1. Transitions of Care Coordination of Care Across Settings Mark Hawk, MSN, ACNP Carla Graf, MS, CNS Bree Johnston, MD

2. Objectives Identify all potential acute care setting disciplines/departments that are involved in the care of this population. Identify all potential acute care setting disciplines/departments that are involved in the care of this population. Explain current evidence-based research regarding “models of care” for transitions across acute settings/units. Explain current evidence-based research regarding “models of care” for transitions across acute settings/units. Identify all potential disposition avenues (SNF, rehab, home, etc.) for acutely hospitalized elders. Identify all potential disposition avenues (SNF, rehab, home, etc.) for acutely hospitalized elders. Recognize common obstacles in providing seamless transitions between acute care settings/providers. Recognize common obstacles in providing seamless transitions between acute care settings/providers.

3. Transitions of Care Insurance Insurance Placement needs Placement needs Need for SNF with on-site dialysis Need for SNF with on-site dialysis Support System Support System Occupying inpatient med-surg bed Occupying inpatient med-surg bed Unable to schedule elective surgery Unable to schedule elective surgery Patient outcome Patient outcome

4. Discontinuity Errors 3 types of errors: 3 types of errors: Medication continuity Medication continuity Test result follow up Test result follow up Workup Workup 49% had at least one error 49% had at least one error (Moore JGIM 2003; 18: 646-51)

5. Transition Passage from one place, state, stage of development to another; also the period or place where such a change is effected (Fletcher 2005) Passage from one place, state, stage of development to another; also the period or place where such a change is effected (Fletcher 2005)

6. What is “Transitional Care”? …a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. …a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. (Coleman, 2003)

7. Transitional Care Encompasses both sending and receiving aspects of transfer Encompasses both sending and receiving aspects of transfer Appropriate information sharing Appropriate information sharing Logistical arrangements Logistical arrangements Education of patient and caregivers Education of patient and caregivers Coordination among varied HCP Coordination among varied HCP Absolutely NECESSARY for those with comp,ex care needs (Fletcher, 2005) Absolutely NECESSARY for those with comp,ex care needs (Fletcher, 2005)

8. An 82 yr old with a hip fracture in an acute hospital setting sees… Paramedics Paramedics Emergency Physician Emergency Physician Nursing Nursing Orthopedic Surgeon Orthopedic Surgeon Hospitalist/Intensivist Hospitalist/Intensivist PT/OT PT/OT Social Services Social Services Nutrition Nutrition

9. This 82 yr old with a hip fracture then is “transitioned” to a Skilled Nursing Facility where he/she sees… SNF Physician SNF Physician SNF Nursing SNF Nursing SNF PT/OT SNF PT/OT

10. Then they are “transitioned” home where they see… Home Care Nurses Home Care Nurses Home Care PT/OT Home Care PT/OT PCP PCP PCP Nurse PCP Nurse PC Pharmacist PC Pharmacist

11. What is the common thread? The patient The patient And the caregivers And the caregivers

12. What breaks the common thread? From the patients’ perspective: From the patients’ perspective: Deficiencies in preparing caregivers and the patient themselves for the transition Deficiencies in preparing caregivers and the patient themselves for the transition Transferring of information across settings Transferring of information across settings Supporting self-management of chronic conditions Supporting self-management of chronic conditions No encouragement to express own preferences of the patient or caregiver No encouragement to express own preferences of the patient or caregiver (Coleman, 2003)

13. Patient Perspective According to a California Health Care Foundation survey, patients rated transition to home lower than ANY other health care experience According to a California Health Care Foundation survey, patients rated transition to home lower than ANY other health care experience Qualitative studies suggest that patients often don’t understand medication SEs, whom they should direct questions to, what warning signs to look for, or when to resume normal activities Qualitative studies suggest that patients often don’t understand medication SEs, whom they should direct questions to, what warning signs to look for, or when to resume normal activities

14. What breaks the common thread? From the caregivers’ perspective: From the caregivers’ perspective: Lack of preparation in “what to expect” and how to respond to the changing needs of their loved ones moving between settings Lack of preparation in “what to expect” and how to respond to the changing needs of their loved ones moving between settings (Coleman, 2003)

15. Often, all that is needed is 1 or 2 more days of acute care!

16. Transitional Care for Learners Helps address the systems based practice (and possible practice based learning) competency Helps address the systems based practice (and possible practice based learning) competency May help move learners beyond the culture of rewarding all discharges May help move learners beyond the culture of rewarding all discharges “You’re awesome - you diuresed the service! “You’re awesome - you diuresed the service! (but with what patient outcomes?) (but with what patient outcomes?) May help learners see patients in the context of their own lives May help learners see patients in the context of their own lives

17. Prevalence In 2000 for every 1000 people aged 65 and over they averaged: In 2000 for every 1000 people aged 65 and over they averaged: 400 ambulatory care visits 400 ambulatory care visits 300 emergency department visits 300 emergency department visits 200 hospital admissions 200 hospital admissions 46 SNF admissions 46 SNF admissions 106 home care admissions 106 home care admissions (Coleman, 2003)

18. Prevalence 2001 Harris Poll commissioned by Robert Wood Johnson Foundation 2001 Harris Poll commissioned by Robert Wood Johnson Foundation On average, older people with one or more chronic conditions sees how many different physicians over the course of one year? On average, older people with one or more chronic conditions sees how many different physicians over the course of one year? Eight! Eight! (Coleman, 2003)

19. Prevalence 23% of hospital patients aged 65 and over are discharged to another institution. 23% of hospital patients aged 65 and over are discharged to another institution. 11.6% are discharged with home care. 11.6% are discharged with home care. 19% of SNF patients are transferred back to an acute care hospital within 30 days, 42% within 24 months. 19% of SNF patients are transferred back to an acute care hospital within 30 days, 42% within 24 months. Ma, et al (2002) studied 920 community dwelling elders DCed from hospital to SNF/Rehab… Ma, et al (2002) studied 920 community dwelling elders DCed from hospital to SNF/Rehab… Nearly 50% had four or more additional institutional transitions over a 12 month period. Nearly 50% had four or more additional institutional transitions over a 12 month period. (Coleman, 2003)

20. Why do poor transitions happen? Fragmented Care Fragmented Care Institutional isolation from one another Institutional isolation from one another Lack of financial incentives Lack of financial incentives Regulatory Regulatory Medicare directed towards each “setting” rather than each “episode” of care Medicare directed towards each “setting” rather than each “episode” of care Few quality indicators to measure performance Few quality indicators to measure performance Professional barriers Professional barriers

21. Why do poor transitions happen? Multiple providers unfamiliar with “scope of care/services” at receiving facility Multiple providers unfamiliar with “scope of care/services” at receiving facility PCP doesn’t have privileges at receiving facility PCP doesn’t have privileges at receiving facility Conflicting recommendations about chronic condition management Conflicting recommendations about chronic condition management Confusing medication regimens-error and duplicity Confusing medication regimens-error and duplicity Lack of follow-up care Lack of follow-up care Inadequate preparation of patient and caregiver for receiving care at next facility Inadequate preparation of patient and caregiver for receiving care at next facility Passive Role of the patient/caregiver Passive Role of the patient/caregiver Transitions often urgent and unplanned Transitions often urgent and unplanned

22. Care Transitions Intervention-Four “Pillars” Medication self-management Medication self-management A patient-centered record A patient-centered record Personal Health Record Personal Health Record Use of a Transition Coach Use of a Transition Coach Primary care and specialist follow-up Primary care and specialist follow-up Knowledge of “red flag” warning symptoms or signs indicative of a worsening condition Knowledge of “red flag” warning symptoms or signs indicative of a worsening condition (Coleman et al, 2004)

23. Medication Reconciliation 2001 Harris Poll for RWJ Foundation… 2001 Harris Poll for RWJ Foundation… 16 million adult Americans with chronic illness revealed that their pharmacist told them that medications prescribed by one or more of their physicians had potentially harmful interactions. 16 million adult Americans with chronic illness revealed that their pharmacist told them that medications prescribed by one or more of their physicians had potentially harmful interactions. (Coleman, 2003) (Coleman, 2003)

24. Medication Reconciliation Forster et al, 2003-19% of patients discharged from a hospital experienced an associated adverse event within 3 weeks. Forster et al, 2003-19% of patients discharged from a hospital experienced an associated adverse event within 3 weeks. 66% of those were adverse drug events 66% of those were adverse drug events

25. 2006 JCAHO National patient Safety Goals Goal 8A: Goal 8A: Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medication the organization provides to those on the list. Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medication the organization provides to those on the list.

26. Goal 8B: Goal 8B: A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization.

27. Anatomy of a “good transition” Communication of vital elements of the care plan Communication of vital elements of the care plan A Common Plan of Care A Common Plan of Care The patient’s goals and preferences The patient’s goals and preferences An “updated” list of problems, baseline physical and cognitive functional status, current medications and allergies An “updated” list of problems, baseline physical and cognitive functional status, current medications and allergies Contact information for the patient’s caregiver and PCP Contact information for the patient’s caregiver and PCP Preparation of the patient and caregiver Preparation of the patient and caregiver

28. Anatomy of a “good transition” Reconciliation of medication list “pre” and “post” transfer Reconciliation of medication list “pre” and “post” transfer Transportation of the patient Transportation of the patient Completion of Follow-up care with a practitioner and/or diagnostic studies Completion of Follow-up care with a practitioner and/or diagnostic studies Availability of diagnostic results Availability of diagnostic results Availability of advance care directives Availability of advance care directives “warning signs” and contact information “warning signs” and contact information

29. Why Coordinate Care? Advance “patient-centered” care Advance “patient-centered” care Support for shared decision-making Support for shared decision-making Promote patient safety Promote patient safety Medication use/errors Medication use/errors Control Medicare costs Control Medicare costs Reduce unnecessary utilization/redundancy of care Reduce unnecessary utilization/redundancy of care JCAHO JCAHO

30. What needs to be done? System level performance measurement System level performance measurement Process measures Process measures Is the patient prepared for transfer? Is the patient prepared for transfer? Is the appropriate information promptly transmitted? Is the appropriate information promptly transmitted? Reconciliation of “pre-” and “post”- transition care regimens Reconciliation of “pre-” and “post”- transition care regimens Information technologies Information technologies

31. What needs to be done? Intervention from “oversight” level Intervention from “oversight” level Medicare Medicare JCAHO JCAHO Change payment policies Change payment policies Financial incentives for institutions/providers Financial incentives for institutions/providers Coding and Billing Changes Coding and Billing Changes

32. Research How to best integrate patient and caregiver into interdisciplinary care team How to best integrate patient and caregiver into interdisciplinary care team How to foster collaboration How to foster collaboration How to identify those patients at high risk for poor transition-related outcomes How to identify those patients at high risk for poor transition-related outcomes Development of performance indicators to track quality of transitions Development of performance indicators to track quality of transitions

33. What does work?-A “Bridging” Model Use of APNs to identify those at high risk for re-admission, follow them through hospitalization and then after discharge to home. Use of APNs to identify those at high risk for re-admission, follow them through hospitalization and then after discharge to home. APNs assume responsibility for comprehensive care in collaboration with the PCP for 4 weeks post discharge APNs assume responsibility for comprehensive care in collaboration with the PCP for 4 weeks post discharge

34. Transition Coach Usually Nurse or NP Usually Nurse or NP Prepares patient for what to expect Prepares patient for what to expect Provides tools Provides tools Follows patient to home or nursing facility Follows patient to home or nursing facility Reconciles pre- and post- discharge medication Reconciles pre- and post- discharge medication Practices role play of next MD visit Practices role play of next MD visit Phone calls after discharge Phone calls after discharge Reinforce plan, ensure follow up Reinforce plan, ensure follow up

35. Tools for transitional care Medication Discrepancy Tool Medication Discrepancy Tool Personal Health Record Personal Health Record Care Transitions Measure Care Transitions Measure

36. CARE TRANSITIONS MEASURE (CTM-3) 1. 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. Strongly Disagree Disagree Agree Strongly Agree N/A/dont’ know 2. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. Strongly Disagree Disagree Agree Strongly Agree N/A/dont’ know 3. When I left the hospital, I clearly understood the purpose for taking each of my medications. Strongly Disagree Disagree Agree Strongly Agree N/A/dont’ know

38. What does work?-Other Models APNs enhancing and encouraging the patient’s & caregiver’s participation in their care management APNs enhancing and encouraging the patient’s & caregiver’s participation in their care management Staff from “receiving” facility visits the patient in hospital and initiates the transition Staff from “receiving” facility visits the patient in hospital and initiates the transition Extended Care Pathways Extended Care Pathways Program for All-Inclusive Care of the Elderly (PACE) Program for All-Inclusive Care of the Elderly (PACE) www.SFGetCare.com www.SFGetCare.com www.SFGetCare.com www.sfgov.org/daas (Dept of Aging and Adult Services) www.sfgov.org/daas (Dept of Aging and Adult Services) www.sfgov.org/daas

39. In Summary Problems related to transitional care are common Problems related to transitional care are common There is evidence that enhanced focus on transitional care improves outcomes There is evidence that enhanced focus on transitional care improves outcomes Multiple tools are available that can help us improve our transitional care Multiple tools are available that can help us improve our transitional care

40. In Summary: High Quality Transitional Care Reliable information on transfer Reliable information on transfer Clear instructions about pending tests, follow up visits, follow up tasks, and medications Clear instructions about pending tests, follow up visits, follow up tasks, and medications Preparation of patient, family, and caregiver Preparation of patient, family, and caregiver Empowerment of patient to assert preferences Empowerment of patient to assert preferences

41. References Coleman EA. (2003). Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society. 51: 549-555 Coleman EA. (2003). Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society. 51: 549-555 Coleman et al. (2004). Preparing patients and caregivers to participate in care delivered across settings: the care transitions intervention. Journal of the American Geriatrics Society. 52: 1817-1825 Coleman et al. (2004). Preparing patients and caregivers to participate in care delivered across settings: the care transitions intervention. Journal of the American Geriatrics Society. 52: 1817-1825