The Changing Landscape: A Confluence of National Attention. Eric A. Coleman, MD, MPH

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1 Infusing True Person Centered Care into Improving the Quality of Transitional Care What Are the Primary Goals for Transitioning Patients from Hospitals? Eric A. Coleman, MD, MPH, AGSF, FACP Professor of Medicine Director, Care Transitions Program University of Colorado at Denver What Are the Primary Goals for Transitioning Patients from Hospitals? Misalignment Match care needs to care settings Prepare patients & family caregivers for self care Prepare receiving team to assume care Payment requirements Patient identified needs Regulatory requirements Professional gratification The Changing Landscape: A Confluence of National Attention 1. One in five Medicare Beneficiaries are readmitted in 30 days 2. National cost of over USD $17 Billion 3. Half of patients readmitted had no physician contact 4. 70% of surgical readmits were for chronic medical conditions

2 Rehospitalization from Skilled Nursing Facilities ~25% of Medicare beneficiaries discharged from the hospital to a SNF are readmitted to the hospital within 30 days Annual cost of $4.3 Billion in 2006 Vincent Mor, Orna Intrator, Zhanlian Feng, and David C. Grabowski Health Affairs, 29, no. 1 (2010): Medicare Payment Advisory Commission (MedPAC) Policies to align incentives to reduce readmissions 1) Public disclosure of hospital 30-day (risk-adjusted) readmission rates 2) Adjust payment based on performance (i.e., readmissions may not receive full payment) 3) Bundling payment across hospitals and MDs Patient Centered Medical Homes: NCQA Care Coordination Requirements Written standards for patient access and communication Coordinate care and follow up for patients who receive care in inpatient and outpatient facilities Actively supports patient self-management Tracks tests and identifies abnormal results systematically Tracks referrals using paper-based or electronic system HHS/CMS Meaningful Use for Electronic Health Records Incentive payments to adopt, implement, upgrade EHRs Demonstrate meaningful use with clear focus on care coordination/care transitions For Eligible Professionals: 25 meaningful use objectives (15 required, 5 chosen from menu of 10) For Hospitals: 24 meaningful use objectives (14 required, 5 chosen from a menu of 10) CMS Care Transitions Theme: A 14 State Collaborative Administration on Aging/CMS Evidence Based Care Transition Grants

3 IHI STAAR Collaborative Four States MA, MI, WA, OH Four key areas Enhanced Assessment Effective Teaching and Learning Real Time Handover Communication Post-Hospital Follow Up nsformingcareatthebedside.htm What Common Conclusion Have the QIOs, AoA, IHI Reached? We Cannot Improve Care By Improving Professional- Professional Interaction--Engaging Patients and Family Is Key No One Provider Can Do This Alone--Cross Continuum Teams Are Is Key! Enter the Community-Based Care Transitions Program (Section 3026) HHS Secretary funds eligible entities to furnish evidence based care transitions services to high-risk Medicare beneficiaries Entities include: hospitals with high readmit rates in partnership with community-based organizations Started April 2011; Up to $500M of eligible funding Partnership for Patients: Two Primary Goals Keep hospital patients from getting injured or sicker.by the end of 2013, to decrease instances of patients acquiring preventable conditions while in hospitals by 40 percent compared to Help patients heal without complication. By the end of 2013, to decrease preventable complications during a transition from one care setting to another, so that the number of patients who must be re-admitted to the hospital would be reduced by 20 percent compared to A Multifaceted Approach A Multifaceted Approach to Improving Quality and Safety During Care Transitions 1. Engage patients and family caregivers 2. Enhance roles of family caregivers 3. Appreciate the culture of cross-setting providers 4. Define accountability during transitions 5. Build professional competency 6. Implement strategies to improve communication 7. Align incentives for cross setting collaboration

4 #1 Foster Greater Patient Engagement Meet consumers where they are with respect to health literacy, cognition, and level of activation in order to provide customized care planning. Encourage patients to express their preferences and then honor these preferences for type of services they desire, the intensity of health care services they receive, and the settings in which they receive them. Time to Retire the Term. Non-compliant What Predicts Execution of Discharge Instructions? Maybe it s not Mabel s heart that is responsible for her HF admits 1) Health literacy 2) Executive cognitive function 3) Activation/locus of control 3) A Simulation Lab.For Patients Led by Lee Greer, MD N. Mississippi Health Services Initially target persons with heart failure Opportunity to road test the discharge care plan and modify based on performance Simulation lab held in dedicated unit (to allow for turning of bed) and has multiple stations Potential to expand to post-acute care arena #2 Elevate the Status of Family Caregivers to Essential Members of the Care Team We cannot afford to ignore the very individuals we rely upon to execute the care plan, monitor patient safety, and serve as de facto care coordinators.

5 The Stats Family Caregivers Standardize Communication for Family Caregiver Role (s) Over 42 million Americans Provide 80 percent of chronic and long term care Economic value of contributions is $450 billion Yet these very same individuals remain invisible T= Primary Tumor Description N= Nodal Involvement D= Direct Care Provision E= Emotional Support C= Care Coordination M= Metastasis A= Advocacy F= Financial Call Attention to A Tension #3 Appreciate the Culture, Strengths, & Limitations of Acute, Post-acute, and Long-term Care Settings Hospital Nursing Home Home Health How Can We Acculturate Professionals Working in Other Settings to Our Own? Building and Fostering Cross Continuum Teams Welcome to my world day reverse site visits Create a one page description of capacity for meeting the needs of persons with acute or chronic health needs Staffing levels on site versus episodic Ability to obtain lab or diagnostic testing Bed hold policy Interdependence to serve a defined population Define priorities and write an aim statement Agree on population metrics that define success Common data sources plus story-telling Identify win-win opportunities

6 #4 Define Accountability During Transitions Patients making transitions need to understand who is the accountable professional overseeing their care at all times. Which Setting is Most Responsible for Readmission in 30 Days? Hospital View 1. Patient 2. SNF 3. Physician Practice 4. Hospitals 5. Government 6. All of above 7. None of above SNF View 1. Hospitals 2. Patients 3. Physician Practice 4. SNF 5. Government 6. All of above 7. None of above Engaging Physicians Case Management Monthly 2007 Consensus Statement Standards Journal of Hospital Medicine 4(6): July/August 2009 Transition responsibility. The sending provider/institution/team maintains responsibility for the care of the patient until the receiving clinician/location confirms that the transfer and assumption of responsibility is complete.

7 #5 Build Professional Competency in Care Coordination Most health care professionals had little exposure to strategies that promote effective care coordination Competencies Could Include: Functioning in a virtual cross continuum team Reaching consensus on follow up phone calls Exploring how the receiving team might (gently) pull the patient from the sending team Sequencing beyond the next hand-over Interact II Toolkit for hospital-based professionals Comprehensive risk tool, intervention and toolkit Mentoring component Model significantly reduces readmissions Toolkit for nursing home professionals Early identification of resident change in status Improve documentation for change in condition Standardize communication with other providers #6 Implement Strategies to Improve Cross Setting Communication Don t Confuse Information with Communication Establish standard operating procedures for the content, timeliness, and mode of health information exchange Take advantage of Meaningful Use guidelines/incentives

8 Standard Transfer Forms Re-Thinking the Transfer (D/C) Form More than protocols for standardized information exchange Thumbnail sketch of who is this individual Goals of care, treatment preferences, function, family caregivers Include expectations for transfer what you hope or anticipate will be accomplished Shift perspective from historical to future Shift orientation from reporting versus action #7 Align Financial Incentives to Promote Cross Setting Collaboration Transitional care exposes one of the greatest weaknesses of our care delivery system that it is not in fact a system. Opportunities now exist to create synergy between improving transitional care and patient-centered medical homes, reduced reimbursement for readmissions, bundled payments, and accountable care organizations. Listen to Your Patients: They Are Telling You How to Improve Transitions What Can Our Patients Teach Us About How We Can Improve Their Experience? Inadequately prepared for next setting Conflicting advice for illness management Inability to reach the right practitioner Repeatedly completing tasks left undone

9 Patients Have Workflows Too! Need to understand what these workflows are and how well they are serving the patients needs Hint they may not be what we would have designed but they may be effective What Does It Mean to Meet Patients at Their Level? Time to Retire the Term. Non-compliant Community Resources and Policies Chronic Care Model Self- Management Support Health System Health Care Organization Delivery System Design Decision Support Clinical Information Systems Trouble with the Southwest Corner of the Chronic Care Model Letting go of control of the agenda has proven challenging Making mistakes is part of the learning process Need to redefine professional gratification Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes

10 What Predicts Execution of Discharge Instructions? Maybe it s not Mabel s heart that is responsible for her HF admits 1) Health literacy 2) Executive cognitive function 3) Activation/locus of control 3) Health Literacy and the Teach Back Approach Use Teach Back to close gaps in understanding between health care providers and the patient and family caregivers The clinician explains information to the patient or family caregiver and then asks in a non-shaming way for the individual to explain in his or her own words what was understood. Closing the loop --the patient is asked to demonstrate how he or she will do what was taught. Screening for Cognitive Impairment Activation Is Developmental Clock drawing test Mini-Cog MMSE 57 Judith Hibbard, (c) Judith Hibbard, PhD University PhD of of Oregon Meeting Patients At Their Level: The Care Transitions Intervention Self-Care Support for the Silent Care Coordinators By default, patients/family caregivers perform a significant amount of their own care coordination They do this without skills, tools and confidence to be effective

11 Teach Patients to Fish or..move in with Them! Persons with chronic health conditions live with them 24/7 or 168 hours per week Fixing problems for patietns represents an implied promise that you will be back to fix the problem again should it arise Key Elements of The Care Transitions Intervention Low-cost, low-intensity, adapt to different settings One home visit, three phone calls over 30 days Transition Coach is the vehicle to build skills, confidence and provide tools to support self-care Model behavior for how to handle common problems Practice or role-play next encounter or visit Elicit patient s health related goal Create a gold standard medication list Four Pillars Medication self-management Follow-up with PCP/Specialist Knowledge of red flags or warning signs/symptoms and how to respond Patient-centered record Home Visit Patient identifies a 30-day health related goal Patient asked: Show me what medications you take and how you take them Transition Coach models the behavior for how to resolve med discrepancies, respond to red flags, and obtain timely follow up Patient and Transition Coach practice or role play next encounter(s) Patient identifies 2-3 questions for next encounter Key Findings of The Care Transitions Intervention Significant reduction in 30-day hospital readmits (time period in which Transition Coach involved) Significant reduction in 90-day and 180-day readmits (sustained effect of coaching) Net cost savings of $300,000 for 350 pts/12 mo Adopted by over 500 leading health care organizations in 38 states nationwide Real World Results John Muir Physician Network (CA) reduced 30 day readmissions from 11.7% to 6.1% and 180 day readmissions from 32.8% to 18.9%. Health East (MN) demonstrated reduced 30-day readmission rate from 11.7% vs 7.2% Crouse Hospital (NY) reduced 30-day readmission rate for heart failure to 9.7%, and average number of days to readmission increased from 86 to 175.

12 Care Transitions Theme Results N= day readmits Care Transitions Intervention Control 30-day readmits 60-day readmits 8% 13% 15% 17% 20% 29% P-value Jane Brock, MD, MSPH Alicia Goroski, MPH Colorado Foundation for Medical Care This material was prepared by CFMC (PM CO 2010), the Medicare Quality Improvement Organization for Colorado, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Summary of Results Readmissions/1000 eligible FFS beneficiaries 14 CT Communities: 4.8% relative improvement 56 Comparison Communities: -0.2% relative improvement A Checklist for Post-Hospital Follow Up Visits Projected cost savings of ~$22M to the Medicare program Coleman EA. The Post-Hospital Follow-Up Visit: A Physician Checklist to Reduce Readmissions. California Health Care Foundation Issue Brief, Oct Results were developed to guide the Care Transitions Theme. These do not represent formal findings about the success of the QIO Program (individual QIOs or collectively) in relation to QIOs obligations under their CMS contracts. How Can Post-Hospital Care Break the Cycle of Readmission? Many new delivery initiatives presume that post-hospital visits can prevent readmissions Patient centered medical homes Bundled payment Accountable care organizations A Gap in Physician Training? No reference to post-hospital visit structure or content in leading textbooks No reference by Boards of Internal Medicine, Family Medicine, Geriatric Medicine A man on the street poll

13 Prior to the Visit Review discharge summary Clarify outstanding questions Reminder call to patient or family caregiver Stress importance of visit & address barriers Remind to bring medication lists and all meds Provide instructions for after-hours care During the Visit Ask the patient to explain his/her goals for visit and what factors 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 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