1. Hamster Healthcare

2. Rates of Rehospitalization within 30 Days after Hospital Discharge Jencks SF et al. N Engl J Med 2009;360:1418-1428

3. Chronic Illness Epidemic Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update

4. Transitional Care (TC) Defined Transitional care – range of time limited services and environments designed to ensure health care continuity and avoid preventable poor outcomes among at risk populations as they move from one level of care to another, among multiple providers and/or across settings.

5. The Billion Dollar U-Turn

6. Quality is Awful!

7. “The transitional period between sites of care is an especially vulnerable time for patients, often characterized by conflicting medical advice, medication errors, and a lack of additional treatments that might have been avoided. Care transitions interventions are designed to target these problems and ease the transition between sites.” Dr. Eric Coleman, MD Transitional Care Programs

8. Dangers of Discharge ¼ of hospitalized patients need further work up >1/3 are not done Missing discharge summary Family not ready to take patient Lack of understanding Hazards in the home Info transfer is missing

9. Transitions are Dangerous… To… From… Within…

10. "If you think that you can run an organization in the next 10 years as you've run it in the past 10 years you're out of your mind." CEO, Coca Cola

11. ... That Culminated in Complex Legislation March 30, 2010 Public Law No. 111-148: Patient Protection and Affordable Care Act: March 23, 2010 Public Law No. 111-152: Health Care and Education Reconciliation Act of 2010: March 30, 2010 REFORM 11

12. Began Jan. 11, 2010 …. 5 years

13. Tuscaloosa HRR Metro Atlanta East Harlingen HRR NW Denver Whatcom County Evansville Omaha Greater Lansing Area Western PA SW NJ Upper Capital Region Providence RI Baton Rouge Miami 14 QIOs with 14 Target Communities 13

14. The Four Pillars of Care Transitions Medication management Patient-centered record (PHR) Follow-up with PCP/Specialist Knowledge of “Red Flags” or warning signs/symptoms and how to respond –Stoplight Tools Dr. Eric Coleman http://www.caretransitions.org/

15. Transition Coaches The ability to shift from doing things for a given patient to encouraging them to do as much as possible for themselves Competence in medication review and reconciliation, and Experience in activating patients to communicate their needs to a variety of health care professionals.

16. Acute Care Hospitalization and ED: The Number One Target in Healthcare Reform !

17. The Beers List

18. Care Transitions Tools: Medication Discrepancy