What is Transition of Care?

Transitions of Care and Reducing Readmissions Jackie Vance, RN, CDONA, FACDONA Director of Clinical Affairs and Industry Relations, AMDA NTOCC is chaired and coordinated by CMSA in partnership with sanofi aventis U.S. US.NMH.10.09.004 What is Transition of Care? The movement of patients from one health care practitioner or setting to another as their condition and care needs change Occurs at multiple levels Within Settings Primary Care ICU Ward Specialty Care Between Settings Hospital Sub-acute facility Ambulatory clinic Senior center Hospital Skilled nursing Home Hospital Across Health States Curative care Palliative care/hospice Personal residence Assisted living Coleman E. http://www.caretransitions.org/definitions.asp Transition Issues Dramatically Impact Patients & Their Caregivers Patient & Caregiver ER ICU In-Patient OUTPATIENT: Home Home Care PCP Specialty Pharmacy Case Mgr. Caregiver Hospice SNF ALF Patient & Caregiver 1

Transition Issues Dramatically Impact Patients & Their Caregivers Patient & Caregiver ER ICU NO Discharge Care Plan OUTPATIENT: Home Home Care PCP Specialty Pharmacy Case Mgr. Caregiver Hospice NO Care Plan NO Medication Reconciliation NO Personal Medicine List NO Medication Reconciliation In-Patient SNF ALF NO Personal Medicine List NO Coordinated Care Plan Patient & Caregiver NO Care Plan NO Medication Reconciliation NO Personal Medicine List Transition of Care Gaps PCP to Specialty poor documentation of clinical information and patients impaired ability to communicate their symptoms to the physician. Within The Hospital - Breakdowns can occur when moving patients things can fall between the cracks. Treatment for one condition may exacerbate another causing a more serious problem. Discharges from the hospital to a home setting or an assisted or skilled nursing facility typically these patients cannot take on a self-management role and ask the right kinds of questions. Patients often get confused and cannot remember what their PCP or Specialist told them. They don t always know the questions to ask Retooling Care Transitions to Reduce Hospitalizations in Medicare Patients 2009 Health Intelligence Network (HIN) Barriers to Care Coordination System level barriers Practitioner level barriers Patient level barriers 2

To Date We Have Not Had Consistent and Accepted Transition Tools Medication Reconciliation Elements Comprehensive Care Plan Health or Clinical Status Transition Summary Patient & Caregiver Tools & Resources Consistent Performance Measures That Apply to All Health Care Settings Accountability for Sending & Receiving Information Aligned Payment Incentives www.ntocc.org Hospital Discharge On discharge from the hospital 30% of patients have at least one medication discrepancy * with possible or probable patient discomfort or clinical deterioration * Most common discrepancy is incomplete prescription requiring clarification. Wong JD, et al. Ann Pharmacother 2008;42:1373-9. Hospital to Home 49% of patients experienced at least 1 medical error Those with a work-up error * were 6 times more likely to be rehospitalized within 3 months * Work-up error occurred if an outpatient test or procedure suggested or scheduled by the inpatient provider was not adequately followed up by the outpatient provider (e.g., colonoscopy for positive fecal occult blood test scheduled at discharge but not documented in outpatient chart). Moore C, et al. J Gen Intern Med 2003;18:646-51. 3

Hospital to PCP transfer Meta-analysis Direct communication between hospital physicians and primary care physicians occurred infrequently Discharge summary Availability at first post-discharge visit low (12%-34%) Remained poor at 4 weeks (51%-77%) Affected quality of care in ~25% of follow-up visits Often lacked important information (e.g., lab results, discharge medications, treatment, follow-up plan) Kripalani S, et al. JAMA 2007;297:831-41. Hospital to Nursing Home Transfers and Adverse Events Adverse drug events (ADEs) attributable to medication changes occurred in 20% of bi-directional transfers 50% of ADEs were caused by discontinuation of medications during hospital stay Boockvar K, et al. Arch Intern Med 2004;164:545-50. Rehospitalizations Medicare Fee-For-Service Analysis of Medicare Claims data from 2003-2004 11,855,702 Medicare beneficiaries discharged from the hospital 19.6% (nearly 1/5) were rehospitalized within 30 days 34% were rehospitalized within 90 days 50.2% of those rehospitalized within 30 days after a medical discharge there was no bill for a visit to a physician office Jencks SF, et al. N Engl J Med 2009;360:1418-28. 4

Our healthcare system operates in silos and information queues incapable of reciprocal operation with other related management systems & different departments of organizations Eric A. Coleman, MD, MPH Working to Address the Issues NTOCC is chaired and coordinated by CMSA in partnership with sanofi aventis U.S. Diversity of Organizations and Professionals Advise and Support NTOCC These groups represent over 200,000 health care professionals, 11,000 employers and 30,000,000 consumers throughout the United States. 5

Working Groups Education & Awareness Tools & Resources NTOCC Policy & Advocacy Health Information Technology Metrics & Outcomes Patient and Family Caregiver Tool Development Taking Care Of MY Health Care & My Medicine List Also available in Spanish & French 6

New Tool Development: Patient Hospital Guide Additional NTOCC Tools & Resources Coming NTOCC Resources Health Information Technology Position Paper Updated Public Policy Concept Paper Electronic Compendium Collection of Transitions of Care Models Elements of Excellence for Safe Transitions of Care Cross Walk of Common Interventions Patient and Family Caregivers Bill of Rights Transitions of Care Risk Stratification Resource 7

NTOCC Considerations Improve communication during transitions with providers, patients, and caregivers Support the implementation of electronic medical records that include standardized data elements Increase the use of case management and professional care coordination Expand the role of the pharmacist in transitions of care Establish points of accountability for sending & receiving Implement a payment system that aligns incentives Develop performance measures to encourage better transitions of care NTOCC. Improving Transitions of Care. The Vision of the National Transitions of Care Coalition. May 2008. Improving Communication National Transitions of Care Coalition (NTOCC) Measures Workgroup. Transitions of care measures. 2008. The Integrated Team Physicians Wellness or Health Coaches Lab and Radiology Professionals Rehab personnel Skilled Case Managers Patient Pharmacists Specialists Hospitalists Nurses Therapists Behavioral Health Family Caregivers Social Workers 8

Collaborative Team Patient Physician Pharmacist Nurse Social Worker Case Manager Allied Health Respiratory Therapist Dietitian Physical Therapist Educator Transition Connector WHO IS THE CONNECTOR? Community Team PCP Specialist Skilled Nursing Facility LTC Services Pharmacy Community Clinic Home Care GCM/CM Rehabilitation Hospice Community Resources Health Plan Medical Home Improving Communication Will Improve Transition Issues My Med List Patient ER Medication Reconciliation Data Elements + Care / Case Transition Process ICU In-Patient OUTPATIENT: Home Home Care PCP Specialty Pharmacy Case Mgr. Care Giver Hospice SNF ALF Care Models, Policy, Advocacy, & Performance Measures 9

Transition of Care Models Care Transitions Intervention - Dr. Eric Coleman - Transition Coaching -http://www.caretransitions.org Transitional Care Model - Dr. Mary Naylor - Advanced Nurse Practitionershttp://www.nursing.upenn.edu/media/transitionalcare/Pages/default.aspx Guided Care - Dr. Chad Boult - Guided Care Nurse - http://www.guidedcare.org Project RED - Dr. Brian Jack - Boston University Medical Center - Reengineering Discharges http://www.bu.edu/fammed/projectred/ Project BOOST - Society of Hospital Medicine http://www.hospitalmedicine.org/resourceroomredesign/rr_caretransi tions/ct_home.cfm Emerging Care Models Transition of Care Clinic - Tallahassee Memorial Hospital Dr. Dean Watson, Chief Medical Officer Rush University Medical Center - Robyn Golden, MA, Director of Older Adult Programs. robyn_golden@rush.edu. Additional Resources NFCA - National Family Caregiver Association - Family Caregiving Resources www.thefamilycaregiver.org CAPS - Consumers Advancing Patient Safety Toolkits www.patientsafety.org NTOCC - National Transitions of Care Coalition Provider & Consumer Tools www.ntocc.org CMSA - Case Management Society of America CM Medication Adherence Guidelines & Disease Specific Adherence Guidelines - www.cmsa.org AMDA s (Dedicated to Long Term Care Medicine TM ) Transitions of Care in the Long Term Care Continuum practice guideline - http://www.amda.com/tools/clinical/toccpg/index.html ACC and IHI Hospital to Home Reducing Readmissions, Improving Transitions - http://www.h2hquality.org/ 10

Elements of Best Practice Medication List/Reconciliation/Adherence Transition Summary at Transition Follow-up Visit PCP/Specialist Care Plan Coaching with Patient and Family Caregivers Post Transition Call and/or Visit Determined by Population Accountability for Sending & Receiving Communication The Pharmacy Opportunity Leadership role in interdisciplinary efforts to establish accurate and complete medication lists Hospital admission and discharge Any change in level of care Encourage community-based providers and health care systems to collaborate in medication reconciliation efforts Educating patients and their caregivers on their role in retaining a current list of medications Assisting patients and caregivers through the provision of a personal medication list ASHP. Medication Therapy and Patient Care: Organization and Delivery of Services Positions. 2009. Patient Protection and Affordable Care Act Improving Quality & Efficiency of Care Reduction of Hospital Readmissions Provisions for Medical Home Provisions for Medication Therapy Management Access to Care Provisions for Care Coordination Community-Based Care Transition programs Chronic Care Disease Management Transitional Care Provisions Wellness Programs Shared Decision Making The Patient Protection and Affordable Care Act. 42 USC 18001 (2010). 11

Care Coordination Definition: Care coordination is a function that helps ensure that the patient s needs and preferences for health services and information sharing across people, functions, and sites are met over time. Coordination maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and high-quality patient experiences and improved healthcare outcomes. National Quality Forum (NQF) - Endorsed Definition and Framework for Measuring Care Coordination. Domains for Care Coordination Health Care Home Proactive Plan of Care and Follow-up Communication Information Systems Transitions or Hand-offs Plus 4 Principles National Quality Forum (NQF) - Endorsed Definition and Framework for Measuring Care Coordination. Developing Care Coordination Measures CMS 9th SOW supports Care Coordination Care Pathways 2009 TJC Patient Safety Standard #8 enhanced Medication Reconciliation to include patient and caregiver involvement and transition Documentation of process NQF Performance Measures for Care Coordination Measures Developed in 2010 Awaiting approval and release URAC incorporating TOC principals in revised CM Standards AMA PCPI Transitions of Care ACP/SHM/ABIM Foundation/PCPI will develop jointly practitioner-level performance measures for transitions of care 12

Improving Transitions of Care Requires Change: Systems Process Workflow Personal behavior changes Who is your Change Agent Team Improving Transitions of Care Identify the change team those individuals who are committed and find positive change an opportunity Define the critical need and match the intervention to the population Narrow the focus; avoid going after the "elephant Ensure all the members of this team are on the same page with the same goal. Now peel back the onion: 1. Run the data analysis to set baseline statistics 2. Define the current process what happens now, what tools are used at what exchange points and are there current performance measures in place 3. Choose the key elements to target for change Implementing the TOC Plan 4. Identify the bi-directional communication process and align accountability 5. Timeframe of study 60-90 days first look 6 months 12 months 6. Assess improvement on timeliness & communication of : Transition Summary Medication Reconciliation Pro-active Care Plan Follow up PCP/Specialist visit Personal Medicine List 7. Review the data: ER Visits Patient Satisfaction with experience Readmissions Follow up visits PCP/Specialist 13

Transitioning The Continuum of Care with Bi-Directional Communication Home Care LTC PCP/Medical Home Community Health Center Advocate Motivational Interventions Health Plan Patient TOC Manager Health Promotion Hospital Specialist Pharmacy Hospice Increase Productivity Employer Providers & Patients with Tools working together & Improved Communication Means Better Transitions of Care Learn more online at Thank You Contact Information Cheri Lattimer - clattimer@acminet.com clattimer@acminet.com 14

References Retooling Care Transitions to Reduce Hospitalizations in Medicare Patients 2009 Health Intelligence Network (HIN) Wong JD, Bajcar JM, Wong GG, et al. Medication reconciliation at hospital discharge: evaluating discrepancies. Ann Pharmacother 2008;42:1373-9. Moore C, McGinn T, Halm E. Tying up loose ends: discharging patients with unresolved medical issues. Arch Intern Med 2007;167:1305-11. Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007;297:831-41. Boockvar K, Fishman E, Kyriacou CK, et al. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med 2004;164:545-50. Jauhar S. To Curb Repeat Hospital Stays, Pay Doctors. New York Times, Dec 1, 2009, Page D6. Available at http://www.nytimes.com/2009/12/01/health/01essay.html. Jencks SF, Williams MV, Coleman EA. Rehospitalization among patients in the Medicare fee-for-service program. N Engl J Med 2009;360:1418-28. References National Transitions of Care Coalition (NTOCC). Improving transitions of care. The Vision of the National Transitions of Care Coalition. May 2008. Available at http://www.ntocc.org/portals/0/policypaper.pdf National Transitions of Care Coalition (NTOCC) Measures Workgroup. Transitions of care measures. 2008. Available at http://www.ntocc.org/portals/0/transitionsofcare_measures.pdf ASHP. Medication Therapy and Patient Care: Organization and Delivery of Services Positions. 2009. Available at http://www.ashp.org/doclibrary/bestpractices/organizationpositions09.aspx. The Patient Protection and Affordable Care Act. 42 USC 18001 (2010). Available at http://www.gpo.gov/fdsys/pkg/plaw-111publ148/pdf/plaw-111publ148.pdf. National Quality Forum (NQF) - Endorsed Definition and Framework for Measuring Care Coordination. Available at http://www.qualityforum.org/projects/care_coordination.aspx. US.NMH.10.09.004 15