1. ADAPTING TRANSITIONAL CARE PROGRAMS WITH PERSON-CENTERED INTERVENTIONS TO IMPACT READMISSION RATES June Simmons, MSW President and CEO, Partners in Care Foundation

2. Partners in Care Foundation

3. Who do we serve? Partners serves older adults, adults with disabilities, and medically fragile adults who require in-home supports after hospital discharge or ongoing supports to avoid institutionalization We offer tailored, person-centered services to patients with diverse health and psycho-social needs in English, Spanish, and Armenian across the state of California Most patients receive managed Medicare

4. Evidence-Based Transitional Care Services Partners offers all three interventions at our CCTP* communities. Care Transitions Bridge Model CTI (Coleman Care Transitions Intervention) HomeMeds In-hospital visit and post- discharge phone calls 30 day duration In-hospital and in-home visits 4 week duration In-Home Medication Review & pharmacist intervention One-time *CCTP: CMS-funded Community-based Care Transitions Program

5. Person-Centered Care Partners’ staff consider which of the 3 care transitions interventions, or combination of interventions, is best suited to decreasing the likelihood of readmission for each individual patient. When selecting an intervention with the patient, we consider the patient’s: Personal goals Level of health risk Social support needs Cognitive status Availability of family/caregivers Neighborhood & local resources Personal comfort and preferences Cultural and linguistic characteristics

6. Interventions Unique to Bridge Set up services prior to discharge Provide discharge preparation information sheet prior to discharge Call patient within 48 hours of discharge Make additional calls or schedule visits to resolve identified problems Use health record to relay information to other providers Track patients progress and address emerging needs at 30-days post discharge Bridge & CTI Pre-discharge hospital visit Assess for and address emerging needs post-discharge Telephone follow-up to ensure adherence to plans Coordinate with other providers and agencies Interventions Unique to CTI Use Personal Health Record (PHR) tool Conduct one home visit 24-72 hours post-discharge Actively engage patient in medication reconciliation Use role-playing and other tools to transfer skills Perform 3 follow-up phone calls to reinforce coaching, self- management, sharing PHR

7. Bridging the Gap Providing flexible, tailored programming for each patient’s needs means reducing readmission risk The Bridge Model allows us to serve patients who: Refuse home visits due to cultural reasons or personal discomfort; Are cognitively impaired and difficult to coach Are still too ill to take responsibility for behavior change Lack caregiver or are otherwise in need of social supports and incapable of making own arrangements Are geographically beyond our reach Across Partners’ 3 CCTP communities, over 9,096 patients were enrolled in the Bridge Model as of 9/30/15.

9. Increasing Bridge Interventions 12/13-9/15

10. Number of Bridge Cases vs CTI Cases

11. A UCLA Study on Partners’ Bridge Patients 7/14-12/14 9.78% Readmission Rate

12. For further information contact: June Simmons, CEO at jsimmons@picf.org Or check our website: picf.org