1. AN OVERVIEW OF TRANSITIONSOF CARE

2. Acknowledgments This work was produced, in part, by a grant from the U.S. Health Resources and ServicesAdministration to the Huffington Center on Aging at Baylor College of Medicine via a subcontract toTexas Womans University - Houston. Used with permission, the principal author for the content was Whitney L. Mills, PhD.The audio files and voice over were done by Sunrise Studios, making this Power Point set Sec. 508 Compliant.This program onTransitions of Care is part of the professional development initiatives of theTexas Consortium Geriatrics Education Center at Baylor College of Medicine andTexas Womans University. No prior permission is needed for educational use. For any commercial use, however, prior approval must be sought.

3. Purpose To provide a definition and broad overview of transitions of care, including core elements, current models, and best practices. To describe the various stakeholders for transitions of care and the outcomes for each group. To provide links to additional resources with detailed information about transitions of care.

4. Transitions of Care Overview

5. Increasing Attention onTransitions Patient Protection andAffordable Care Act of 2010 Accountable Care Organizations (ACOs) include doctors, hospitals, long-term care settings, and other health care providers working as a group Centers for Medicare and Medicaid Services (CMS) has put a spotlight on transitions of care Focus is on new programs that incentivize coordination across sites and help reduce avoidable readmission, while providing support to individuals and caregivers experiencing a transition of care

6. What are transitions of care? Transitions of care: the movement of patients between healthcare locations, providers, or different levels of care within the same location as conditions and needs change Transitional care: a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location The American Geriatrics Society Health Care Systems Committee, Coleman, E.A., & Boult, C. (2003). Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 51, 556-557.

7. What are transitions of care? Transitions can occur: Within settings Between settings Across health states Between providers Settings may include: Hospitals Subacute/postacute nursing facilities Patients home Primary/specialty care offices Long-term care settings

8. Importance ofTransitions of Care Impact of poor transitions on patients Older adults typically have complex care needs, resulting in the need to receive care from different providers across several settings Following hospital discharge, older adults and their caregivers may be faced with the increased burden of self-care tasks and complex medication changes May be left feeling overwhelmed, confused, and uncertain if they are not properly prepared for the challenges of the extended recovery process

9. Importance ofTransitions of Care Impact of poor transitions on patients During transitions of care, older adults have increased risk for adverse events Hospital readmission Emergency room visits Long-term care placement Medication errors Delays in follow-up care Mortality

10. Importance ofTransitions of Care Impact on hospitals and health care systems Increased use of hospital, emergency, post-acute, and ambulatory services Estimated that 18-20% of all Medicare patients are readmitted to hospital within 30 days 90% of these admissions are unplanned Costs: $12-17 billion per year Medication errors cost at least $3.5 billion per year Coleman EA. Falling Through the Cracks: Challenges and Opportunities for Improving Transitional Care for Persons with Continuous Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):549-555.; Institute of Medicine of the National Academies. Preventing Medication Errors: Quality Chasm Series. The National Academies Press, 2007

11. Where does it all go wrong? Points of breakdown in transition process Preparation of the patient and/or caregiver Communication of the plan of care Medication reconciliation Transportation of the patient Patient attendance at follow-up appointments Communication of diagnostic imaging/laboratory testing results Availability of advance care directives

12. Barriers to ImprovingTransitions Delivery System Level Healthcare fragmented into independent silos Timely transmission of vital information Incentives to prescribe or substitute medications according to its own formulary Insurance coverage often drives service delivery Understanding and follow-through with care plan Importance of transitions of care underappreciated Familiarity with setting to which patients are sent Coleman EA, Berenson RA. Lost in transition: Challenges and opportunities for improving the quality of transitional care. Ann Intern Med 2004

13. Barriers to ImprovingTransitions Clinician Level Growing reliance on institution-based physicians Involvement of multiple specialists Nursing and SNF staff shortages Poor collaboration and communication Changing roles of social workers and care managers

14. Barriers to ImprovingTransitions Patient Level Little advocacy for improved transitions of care Older patients and their caregivers are often not adequately informed about their situation Lack of empowerment Documents received at discharge may be confusing Communication

15. Improving quality of transitions of care 1. Foster greater engagement of patients and family caregivers 2. Elevate status of family caregivers as essential members of the care team 3. Implement performance measurement 4. Define accountability during transitions 5. Build professional competency in care coordination 6. Explore technological solutions to improve cross- setting communication 7. Align financial incentives to promote cross setting collaboration http://www.caretransitions.org/What_will_it_take.asp

16. National Models and Best Practices

17. CareTransitions Intervention Goal: to improve care transitions by providing patients with tools and support that promote knowledge and self-management of their condition as they move from hospital to home Population: General medicine patients with complex care needs Key Provider: Transitions Coach

18. CareTransitions Intervention Key Elements Personal Health Record Discharge Preparation Checklist Session withTransitions Coach while admitted to hospital Follow-up visits and phone calls fromTransitions Coach

19. CareTransitions Intervention Key Elements The Four Pillars Medication Self- Management Patient is knowledgeable about medications Patient has a medication management system Dynamic Patient- Centered Record Patient understand and utilizes the personal health record (PHR) to facilitation communication and ensure continuity of care plan across providers and settings Patient or informal caregiver manages the PHR Follow-up Patient schedules and completes follow-up visit with the PCP or specialist Patient is empowered to be an active participant in these interactions Red Flags Patient is knowledgeable about indications that their condition is worsening and how to respond

20. CareTransitions Intervention Outcome: Readmission rates observed within 180 days of hospital discharge 8.30% 16.70% 25.60% 11.90% 22.50% 30.70% 30-day Rehospitalization 90-day Rehospitalization 180-day Rehospitalization Intervention Group (n=379) Control Group (n=371)

21. Transitional Care Model Goal: to develop a streamlined plan of care to prevent hospital readmissions and prepare patient and caregiver to implement plan with active engagement of patients/caregivers and in collaboration with patients physicians and other health care team members Population: General medicine patients, focused on older adults with two or more risk factors Key Provider: Transitional Care Nurse

22. Transitional Care Model Key Elements Transitional Care Nurse (TCN) In-hospital assessment, preparation, and development of evidence-based plan of care Regular home visits and ongoing telephone support TCN accompanies patients to initial follow-up appointments

23. Transitional Care Model Outcome: Readmission rates observed during 52- week follow up after index hospital admission 10% 28% 48% 23% 56% 61% Readmitted within 6 weeks Readmitted within 26 weeks Readmitted within 52 weeks TCM Group Control Group

24. Transitional Care Model Outcome: Total health care costs observed during 52- week follow- up after index hospital admission $3,630 $7,636 $6,661 $12,481 26 weeks after discharge 52 weeks after discharge TCM Group Control Group

25. Project RED Project Re-Engineered Discharge Goal: to enhance the care of patients transition from hospital to home through use of a quality improvement toolkit to reduce readmission rates, improve patient and family preparation for discharge, and enhance patient satisfaction Population: General medicine patients Key Provider: Patient Discharge Advocate, Pharmacist

26. Project RED Key Elements Checklist Medication reconciliation Reconcile discharge plan with national guidelines Follow-up appointments Outstanding tests Post-discharge services Written discharge plan What to do if a problem arises Patient education Assess patient understanding Discharge summary to primary care physician Telephone reinforcement with physician

27. Project RED Outcomes: Number of patients utilizing health services within 30 days of index hospital admission 166 90 76 116 61 55 Hospital Utilizations Emergency Dept Visits Readmissions Usual Care Group (n=368) Intervention Group (n=370)

28. Project RED Outcomes: Outcomes obtained during 30-day follow-up phone call presented by number of patients 217 275 135 163 242 292 190 197 Able to ID discharge diagnosis Able to ID PCP name Visited PCP Felt "prepared" or "very prepared" to leave hospital Usual Care Group (n=308) Intervention Group (n=307)

29. Project BOOST Better Outcomes for Older adults through SafeTransitions Goal: to improve the care of patients as they transition from the hospital to home Population: general medicine patients, focused older adults Key Provider: hospitalist nurse

30. Project BOOST Key Elements Assessment at hospital admission Provide education and preparation to patient throughout admission Patient education and medication reconciliation at discharge using teach-back method Schedule follow-up appointment Follow-up phone call within 72 hours for high-risk patients

31. Project BOOST Key Elements -Toolkit Broad assessment of admitted patients Risk-specific patient/caregiver discharge preparation Teach-back method Follow-up calls to patients within 72 hours of discharge on how to care for themselves

32. Project BOOST Outcomes: 30-day readmissions and patient satisfaction (n=30) 12% 7% 52% 68% Pre-Intervention 90 Days Post-Intervention Readmissions Patient Satisfaction

33. Project BOOST Outcome: Cost analysis $21,389 $412,544 $11,285 $268,942 Emergency Dept Visits Hospital Visits Usual Care Group (n=376) Intervention Group (n=373)

34. INTERACT II Interventions to Reduce Acute CareTransfers Goal: To improve care of nursing home (NH) residents by identifying situations that commonly result in transfers to the hospital and working together to manage them effectively and safely in the NH without transfer whenever possible Population: NH residents Key Providers: NH staff members of all disciplines and levels

35. INTERACT II Key Elements ClinicalTools A set of communication tools, care paths, advance care planning designed to: Indentify changes in resident condition Evaluate these changes Manage some conditions in NH Document changes and how they were assessed/managed Communicate effectively with staff in NH and staff at local hospital

36. INTERACT II Outcome: Mean hospitalization rate per 1000 resident days 3.99 4.01 3.96 2.69 3.32 3.13 3.71 2.61 All Intervention Facilities (n=25) "Engaged" Intervention Facilities (n=17) "Not Engaged" Intervention Facilities (n=8) Control Facilities (n=11) Pre-Intervention During Intervention

37. Common Ground

38. Common Ground - Interventions Medication reconciliation and management Plan for how follow-up tests and appointments will be completed Red flags indicating condition is worsening and appropriate response for each Summary of care provided by discharge setting and a common plan of care across sites Contact information for PCP and emergency care Foll0w-up call or visit from designated individual

39. Common Ground - Outcomes Health care system Reduced hospitalization/readmission rates Reduced costs Improved quality of care Improved communication with patient and other health care providers Patients Increased satisfaction Better prepared at discharge (e.g., able to identify index diagnosis, able to name PCP, etc.) Greater attendance at follow-up appointments Improved communication with health care team

40. Common Ground - Coaches Get involved while the patient is still in the hospital Provide education and preparation for discharge throughout the hospital stay Ensure follow-up appointment has been scheduled Ensure information regarding care plan has been transmitted to next care site and/or to patient Follow-up phone call and/or visit to ensure patient is following care plan and has no new questions

41. http://www.caretransitions.org/ documents/Physicians_Need_t o_Know_About_Coaches.pdf

42. Additional Resources

43. ProjectWebsites CareTransitions Intervention http://www.caretransitions.org TransitionalCare Model http://www.transitionalcare.info ProjectRED https://www.bu.edu/fammed/projectred ProjectBOOST www.hospitalmedicine.org/BOOST Interact II http://interact2.net

44. More Information NationalTransitions of Care Coalition www.ntocc.org AHRQ bibliography on transitions of care http://healthit.ahrq.gov/portal/server.pt/community/health_it_ tools_and_resources/919/care_transitions

45. Acknowledgments This work was produced, in part, by a grant from the U.S. Health Resources and ServicesAdministration to the Huffington Center on Aging at Baylor College of Medicine via a subcontract toTexas Womans University - Houston. Used with permission, the principal author for the content was Whitney L. Mills, PhD.The audio files and voice over were done by Sunrise Studios, making this Power Point set Sec. 508 Compliant.This program onTransitions of Care is part of the professional development initiatives of theTexas Consortium Geriatrics Education Center at Baylor College of Medicine andTexas Womans University. No prior permission is needed for educational use. For any commercial use, however, prior approval must be sought.