TRANSITIONS OF CARE: INCREASING PATIENT ENGAGEMENT AND COMMUNICATION ACROSS HEALTH CARE SETTINGS Leslie Lentz, BA Care Transitions Project Coordinator Health Care Excel, the Indiana Medicare Quality Improvement Organization Indiana Association for Home and Hospice Care May 12, 2010 Care Transitions: A community-wide Centers for Medicare & Medicaid Services (CMS) project focusing on improving patients transitions across care settings to reduce avoidable hospitalizations. CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)CARE TRANSITIONS INITIATIVE 2 1
NATIONAL CARE TRANSITIONS INITIATIVE: PARTICIPATING COMMUNITIES Baton Rouge, Louisiana Greater Lansing, Michigan Metro Atlanta, Georgia East North West Denver, Colorado Providence, Rhode Island Tuscaloosa, Alabama Western Pennsylvania Evansville, Indiana Harlingen, Texas Miami, Florida Omaha, Nebraska Southwestern New Jersey Upper Capitol Region, New York Whatcom County, Washington 3 THE DRIVING FORCES: RE-HOSPITALIZATIONS About 1 in 5 Medicare beneficiaries are re-hospitalized within 30 days of discharge Majority of Medicare beneficiaries who are hospitalized have been hospitalized before within the past year More than 85% of these hospitalizations are unplanned Estimates show 20-40% of re-hospitalizations are preventable Of Medicare beneficiaries re-admitted within 30 days, over 50% receive no post-acute care between discharge and re-admission 4 2
TYPICAL FAILURE MODES IN THE TRANSITION PROCESS Medication errors and/or adverse events Poor, incomplete, or missing discharge instructions Lack of follow-up appointment Follow-up scheduled too long after hospitalization Lack of social support Confusion over self-care instructions Lack of adherence to medications, therapies, and diet Ineffective provider-to -provider communications (skills and tools) 5 TARGETED AREAS FOR IMPROVEMENT Communication Medication reconciliation Patient empowerment and self management skills Physician follow-up Plan of care 6 6 6 3
TRANSITIONING PATIENTS ACROSS HEALTH CARE SETTINGS: Identifying the issues Communication -Provider -Provider Provider Patient Medication reconciliation - Discontinued, new, continuing meds Follow-up care - Whom to call with questions - Scheduled follow-up appointments 7 MAJOR STRATEGIES TO REDUCE AVOIDABLE READMISSIONS Post Discharge Promote patient and caregiver self-management Coaching home visits and/or telephonic follow-up Telehealth for at-risk patients Personal Health Records for information management Emergency Care Plans and Zone Tools for symptom management Verification that follow-up appointments are scheduled 8 4
Home Health Best Practice Assessment Does your agency use standardized forms, communication methodologies (SBAR, etc.), or health information systems that regulate and support effective care transitions? Does your agency use a patient personal health record (PHR)? Does your agency perform chart reviews to assess whether information on the referral, transfer, or discharge forms was accurate, complete, and consistent? Does your agency have a process for physician offices to provide information and changes in plan of care related to physician office visits? Yes No 92% 8% 12% 88% 22% 78% 33% 67% 9 Home Health Best Practice Assessment Has your agency implemented any of the following best practices that support transitional care coordination? Yes Hospitalization risk assessment 78% 12% Disease management 89% 11% Emergency care planning Medication management No 78% 12% 44% 56% Phone monitoring and frontloading visits 78% 12% Physician relationships 78% 12% Patient self-management 44% 56% 10 5
Sick people don t learn well. More than half of patients over age 70 years responding to a post-hospitalization telephone survey did not recall anyone talking with them about how to care for themselves after hospitalization. Journal of Hospital Medicine, September 2007 11 COACHING METHODOLOGY: INCREASING PATIENT ENGAGEMENT Care Transition Intervention or coaching model created by Eric Coleman, MD During a four-week program, patients are supported by a transition coach, and learn self-management skills to ensure their needs are met during the transition from hospital to home. Four pillars of the intervention Personal health record (PHR) Follow-up Red flags Medication self-management 12 12 6
My Medications are: Personal Health Record Remember to take this Record with you to all of your doctor visits. Medication Dose Allergies: 13 "Studies show that doctors base up to 80% of their diagnoses on what patients tell them about their symptoms, history, and lifestyle. http://www.seniorjournal.com/news/health/2007/7-07-19-coachingfordoctor.htm 14 7
Average time a physician allows a patient to talk before taking the lead. www.npsf.askmethree.org 15 What is Health Literacy? The ability to read, understand, and act on health information. We must close the gap between what health care professionals know and what the rest of America understands. Dr. Richard Carmona, U.S. Surgeon General 2002-2006 16 8
Patient Discharge Instructions Improving Transitions of Care, Jann 17 Dorman, Senior Director CMI, KAISER Permanante 17 18 9
What questions do you ask? 1. What Is My Main Problem? 2. What Do I Need to Do? 3. Why Is It Important for Me to Do This? 19 Getting Information in Plain Language The doctor says: You have hypertension. 20 1.What Is My Main Problem? In plain language: Your blood pressure is too high. 20 10
Getting Information in Plain Language The doctor says: You need to abstain from high-sodium foods. 2. What Do I Need to Do? In plain language: You need to eat less salt, read food labels carefully, and you need to exercise more. 21 Getting Information in Plain Language 3. Why Is It Important for Me to Do This? In plain language: If you eat healthy food, and exercise, you can stay out of the hospital and feel better. 22 11
TEACH-BACK METHODOLOGY CRUCIAL TO IMPROVING PATIENT ENGAGEMENT Bad: Do you understand how to take your medications? Better: In the past week, how often did you take your medications? Best: Tell or show me how you took your medications. I speak very quickly sometimes. I want to make sure I have clearly explained everything correctly. (shame-free delivery) 23 PLAIN LANGUAGE: USING PLAIN LANGUAGE WHAT WE WE COULD COULD SAY INSTEAD SAY INSTEAD OF Angina Atherosclerosis Benign Carcinoma Immunization Hypertension Negative test Take one tablet twice daily for seven days PRN Ophthalmic use only Chest pain Clogged blood vessels Not cancer Cancer Shot, vaccine High blood pressure Normal test Take one pill at 8:00 a.m. and another pill at 8:00 p.m. for seven days When you need it Put it in your eyes 24 12
HH-CAHPS /CARE TRANSITIONS COMMUNICATION #17. In the last 2 months of care, how often did home health providers from this agency explain things in a way that was easy to understand? Never Sometimes Usually Always 25 25 HH-CAHPS /CARE TRANSITIONS WHAT IS MY MAIN PROBLEM? WHAT DO I NEED TO DO? WHY IS IT IMPORTANT FOR ME TO DO THIS? # 12. In the last 2 months of care, did home health providers from this agency talk with you about the purpose for taking your new or changed prescription medicines? 26 26 13
HH-CAHPS /CARE TRANSITIONS MEDICATION RECONCILIATION #4. When you started getting home health care from this agency, did someone from the agency talk with you about all the prescription and over-the-counter medicines you were taking? Yes No Do not remember 27 27 OASIS C AND CARE TRANSITIONS 28 14
INTERVENTION PILOTS IN OUR COMMUNITY Intervention Redesign of case management processes Coaching Number of Organizations Implementing 5 8 Type of Stakeholder Hospital Inpatient Rehabilitation Hospital, Home Health, Community Pharmacist involvement 4 Hospital Telephonic follow-up 4 Hospital Telehealth 6 Home Health Early warning and reporting 4 Nursing Home Redesign of educational materials and processes 6 Hospital, Inpatient Rehabilitation, Home Health 29 Congestive Heart Failure Zones for Management Your Goal Weight: Green Zone: All Clear No shortness of breath No swelling No weight gain No chest pain No decrease in your ability to maintain your activity level Yellow Zone: Caution If you have any of the following signs and symptoms: Weight gain of 3 or more pounds Increased cough Increased swelling Increase in shortness of breath with activity Increase in the number of pillows needed Anything else unusual that bothers you Call your home health nurse if you are going into the YELLOW zone Red Zone: Medical Alert Unrelieved shortness of breath: shortness of breath at rest Unrelieved chest pain Wheezing or chest tightness at rest Need to sit in chair to sleep Weight gain or loss of more than 5 pounds Confusion Call your physician immediately if you are going into the RED zone 03/26/2009 Source: www.improvingchroniccare.org Green Zone Means: Your symptoms are under control Continue taking your medications as ordered Continue daily weights Follow low-salt diet Keep all physician appointments Yellow Zone Means: Your symptoms may indicate that you need an adjustment of your medications Call your home health nurse. Name: Number: Instructions: Red Zone Means: This indicates that you need to be evaluated by a physician right away Call your physician right away Physician: Number: This material was prepared by the Improving Chronic Illness Program, supported by the Robert Wood Johnson Foundation,adapted by Health Care Excel, the Medicare Quality Improvement Organization for Indiana, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency ofthe U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 99SOW-IN-TRAN-09-026 03/26/2009 Sample of Patient Engagement Tool 30 30 15
Sample of Patient Engagement Tool 31 Indiana Care Transitions Project QIOCareTransition@inqio.sdps.org 32 This material was prepared by Health Care Excel, the Medicare Quality Improvement Organization for Indiana, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contentspresenteddo not necessarilyreflectcms policy. 9SOW-IN-TRAN-10-013 04/22/2010 16
ONE PROVIDER S SUCCESSFUL INTERVENTION IN THE EVANSVILLE COMMUNITY. 33 Melissa Brewer, RN Deaconess Home Care Telehealth Coordinator Evansville, Indiana 17