Improving Care Transitions
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- Alice Sparks
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1 Care Transitions Collaborative Improving Care Transitions Laura Cole, RN South Carolina Partnership for Health
2 SPECIFIC QUESTIONS WE WILL EXPLORE TODAY: Why the focus on care transitions? What strategies are affective to improve Care transitions? What are some examples of successful care transitions initiatives in SC?
3 CARE TRANSITIONS DEFINITION Refers to the patients moving between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness* (*Source: Care Transitions Program, University of Colorado).
4 Do you want to be the driver or the passenger
5 Measures affected by Care Transitions Value Based Purchasing HCAHPS Mortality Core Measure Meaningful use Readmissions BlueCross/BlueShield Rewarding Excellence Program
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7 FY % reduction July 2008-June 2011 AMI, HF, Pneumonia FY % reduction July2009-June 2012 AMI, HF, Pneumonia FY % reduction Hospital Readmission Reduction Program July 2010-June 2013 AMI, HF, Pneumonia, COPD, Total Hip and Knee Arthroplasty FY % reduction July June 2014 Proposed AMI, HF, Pneumonia, COPD Total Hip and Knee Arthroplasty Ischemic stroke, and All cause
8 Rewarding Excellence Rewards top-performing hospitals with increased payments for the quality of care they provide Quality measures include key safety and efficiency measures, as well as patient experience. GOAL: To compensate hospitals for the quality of care provided to patients, not just the quantity of procedures performed.
9 Know where you are, then decide where you are going?
10 Have you looked at your care transitions processes? Has your team performed a hospital specific Root Cause Analysis to better understand your needed areas for quality improvement? (i.e. Process mapping, SWOT analysis, fishbone, etc) Yes No
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13 Care Transitions Coach Does your facility use personnel dedicated as Transitions Coaches? Fully integrated In Process Implemented in sub populations Not a current focus
14 Inpatient Outpatient
15 Outpatient Where is the patient discharged too? What is that provider able to provide for the patient? How are post acute care appointment scheduled? What information is shared with the facility/pcp? When is it Shared? What resources does your patient have after discharge if they have a question or concern? Do community organizations know about your effort? What can they provide?
16 Community Meetings Within the last year how often has your team met with community members regarding care transitions? weekly monthly quarterly yearly as needed never
17 Hospital Specific Are you screening patients for risk factors associated with higher readmission rates? If so what are you doing to mitigate those factors? What information are you providing to patients? Are patients active participants in the decision making in the hospital and at discharge? Are you having multidisciplinary rounds? How affective are they?
18 Risk Assessment Has your facility implemented a tool for readmission risk assessment (e.g. Target tool, LACE, other)? Fully integrated In process Implemented in sub populations Not a current focus
19 Multidisciplinary Rounds Does your facility have a multidisciplinary rounds to address care transitions needs? Fully integrated In Process Implemented in sub populations Not a current focus
20 TeachBack Has your facility implemented Teach Back? Fully integrated In process Implemented in sub populations Not a current focus
21 Discharge Instructions Has your facility implemented a transition record (i.e. discharge instructions) that addresses the 10 elements from National Quality Forum? (see list in next question) Fully integrated In process Implemented in sub populations Not a current focus
22 The in-between Who calls the patient? What questions does the team ask? Is there a way to close the loop on discharge summaries
23 Follow up phone calls Has your facility implemented followup phone calls? Fully integrated In process Implemented in sub populations Not a current focus
24 Discharge Summaries Has your facility implemented strategies to improve discharge summaries? Fully integrated In process Implemented in sub populations Not a current focus
25 Follow up appointments Has your facility implemented a strategy for timely followup appointments? Fully integrated In process Implemented in sub populations Not a current focus
26 Where to start??? Remember you will not change readmissions rates in a day Start small Make it a priority: create a budget In cooperate things you are already doing Remember the multidisciplinary team-assignments Your communities want to help
27 30 day readmission relative rate improvement CY 2012 vs Prevented Relative Rate Diagnosis Readmissions Improvement All Cause % AMI % COPD % HEART FAILURE % PNEUMONIA % *All payers
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