Community Care Coordination Cross Continuum Care IHC Medical Home Conference September 5, 2012 Des Moines IA

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1 Community Care Coordination Cross Continuum Care IHC Medical Home Conference September 5, 2012 Des Moines IA Peg Bradke, RN, MA Director of Heart Care Services St. Luke s Hospital, Cedar Rapids, IA Session Objectives This session will discuss cross continuum team improvement strategies and office practice process implementation to create ideal transition home management. Learn about enhanced teaching, Teach Back, learning and assessment opportunities for improvement in the office practice setting. 2 What We Are Learning About Timely Follow Up Care There is no consensus about how soon patients need to be seen after discharge from the hospital. In general, it is a challenge to schedule appointments with office practices. Hospitals need to create processes for assigning patients to primary care provider if they don t have one. Follow up phone calls give caregivers the opportunity to reinforce education and assess self care knowledge through the use of Teach Back, but often, patients are receiving multiple calls. Need a much deeper understanding of how best to meet the needs of high risk patients: front loaded home care visits, office practice appointments within 48 hours, supplemental transitional care by APNs or RNs or intensive care management through primary care or health plans? 3 1

2 I had a great time tonight, and I d like to see you again in four to six weeks. 4 Ensure Timely Post Hospital Follow Up Typical Failures: Medication errors; Discharge instructions that are confusing, contradictory to other instructions, or not tailored to a patient s level of health literacy; Lack of scheduled follow up appointment with appropriate care providers, including specialists; Follow up visit too long after hospitalization; Follow up visit made the sole responsibility of the patient; Lack of an emergency plan with number the patient should call first; Multiple care providers, resulting in patient confusion about which provider is in charge; Lack of patient social support 5 Need for a Paradigm Shift Past Focus Traditional focus on discharging patients a handoff D/C to home Hospital problem Focus is on what clinicians are teaching Patient is the recipient of the care Immediate focus on clinical needs Focus on patient care needs in each setting Focus Going Forward Facilitating transitions in care with a shift to handover (senders and receivers codesign the process) Admission to Home (30 day LOS) Continuum issue Focus on what the patient is learning Patient and defined family are essential members of the care team. Initiating a post acute plan to meet the comprehensive needs of the patient. Focus on the whole person and their needs within social situation over time Focus on the patient s experience over time 6 2

3 Critical Capabilities for Care Redesign Include: Cross continuum participation and alignment The development and use of standardized tools and compatible information infrastructure Horizontal leaderships and executive sponsorship; and Effective external and internal learnings 7 Vision for Cross Continuum Teams Understanding mutual interdependencies, the hospital based teams co design care processes with their cross continuum care partners and collaborate to solve problems to improve the transition out of the hospital and reception into community settings of care. 8 Cross Continuum Teams One of the most transformational changes in the STAAR Collaborative. Reinforces that readmissions are not solely a hospital problem. New competencies in partnering across care settings will be a great foundation for integrated care delivery models. Secondary objectives come into focus: develop data analytics, performance improvement, clinical integration, and other competencies critical for additional value based reforms. 9 3

4 CCT s Role in Ensuring Post Hospital Care Follow Up Determine ideal timing for follow up clinic appointment. Determine who is the best clinical provider (from the patient s perspective) to complete follow up phone calls. Design Patient Education materials to use across the continuum that are consistent and build on needed information as patient progresses. Collaborate with payers and post acute care providers to determine eligibility for intensive care management and best clinical provider for various patient populations (Care Transitions Intervention, APN Transitional Care, HF Clinic, Patient Centered Medical Home, Evercare, etc.). Other emerging best practices? 10 Timely Post Hospital Follow Up Follow up phone calls can be conducted by various caregivers such as Advance Practice Nurses, staff at a call center, a case manager, or the nurse who cared for the patient while in the hospital. During calls, verify (using teach back) that: The patient understands how and when to take medications and other critical elements of self care. The patient recalls why, when and how to recognize worsening symptoms and when and how to call for help. The patient will keep the physician appointment. 11 Hospitalist Partnering with Primary Care Randomized, controlled study. Connecting patients to their primary care after discharge. Intervention patients received a user friendly Patient Discharge Form. Upon arrival home, a telephone outreach call from a nurse at the primary care side. Balaban, Richard, MD. J Gen Intern Med 22(08):

5 Results Only 25.5% of intervention patients had 1 or more undesirable outcomes compared to 55.1% of the concurrent control group. Only 14.9% of the intervention patients failed to follow up within two days compared to 40.8% of controlled. Only 11.5% of recommended outpatient workups in the intervention group were incomplete versus 32.2% in the concurrent group. 13 High Risk Patients Patient has been admitted two or more times in the past year Patient or family caregiver is unable to Teach Back, or the patient or family caregiver has a low degree of confidence to carry out self care at home Moderate Risk Patients Patient has been admitted once in the past year Patient or family caregiver is able to Teach Back most of discharge information and has a moderate degree of confidence to carry out self care at home Low Risk Patients Patient has had no other hospital admissions in the past year Patient or family caregiver has a high degree of confidence and able Teach Back how to carry out selfcare at home 14 Prior to discharge: High Risk Patients Moderate Risk Patients Prior to discharge: Low Risk Patients Prior to discharge: Schedule a face to face follow up visit within 48 hours of discharge. Care teams should assess whether an office visit or home health care is the best option for the patient. If a home health care visit is scheduled in the first 48 hours, an office visit must also be scheduled within 5 days. Initiate intensive care management programs as indicated (if not provided in primary care or in outpatient specialty clinics (e.g. heart failure clinics) Provide 24/7 phone number for advise about questions and concerns. Initiate a referral to social services and community resources as needed Schedule a follow up phone call within 48 hours of discharge and schedule a physician office visit within 5 to 7 days. Initiate home health care or transitional care services (eg. CTI) as needed. Provide 24/7 phone number for advise about questions and concerns. Initiate a referral to social services and community resources as needed. Schedule a followup phone call within 48 hours of discharge and schedule a physician office visit as ordered by the attending physician. Provide 24/7 phone number for advise about questions and concerns. Initiate a referral to social services and community resources as needed. 15 5

6 Post Hospital Follow up Visit Coleman, EA. The Post Hospital Follow Up Visit: A Physician Checklist to Reduce Readmissions. California Health Care Foundation Issue Brief, October Laying the Groundwork Meet with hospitalists to redesign summary. Action oriented If/Then statements Mode and timeliness of communication Create access for hospital follow up visits Prior to the Visit Review discharge summary. Clarify outstanding questions. Reminder call to patient or family caregiver. Stress importance of visit and address barriers. Remind to bring medication lists and all meds. Provide instructions for after hours care

7 During the Visit Ask the patient to reflect on the factors that may have contributed to hospital admission. Perform medication reconciliation. Instruct patient in self management. Explain warning signs and how to respond. Provide instructions for seeking after hours care Provide Effective Teaching and Facilitate Learning Clinicians readily embrace Ask Me 3 and Teach Back techniques to enhance patient and family caregiver education. There is value in planning multiple teaching sessions with patients and family caregivers. There is a need for uniform and patient friendly teaching materials in all clinical settings for the common clinical conditions. Change documentation fields in EMR from what has been taught to what is the patient s understanding of? 20 IOM, 2004: Health Literacy is fundamental to quality care Relates to 3 of the 6 aims in IOM Quality Chasm Report: Safety Patient centered care Equitable treatment 21 7

8 Health Literacy If they don t do what we want, we haven t given them the right information. Vice Admiral Richard Carmona, Former Surgeon General 22 Closing the Loop Checkpoints to evaluate how well transactions are going How well we are doing giving the information How often do we close the loop? 23 Paradigm Shift The patient is noncompliant vs. Asking: What is our responsibility as the sender of the information? 24 8

9 Enhanced Teaching and Learning Utilizing Teach Back Explain needed information to the patient or family caregiver. You do not want your patient to view teach back as a test, but rather of how well you explained the concept. You can place the responsibility on yourself. Can be both a diagnostic and teaching tool. 25 Using Teach back Ask in a non shaming way for the individual to explain in his or her own words what was understood. Example: I want to be sure that I did a good job of teaching you today about how to stay safe after you go home. Could you please tell me in your own words the reasons you should call the doctor? 26 Enhanced Teaching and Learning Redesign patient teaching: Stop and check for understanding using teach back after teaching each segment of the information. If there is a gap, review again. If your patient is not able to repeat the information accurately, try to re phrase the information rather than just repeat it. Then, ask the patient to repeat again until you feel comfortable that the patient understood. 27 9

10 Redesign Patient Teaching Slow down when speaking to the patient and family, and break messages into short statements. Take a pause. Be an active listener. Use plain language, breaking content into short statements. Segment education to allow for mastery. 28 COPD Teach back Questions What should you do first if you are having more trouble with your breathing? What is the name of your fast acting/rescue inhaler? How often do you use it? If your shortness of breath continues without getting better, what should you do? What are the warning signs for you that would indicate that you should call your doctor? What should you do to prevent from having a flare up (getting worse) with your breathing and lungs? 29 At the Conclusion of the Visit Print reconciled, dated medication list and provide a copy to the patient, family caregiver, home health nurse Communicate revisions to the care plan to family caregivers, home health nurses Ensure that the next appointment is made 30 10

11 Co designing Processes to Improve Transitions Hospitals Office Practices Home Care Skilled Nursing Facilities Perform an enhanced assessment of posthospital needs Provide effective teaching and facilitate enhanced learning Ensure posthospital care follow up Provide real time handover communications Provide timely access to care following a hospitalization Prior to the visit: prepare patient and clinical team During the visit: assess patient and initiate new care plan or revise existing plan At the conclusion of the visit: communicate and coordinate ongoing care plan Meet the patient, family caregiver(s), and inpatient caregiver(s) in the hospital and review transition home plan Assess the patient, initiate plan of care, and reinforce patient self management at first post discharge home care visit Engage, coordinate, and communicate with the entire clinical team Ensure that SNF staff are ready and capable to care for the resident patient s needs Reconcile the Treatment Plan and Medication List Engage the resident and their family or caregiver in a partnership to create an overall place of care Obtain a timely consultation when the resident s condition changes 31 Evidence Based Models for Intensive Care Management Advanced Practice Nurse Driven Transitional Care APNs use an evidence based protocol for care based on national heart failure guidelines and designed especially for this patient care group and their caregivers. Naylor MD, et al. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. J Am Geriatric Soc., 2004 May;52(5): The Care Transitions Intervention: SM Transitions Coach A Transitions Coach empowers patients with skills, tools and confidence to ensure their needs are met during the transition from hospital to home Heart Failure or Specialty Clinic minute visits Reinforce teach back Medication reconciliation Assess self management Referrals to interdisciplinary team as needed Telephone follow up individualized based on need Follow up assessment sent to PCP after each encounter 33 11

12 Access the How to Guide: fficepracticereducerehospitalizations.aspx 34 Analysis of Results to Date Reducing readmissions is dependent on highly functional crosscontinuum teams and a focus on the patient s journey over time. Explicit focus on patient and family centered work. Importance of engaged Executive Leadership and Physician Leadership. Improving transitions in care requires co design of transitional care processes among senders and receivers. Frontline clinicians and staff involvement in developing the process improvements. Stories are as important as data. Providing intensive care management services for targeted highrisk patients is critical. Reliable implementation of changes in pilot units or pilot populations requires 18 to 24 months. Information Technology design is part of the work. 35 Questions? 36 12

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