissions. Readmissions are a symptom Readmissions are a failure in healthcare system It is about the quality and outcomes of the underlying care being provided Real goal is to change the health care delivery system Linda Magno, CMS

6. Health Care Delivery “System”  Independent actions by many -- We pay individuals not teams Sofaer  Narrow perceived accountability –We are all specialists Naylor  Lack of systems to bridge transitions Naylor  No integrated health care record Lynn  No feedback to clinicians on quality of care Lynn

7. No Investment in Systemness Fee-for-service payment encourages specific, condition-oriented care, by which an individual with multiple conditions is treated by multiple providers Fee-for-service model allots more generous payments for procedures and specialists’ services, thereby discouraging physicians from entering the primary care fields that are more compatible with the role of care coordination Guterman, Stuart “ENHANCING VALUE IN MEDICARE: CHRONIC CARE INITIATIVES TO IMPROVE THE PROGRAM” 2007

8. Health Care System is an Oxymoron AA Medicare patient sees 2 PCPs and 5 specialists in 4 different practices in a year Pham AA PCP seeing 257 Medicare patients a year has network of 183 peers in 108 different practices Pham –5–55 other PCPs –5–55 medical Specialists –5–55 surgeons And no common record! *Edgman-Levitan

9. A View from the Bed and Bedside The patient is the only unifying thread across the continuum of care Family caregivers are the de facto care coordinators Family caregivers are “disenfranchised care contractors and coordinators” HIPAA became a good excuse not to communicate with family caregivers…” Yet, they provide care over years…and years….and years Carol Levine, National Quality Forum, March 27, 2008

10. Outcome of Fragmented System  1/4 to 1/3 of older patients with chronic conditions have to return to the hospital due to complications that could have been prevented Naylor  For transfers to SNF, 19% of patients are transferred back to hospital within 30 days. One-third of these are unnecessary Coleman  For community dwelling older adults that are hospitalized and then go to SNF or Rehab, nearly 50% underwent 4 “transitions” over the next year Coleman

11. Discharge Planning vs. Transitions of Care  67% of hospitalized patients reported having their medications reviewed at the time of discharge Commonwealth Fund  The average transition from hospital includes a medication error Lynne  81% of patients requiring assistance with basic functional needs failed to have a home care referral, and…  64% said no one at the hospital talked to them about managing their care at home Clark

12. Arbaje

13. CMS is testing various solutions All of them are focused on complex, chronic, frail Medicare beneficiaries Poor transitional care is especially dangerous for older adults and those with complex, chronic illness If you have a transition in the past, you are at highest risk for another transition Magno

14. New Competencies Needed Power of senders and receivers meeting together Moving past blame and finger-pointing Establishing standard communication processes Addressing shared health information IHI

15. Working as a Team Across Boundaries “When it comes to strong care transitions of complex patients at the end of a hospital stay, the hands that discharge and receive the patient are equally important” Sound Practices, 12/20/11 Sound Physicians

16. Audience Questions 16 How do these comments affect your practice and profession? Are you aware of similar efforts locally? How are insurance companies involved? What barriers do you see to implementing a care transitions approach? Have you been involved in such an activity in your practice setting? As a clinical educator, what are two or three teaching points you can add to courses you teach?