1. Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention Monique Parrish, Dr.PH, MPH, LCSW

2. Background: Coleman Care Transitions Model Background: Coleman Care Transitions Model Qualitative Studies – Inadequately prepared for next setting – Conflicting advice for illness management – Inability to reach the right practitioner – Repeatedly completing tasks left undone

3. The “Silent” Care Coordinators By default, older patients and family caregivers function as their own care coordinators First line of defense for transition related errors Model explicitly recognizes their role as integral members of the interdisciplinary team

4. Randomized Controlled Trial

5. VariableInterventionControlP-Value Age (years)76.076.40.52 Female (%)48.252.30.26 Married (%)58.253.80.23 Lives alone (%)30.930.80.99 Sad or Blue (%)30.326.40.24 CHF (%)16.512.90.17 COPD (%)17.018.50.61 Arrhythmia (%)12.819.00.02 CAD (%)14.113.50.81 Chronic Disease Score 6.87.10.31

6. VariableInterventionControlP-Value Prior Hosp (%) 1+ past 6 mo 29.326.10.36 Prior ED (%) 1+ past 6 mo 40.338.90.69 D/C Destin. Home (%) Homecare (%) SNF (%) Other (%) 50.8 24.7 21.0 3.5 52.9 25.9 19.3 1.9 0.71 Friday D/C (%)14.616.50.48

7. VariableInterventionControl Adjusted P-value Re-hospitalized w/in 30 days 8 %12 %0.048 Re-hospitalized w/in 90 days 17 %23 %0.04 Re-hospitalized w/in 180 days 26 %31 %0.28

8. VariableInterventionControl Adjusted P-value Readmit for Same Dx w/in 30 days 3 %5 %0.18 Readmit for Same Dx w/in 90 days 5 %10 %0.04 Readmit for Same Dx w/in 180 days 9 %14 %0.046

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

10. The Care Transitions Intervention: Designed to encourage older patients and their caregivers to assert a more active role during care transitions

11. The Four Pillars

12. Four Pillars Medication Self-Management Patient Centered Health Record (PHR) Primary Care Provider/Specialist Follow- Up Knowledge of Red Flags

13. Pillar #1: Medication Self-Management Focus: reinforcing the importance of knowing each medication – when, why, and how to take what is prescribed, and developing an effective medication management system

14. Pillar #2: Personal Health Record (PHR) Focus: providing a health care management guide for patients; the PHR is introduced during the hospital visit and used throughout the program

15. Key Elements of the Personal Health Record Record of patient’s medical history Red flags, or warning signs Medication list and allergies Advance Directives Structured Checklist of critical activities (instructions, f/u appointments) Space for patient questions and concerns

16. My Medications are: Medication Dose ______________________________ Allergies: _____________________ Reason Side Effects ______________________________ Remember to take this Record with you to all of your doctor visits PersonalHealthRecord The Personal Health Record of: Josephine Patient Personal Information: Address: Home Phone#: Birth Date: Patient ID# PCP Name: Advanced Directives?: Hospitalization Information: Admitted: _/_/_ Discharged: _/_/_ Reason for Hospitalization: ___________________________________________ Caregiver Information: Name: Phone #: Relation to Patient: Personal History Please check any illnesses or health problems listed below that you have ever experienced.  Arthritis  Abnormal Heart Rhythm  Cancer  Diabetes  Hardening of the Arteries  Heart Disease  Heart Failure  High Blood Pressure  Hip Fracture  Lung Disease  Medical/Surgical Back conditions  Pneumonia  Stroke  Other: ____________________ After I leave the hospital… 1. I will write down questions I have about my condition. 2. I will take all bottles of medicine I am using to each doctor visit. 3. I will call _________________ immediately at (XXX) XXX-XXX if I experience any of the following: Temperature above 101° F Uncontrollable pain Increased confusion Increased redness or d drainage around wound Questions about which medications to take Before I leave the hospital…. qI have the instructions I need to keep my health condition from becoming worse. qI know what symptoms to watch out for. qI know the name and phone number of who to call if I see any of these symptoms. qMy family or someone close to me knows what I will need once I leave the hospital. qI know what medications to take, how to take them, and possible side effects. qI will schedule a follow up appointment with my primary care doctor. qI will have a clear and complete copy of my discharge instructions.

17. Goal Attainment “What is one personal goal that is important for you to achieve one month after you get home?”

18. Response Categories 1. I have not worked on it 2. I have not met that goal, but am working on it 3. I have met the goal as well as I expected 4. I have met the goal better than I expected

19. Findings Patients who worked with the Transition Coach were more likely to achieve their goals around symptom control and functional status

20. Pillar #3: Primary Care Provider/Specialist Follow-Up Focus: enlist patient’s involvement in scheduling appointment(s) with the primary care provider or specialist as soon as possible after discharge

21. Pillar #4: Knowledge of Red Flags Focus: patient is knowledgeable about indicators that suggest that his or her condition is worsening and how to respond

22. Key Elements of Intervention “Transition Coach” (Nurse or Nurse Practitioner) – Prepares patient for what to expect and to speak up – Provides tools (Personal Health Record) Follows patient to nursing facility or to the home – Reconciles pre- and post-hospital medications – Practices or “role-plays” next encounter or visit Phone calls 2, 7 and 14 days after discharge – Single point of contact; reinforce, ensure follow up

23. Intervention Activities – Hospital Visit* – Home Visit – 2-Day Follow-Up Call – 7-Day Follow-Up Call – 14-Day Follow-up Call

24. First Interaction (Hospital or Home Visit) Introduce the Program – Structure of the intervention: visits and calls – Role and purpose of the coach – Accessibility of the coach Introduce and complete the Personal Health Record Assure Coverage of Intervention Activities Checklist (Four Pillars)

25. 2, 7 and 14-Day Phone Calls Follow-up on issues discussed during hospital/home visit. Review the Four Pillars as they apply to each patient at the appropriate stage in the transition (see Intervention Activities Checklist)

27. Anticipated Cost Savings For 350 chronically ill older adults with an initial hospitalization, anticipated net costs savings over 12 months: US$ 295,594

28. Coaching What is coaching? How does coaching differ from what nurses, social workers, and community workers do to help patients?

29. Key Attributes for the Transition Coach Ability to shift from a “doing” role to a coaching role Skill and knowledge to manage and reconcile medications A strong enough sense of empowerment to empower a patient and/or caregiver Ability to engage in critical thinking within the framework of a care plan

30. Took Kit for Coaches Medication Discrepancy Tool (promoting Medication Safety) Intervention Activities Checklist PHR

31. Introducing the Medication Discrepancy Tool (MDT) Patient-centered Applicable across a variety of health settings Identify patient- and system-level factors Items need to be actionable at point of care

33. Non-Intentional Non-Compliance Prior to hospitalization, a patient was prescribed Digoxin 0.25 mg daily The patient’s discharge instructions read, “Digoxin 0.125 mg daily” The patient had only the pre-hospitalization 0.25 mg Digoxin pills and had been taking these since discharge

34. Intentional Non-Compliance A patient was admitted to the hospital for COPD exacerbation Following discharge, he was not using his maintenance steroid inhaler because he believed that “that medication makes my breathing worse”

35. D/C Instructions Incomplete or Illegible The patient’s hospital discharge instructions were written as follows: “KCl 10 mEq BID”

36. 14 Percent Experienced 1+ Med Discrepancies 62 percent experienced one 25 percent experienced two 8 percent experienced three 5 percent experienced four or more

37. Patient-Level Contributing Factors Non-intentional non-adherence34% Money/financial barriers6% Intentional non-adherence5% Didn’t fill prescription5% Other1% Subtotal51%

38. System-Level Contributing Factors D/C instructions incomplete/illegible16% Conflicting info from different sources15% Duplicative prescribing8% Incorrect label4% Other7% Subtotal49%

39. 30-Day Hospital Re-Admit Rate Patients with identified med discrepancies 14.3% Patients with no identified med discrepancies 6.1% P=0.041

40. The lack of quality measures for care transitions remains a significant barrier to quality improvement

41. Brief History of the Care Transitions Measure (CTM) Qualitative studies shaped items Transition-specific items => Common set of items Items discriminate among facilities CTM endorsed by NQF in May 2006 Supported by The National Institute on Aging and The Commonwealth Fund

42. CTM Items The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital When I left the hospital, I had a good understanding of the things I was responsible for in managing my health When I left the hospital, I clearly understood the purpose for taking each of my medications

43. Demand for the CTM Over 1400 requests for permission to use from 15 Countries Adopted by WHO multi-national (Europe) hospital quality collaborative Highmark Blue Cross Blue Shield P4P Maine to vote on statewide public reporting

44. Qualitative Evaluation To evaluate the efficacy of the intervention To augment the quantitative findings

45. Conclusion: Qualitative Data Patients appreciated the follow-up, expertise, support and accessibility of the Transition Coach. Reception of the PHR was mixed, with ½ using it, and ½ not at 30+ days post-intervention. Barriers to successful implementation of intervention

46. Transition Coach Competence – “She was always able to answer my questions” Accessibility – “There was somebody I could go to if I needed, if I had any questions, I knew I had somebody I could call.” Security – “I was pretty skeptical about it. But it turned out to be a real beneficial thing…the program gives you a real inner comfort—when you’ve confirmed that you’re doing it right and you know what to expect.”