The New World of Healthcare

for the Elderly: Care

Transitions

Hamster Healthcare

Rates of Rehospitalization within 30 Days after Hospital Discharge

Jencks SF et al. N Engl J Med 2009;360:1418-1428

Chronic Illness Epidemic

Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update

The Boomers are Coming to Medicare

The Boomers are Coming to Medicare

Transitional Care (TC) Defined

Transitional care – range of time limited services and environments designed to ensure health care continuity and avoid preventable poor outcomes among at risk populations as they move from one level of care to another, among multiple providers and/or across settings.

The Billion Dollar U-Turn

Quality is Awful!

“The transitional period between sites of care is an especially vulnerable time for

patients, often characterized by conflicting medical advice, medication errors, and a lack of additional treatments that might have been avoided. Care transitions

interventions are designed to target these problems and ease the transition between

sites.”

Dr. Eric Coleman, MD

Transitional Care Programs

Dangers of Discharge

• ¼ of hospitalized patients need further work up

• >1/3 are not done• Missing discharge summary• Family not ready to take patient• Lack of understanding• Hazards in the home• Info transfer is missing

Transitions are Dangerous…

• To…

• From…

• Within…

"If you think that you can run an organization in the next 10 years as

you've run it in the past 10 years you're out of your mind."

CEO, Coca Cola

. . . That Culminated in Complex Legislation March 30,

2010Public Law No. 111-148: Patient Protection and Affordable Care Act: March 23, 2010

Public Law No. 111-152: Health Care and Education Reconciliation Act of 2010: March 30, 2010

REFORM

13

Began Jan. 11, 2010 …. 5 years

Tuscaloosa HRR

Metro Atlanta East

Harlingen HRR

NW Denver

Whatcom County

Evansville

Omaha

Greater Lansing Area

Western PA

SW NJ

Upper Capital Region

Providence RI

Baton Rouge

Miami

14 QIOs with 14 Target Communities

15

The Four Pillars of Care Transitions• Medication management• Patient-centered record

(PHR)• Follow-up with

PCP/Specialist• Knowledge of “Red Flags”

or warning signs/symptoms and how to respond – Stoplight Tools

Dr. Eric Coleman

http://www.caretransitions.org/

Transition Coaches

• The ability to shift from doing things for a given patient to encouraging them to do as much as possible for themselves

• Competence in medication review and reconciliation, and

• Experience in activating patients to communicate their needs to a variety of health care professionals.

Acute Care Hospitalization

and ED:The Number

One Target in Healthcare Reform !

The Beers List

Care Transitions Tools: Medication Discrepancy

My Medications are:Medication Dose______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________Allergies: _____________________

Reason Side Effects______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

____________________________________________________________Remember to take this Record with youto all of your doctor visits

PersonalPersonalHealthHealthRecordRecord

The Personal Health Record of:

Josephine Patient

Personal Information:

Address:

Home Phone#:

Birth Date:

Patient ID#

PCP Name:

Advanced Directives?:

Hospitalization Information:

Admitted: _/_/_ Discharged: _/_/_

Reason for Hospitalization:

___________________________________________

Caregiver Information:

Name:

Phone #:

Relation to Patient:

Personal History

Please check any illnesses or health

problems listed below that you have

ever experienced.

Arthritis

Abnormal Heart Rhythm

Cancer

Diabetes

Hardening of the Arteries

Heart Disease

Heart Failure

High Blood Pressure

Hip Fracture

Lung Disease

Medical/Surgical Back conditions

Pneumonia

Stroke

Other: ____________________

After I leave the hospital…

1. I will write down questions I have about my condition.

2. I will take all bottles of medicine I am using to each doctor visit.

3. I will call _________________

immediately at (XXX) XXX-XXX if I experience any of the following:

• Temperature above 101° F

• Uncontrollable pain

• Increased confusion

• Increased redness or d

drainage around wound

• Questions about which

medications to take

Before I leave the hospital…. I have the instructions I need to

keep my health condition from becoming worse.

I know what symptoms to watch out for.

I know the name and phone number of who to call if I see any of these symptoms.

My family or someone close to me knows what I will need once I leave the hospital.

I know what medications to take, how to take them, and possible side effects.

I will schedule a follow up appointment with my primary care doctor.

I will have a clear and complete copy of my discharge instructions.