1. STEP Safe Transitions for Every Patient A CURRICULUM FOR PRIMARY CARE TRANSITIONS IN PRIMARY CARE

2. TODAY’S AGENDA REVIEW NEED TO ADDRESS CONTENT OF PATIENT TRANSITIONS INTRODUCE MNEMONIC - PRIMARY AUDIENCE PARTICIPATION TO FOCUS ON SAFE TRANSITIONS FOR EVERY PATIENT

3. STEP ACGME CORE COMPETENCIES PATIENT CARE MEDICAL KNOWLEDGE PRACTICE BASED LEARNING SYSTEMS BASED PRACTICE PROFESSIONALISM INTERPERSONAL SKILLS & COMMUNICATION

4. DEFINITION OF HANDOFF PER JOINT COMMISSION Handoff relates to the process of passing patient-specific information from one caregiver to another, from one team of caregivers to the next, or from caregivers to the patient and family for the purpose of ensuring patient care, continuity, and safety

5. IS THERE A PROBLEM? PCPs receive feedback from specialists 55% of the time 49% of referrals to specialists have no information 30% of adults seen in an Emergency Room report their PCP was not informed As few as 20% of PCPs received info about discharge plans/meds when their patient is discharged from the hospital

6. IMPACT 1 in 5 patients experiences an adverse event within 2 weeks of hospital discharge 2/3 of these could be prevented or ameliorated with better coordination Nearly 10% of pending lab results at discharge need action but physician was unaware Breakdown in communication was the leading root cause of sentinel events reported to the Joint Commission in the US between 1995 and 2006

7. ASSESSMENT According to Hearst Corp 200,000 die per year from medical errors and/or hospital acquired infections Inadequate or absent care transitions may lead to above negative outcomes Adoption of a consistent communication process should reduce misinformation and improve patient care

8. Transitions on Patient Care Intra-hospital setting Inter-hospital setting Transitions to/from the primary care medical home

9. Patient Physician Hospital Hospitalist Home Health PT/OT Consultant Insurance Patient Centered Medical Home PATIENT CENTERED MEDICAL HOME

10. STEP -Safe Transitions for Every Patient P.R.I.M.A.R.Y. Mnemonic P-person/pt R-reason for transition I-input from “receiver” M- medical course/questions A-assessment R-recommendation / responsible party Y-your turn

11. STEP – IN SUMMARY A PROCESS TO IMPROVE CARE TRANSITIONS TO AND FROM THE MEDICAL HOME DESIGN IS PRIMARY CARE FOCUSED ULTIMATELY IMPROVE MEDICAL CARE FOR THE PATIENT