1. Essential Interventions for Improving Transitions of Care Presented By:Cheri Lattimer, RN, BSN - Executive Director, NTOCC & CMSA NTOCC is a 501(c)(4) nonprofit coalition.

2. Our healthcare system operates in “silos” and information queues – incapable of reciprocal operation with other related management systems & different departments of organizations © Eric A. Coleman, MD, MPH

3. Transition Issues Dramatically Impact Patients & Their Caregivers Patient & Caregiver Caregiver ERERICUICU In-PatientIn-Patient Patient & Caregiver OUTPATIENT: Home Home Home Care Home Care PCP PCP Specialty Specialty Pharmacy Pharmacy Case Mgr. Case Mgr. Caregiver Caregiver Hospice HospiceOUTPATIENT: Home Home Home Care Home Care PCP PCP Specialty Specialty Pharmacy Pharmacy Case Mgr. Case Mgr. Caregiver Caregiver Hospice Hospice SNFSNFALFALF

4. OUTPATIENT: Home Home Care PCP Specialty Pharmacy Case Mgr. Caregiver Hospice Patient & Caregiver ERICU In-Patient Patient & Caregiver SNFALF NO Medication Reconciliation NO Personal Medicine List NO Coordinated Care Plan NO Discharge Care Plan NO Care Plan NO Medication Reconciliation NO Personal Medicine List NO Care Plan NO Medication Reconciliation NO Personal Medicine List Transition Issues Dramatically Impact Patients & Their Caregivers & Providers

5. To Date We Have Not Had Consistent and Accepted Transition Tools Medication Reconciliation Elements Comprehensive Care Plan Health or Clinical Status Transition Summary Patient & Caregiver Tools & Resources Consistent Performance Measures That Apply to All Health Care Settings Accountability for Sending & Receiving Information Consistent HIT solutions for EHR, PHR, MMS

6. Jenks NEJM 2009 Hospital Readmissions SOURCE: Jencks, SF, Williams MV, EA Coleman, EA. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360 (14): 1418-1428

7. Continuum of Care & Spectrum of Services Palliative Care Hospice Doctor's Office Case/Disease Management Long Term Acute Hospital Sub-acute Rehab Home Health Skilled & LTC Specialist Health & Wellness Health Health Enrollment OP Therapies Acute Hospitalization Diagnostic & Treatment Center Skilled Nursing Care Respite Care How will you coordinate care beyond your service?

8. Waves of Change New models of health care delivery and reimbursement are quickly evolving Their success is contingent on effective care coordination This in turn requires interprofessional and transdisciplinary collaboration

9. Goals Of These New Models Minimize fragmentation & improve transitions of careFocus on patient safety and quality of careImprove the patient’s experience with careExpand access to careReduce the cost of effective carePayment that recognizes value of patient-centered care

11. Seven Essential Intervention Categories Source: http://www.NTOCC.org/compendium (2011) Medications Management Transition Planning Patient and Family Engagement / Education Information Transfer Follow-Up Care 1 2 3 4 5 Healthcare Providers Engagement Shared Accountability across Providers and Organizations 6 7 http://www.ntocc.org/Toolbox/browse/

12. Waves of Change Keeping these interventions in mind let’s look at several of the categories and how various programs are having successful outcomes. Thank you Cheri Lattimer RN, BSN clattimer@cm-innovators.com