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Implementing Care Transition Strategies to

Improve Medication Management and

R d A t C H it li tiReduce Acute Care Hospitalizations

New England Home Care Conference and Trade ShowMay 31 & June 1, 2012

PresentersPresenters• Colleen Bayard PT, MPADirector of Regulatory and Clinical Affairs,Home Care Alliance of Massachusetts

• Jeanne Ryan, OTR, MA, CHCE, COS-CExecutive Director, VNA & Hospice of

Cooley Dickinson/Cross-Continuum Services

Board of Directors, Home Care Alliance of Massachusetts

VNA & Hospice of Cooley VNA & Hospice of Cooley DickinsonDickinson

• STAAR Initiative: STate Action on Avoidable Re-hospitalizations

• Hampshire County Cross ContinuumHampshire County Cross Continuum Team

• 3026 Application

• Coaching Networking Breakfast

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Home Care Alliance of Home Care Alliance of MassachusettsMassachusetts

• STAAR Initiative: STate Action on Avoidable Re-hospitalizations

• Opt-In Response team

• ASAP Coordinating Group

• Technical Assistance 3026

ObjectivesAt the end of this program the learner will:• 1. Identify 3-4 partners in transition process from one care

setting to the next.

• 2. Identify 2-3critical pieces of patient information necessary to insure seamless transitions between care settings.

• 3) State 2 – 3 of the challenges agencies face when promoting home care.

• 4)Identify 3 – 4 components of the standards that address transitions to and from home care.

International Perspective

• U.S. ranks last of 8 countries for access, coordination & safety in health care

• 54% of chronically ill did not get54% of chronically ill did not get recommended care, fill prescriptions or see a doctor

• 1/3 of U.S. patients experience poorly coordinated care

2008 Commonwealth Fund International Health Policy survey

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National Perspective

• 17.6% of Medicare beneficiaries are re-hospitalized within 30 days of discharge, accounting for $15 billion in spending

Estimates sho that 76% of these readmissions ma be• Estimates show that 76% of these readmissions may be preventable

• Of Medicare beneficiaries re-admitted within 30 days, 64% receive no post acute care between discharge and readmission

MedPAC: June 2007 Report to Congress: Promoting Greater Efficiency in Medicare

National Perspective-Home Health

• Nationally, 28% of home care patients are hospitalized unexpectedly

• Nearly 58% of acute care hospitalizations occur within the first three weeks of a home health admissionfirst three weeks of a home health admission

• 25% of ACH occur within seven days of home health admission

• 68% of ACH patients had been hospitalized within the two weeks prior to a home health admission

• 40% of hospitalizations are avoidable

State PerspectiveMassachusetts Readmission Rates

• “Massachusetts is not doing the best job in care transitions. We are 41st out of 50, in hospital readmissions and being 50 is being last. If we merely met the standards of Vermont which is number one in the country thatof Vermont, which is number one in the country, that would be 6000 fewer hospital readmissions yearly and would save $73 million per year just with Medicare alone. We need to spend more attention on Care Transitions; what gets attention gets done.”

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Contributing Factors to High Readmission Rate

Patients are more chronically ill, more frail, and have more complex care needs:

• Multiple diagnoses/chronic co-morbidities• May see several physicians (average 4-6)• Average 13-16 medications per day• May be cognitively impaired• May not have a Primary Care Physician• Access to and/or lack of community services• May lack a caregiver for safe transition to home

Care Transition

• “The movement of a patient between health care practitioners and/or settings as their condition and care needs change during the g gcourse of a chronic or acute illness”

Transition Points

• During transitions, patients with complex medical needs, primarily older patients, are at risk for poorer outcomes due to pmedication errors and other errors of communication among the involved healthcare providers and between providers and patients/family caregivers

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Discharge

Historically, movement of patient between practitioners or settings has been viewed as a discharge which has implied an:g p

• “Unloading” of the patient• “Out of sight, out of mind” mentality• “They’re your problem now”

Coordinating Care Across the Coordinating Care Across the ContinuumContinuum

• Patient-centered care is built upon processes which support the “best interest of the patient and their families”

• Patients want their care to be coordinated in a way that keeps them home and prevents them from being readmitted to the hospital

Coordinating Care Across the Coordinating Care Across the ContinuumContinuum

• Therefore, hospital readmissions are viewed as:

• Non-patient centered careNon patient centered care

• A failure of service providers to coordinate a patient’s care across the continuum

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STAAR InitiativeSTate Action on Avoidable Rehospitalizations

• • Commonwealth Fund-supported initiative to reduce• avoidable re-hospitalizations, taking states as unit of• intervention• – May 1, 2009 launch• – Anticipated 4-year initiative• • State-based Initiatives• – Public, non-governmental, and/or private sector leadership• focused specifically on re-hospitalizations• – 3 states selected to receive Commonwealth Fund-IHI supported• technical assistance (Massachusetts, Michigan, Washington

STAAR InitiativeSTate Action on Avoidable Rehospitalizations

• High-leverage opportunities for action• 1. Improve Transitions for All Patients• a) Transitions “out” of the hospital• b) Reception “in” to home (home health, office practice)• c) Reception “in” to skilled nursing (post-acute rehab, NH)• 2. Proactively Address the Needs of “High Risk” Patients• a) Enhanced services for high risk patients• 3. Engage Patients/Caregivers• a) Proactive role, navigating/advocacy skills• b) Shared care plans• c) Proactive advanced care planning

STAAR InitiativeSTate Action on Avoidable Rehospitalizations

• May 2009 to Fall 2010• • Front-line process improvement technical assistance• – May 2009: identify 15-20 hospitals in MA to improve transitions out• – June-August 2009: hospitals and cross-continuum partners complete

prework*• – September 2009: Transitions Out collaborative launch in MA• – October 2009-Dec 2010: process improvements active phase• – Fall 2010 : Reception In collaborative launch in MA• – Fall 2010 : Second wave of Transitions Out collaborative

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STAAR InitiativeSTate Action on Avoidable Rehospitalizations

• Cross Continuum Team made up of staff from Cooley Dickinson Hospital, VNA & Hospice of Cooley Dickinson and local p yNursing facilities launch Transitions Out collaborative in Fall of 2009

AIMAIM•To decrease the 30 day readmission rate at Cooley Dickinson Hospital (CDH) from-11.3% (baseline Jan-Dec 08) by 25% to 8.5% by June 30, 2010.

•Decrease ACH Rate by 10% by 12/31/10

•Improve Management of Oral Medication by 25% 12/31/11

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System Approach System Approach “It takes a community to reduce readmissions”“It takes a community to reduce readmissions”

HomeAmherst

Advocacy Group

PCP Offices E.D.

Tele-metry Unit

Case Manage-

ment

Med/Surg Unit

PCP Offices

SNFVNACardiac Rehab Home

Community Hospital Community

Patient Journey Through the Microsystems

Goal = Improve communication at the handover transitions of care

2222

Readmit Interview &

Complex CM Planning

Hand-off communicatio

nAdmission

Nurse

Med Recon-ciliation

IDR Work-sheet

Pneum

Zone Tool

Teach B k

PCP appts made

prior to D/C

Teaching in first visitComplete Adm at 2nd visit

Tests of Change

CHF Zone Tool Teach

Back &Nurse

Training

Patient Unit

"Status Board"

DPH Universal Transfer

Form

PCP appointments in 72 h

LOS Rounds

Interact Transfer

Form

Palliative Screening

and Referral

CHF Zone Tool

Teach Back

AssessmentAssessment

• 40% patients readmitted within 7 days of discharge

• Frequent complaints from post acute providers regarding discharge planning processes and hand off communication.

DiagnosisDiagnosis

• Lack of standardized systems for discharge planning processes.

• No feedback/communication process to assure post acute providers receive information needed to provide patient care post discharge.

• Medications errors, omissions, duplication when patient moves across settings

• Each settings gives patient and family different disease management

• Information

p g

• Lack of adequate medication reconciliation at each transition

• Lack of standardized education material given to patients and families regarding disease management

Team MembersTeam MembersName Title FacilityVickie Bishop Ast Director Nursing Calvin Coolidge Nursing & Rehab

Lisa Mercier Director of Nursing Calvin Coolidge Nursing & RehabDaniel Barrieau Director Respiratory Therapy Cooley Dickinson Hospital

Linda Chastain RN, Pulmonary Clinic Cooley Dickinson Hospital

Tammy Cole-Poklewski Director, Quality, Patient Safet Cooley Dickinson Hospital

Sally Crowthers Clinical Director, Med / Surg NCooley Dickinson Hospital

Shannon Dillard QI Coach Cooley Dickinson Hospital

Peter Elsea MD, Hospitalist Cooley Dickinson Hospital

Warren Fisher MD, Medical Director Cooley Dickinson Hospital

Geri Molaghan CHF Coordinator Cooley Dickinson Hospital

Jay Pasternack Behavioral Health Cooley Dickinson Hospital

Christine Plantier Complex Case Manager Cooley Dickinson Hospital

Carol Smith Exec VP/COO Cooley Dickinson Hospital

Nancy Sunflower Charge Case Manager Cooley Dickinson Hospital

Diane Walker Clinical Dietician Cooley Dickinson Hospital

Ann Careau Director Marketing Cooley Dickinson VNA & Hospice

Kelli Barrieau Director, Quality VNA Cooley Dickinson VNA & Hospice

Jeanne Ryan Exec Director VNA/Hospice Cooley Dickinson VNA & Hospice

Sally Dunn Client Represenative Curaspan (eDischarge software)

Mark Bird Social Worker Hampshire Care Nursing Home (Ov

Robert Gallant Exec Director Highland Valley Elder Service

Nancy Maynard Highland Valley Elder Service

Michelle Wuest Administrator Linda Manor Extended Care Facility

James Lomastro Administrator Northampton Rehab & Nursing

Cheryl Pascucci Vice President NP Care (independent NP group co

Jeffrey Zesiger MD, Medical Director Private Physician

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Team MembersTeam MembersName Title FacilityVickie Bishop Ast Director Nursing Calvin Coolidge Nursing & Rehab

Lisa Mercier Director of Nursing Calvin Coolidge Nursing & RehabDaniel Barrieau Director Respiratory Therapy Cooley Dickinson Hospital

Linda Chastain RN, Pulmonary Clinic Cooley Dickinson Hospital

Tammy Cole-Poklewski Director, Quality, Patient Safet Cooley Dickinson Hospital

Sally Crowthers Clinical Director, Med / Surg NCooley Dickinson Hospital

Shannon Dillard QI Coach Cooley Dickinson Hospital

Peter Elsea MD, Hospitalist Cooley Dickinson Hospital

Warren Fisher MD, Medical Director Cooley Dickinson Hospital

Geri Molaghan CHF Coordinator Cooley Dickinson Hospital

Jay Pasternack Behavioral Health Cooley Dickinson Hospital

Christine Plantier Complex Case Manager Cooley Dickinson Hospital

Carol Smith Exec VP/COO Cooley Dickinson Hospital

Nancy Sunflower Charge Case Manager Cooley Dickinson Hospital

Diane Walker Clinical Dietician Cooley Dickinson Hospital

Ann Careau Director Marketing Cooley Dickinson VNA & Hospice

Kelli Barrieau Director, Quality VNA Cooley Dickinson VNA & Hospice

Jeanne Ryan Exec Director VNA/Hospice Cooley Dickinson VNA & Hospice

Sally Dunn Client Represenative Curaspan (eDischarge software)

Mark Bird Social Worker Hampshire Care Nursing Home (Ov

Robert Gallant Exec Director Highland Valley Elder Service

Nancy Maynard Highland Valley Elder Service

Michelle Wuest Administrator Linda Manor Extended Care Facility

James Lomastro Administrator Northampton Rehab & Nursing

Cheryl Pascucci Vice President NP Care (independent NP group co

Jeffrey Zesiger MD, Medical Director Private Physician

#1#1Lack of Standardized Transition ProcessLack of Standardized Transition Process

• Create standardized transition process from start to finish

• Cross Continuum service providersCross Continuum service providers collaborate to create the process

What information do we each need as the patient moves from one setting to the next? Let’s create the transition process together.

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eDischarge Case Management eDischarge Case Management CURRENT PROCESSCURRENT PROCESS

Patient needs post acute provider

Case Mgr. open eDischarge file for patient & load with patient information from;

-medical record (prog notes)-transfer orders (1, 2, 3 pgs)

Case Mgr. asks patient for their choice of facility or

Post acute gets back to hospital -accept-decline

Pending additional information needed

Additional Patientyother provider

Case Mgr. "make referral"-put in criteria -SNF -Hosp Match selection -Acute Rehab to patient -IV/DME specific request

Case Mgr. eDischarge-implementation page,

write narrative notes/may send additional

information as requested

Case Mgr. send to postacute provider & wait

for response

information needed from post acute

Patient discharge to post acute

Post acute notifies Case Mgr.

of need for additional

information

Patient needs post acute care

eDischage loaed with patients information

(goal: 1 page/day for patient with all required info.)

eDischarge Case Management FUTURE PROCESS

eDischarge "match" & information sent

Post acute accepts

Patient discharged to post acute & all

information needed is received

#2:No Feedback loop from Post Acute Providers#2:No Feedback loop from Post Acute Providers

Create feedback loop via: • “Post Discharge Communication Survey” to

insure all service providers are receivinginsure all service providers are receiving necessary information at transition point.

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Post Discharge SurveyPost Discharge SurveyPost Discharge HAND OFF COMMUNICATION Survey

In an effort to improve our discharge planning process the Cooley Dickinson Hospital Readmission Team and the Case Management Department are requesting your feedback about the information provided to your facility at the time of this patients discharge. Please take the time to respond to the questions below.

The completed survey can be faxed to 582-2264. Thank you in advance for your time.

Tammy Cole-Poklewski, RN MS Director Care Management & Standards Compliance Readmission Team Leader

Date of Discharge from Cooley Dickinson Hospital: ___________________________ Name of your agency: _________________________________ Name of contact person at your facility:____________________Telephone #: ________________ Patient Name:_____________________________ Date of Birth:___________________ Yes No Comment 1 Did you receive the discharge summary when

the patient arrived at your facility?

2 Did you receive the discharge paperwork and page 3 referral?

3 If the patient was discharged and needed supplies for care were the supplies sent by CDH to your facility? (i.e., colostomy supplies or other special order supplies that usually take a couple days to obtain)

4 Has the family or patient presented any concerns regarding their stay at Cooley Dickinson Hospital?

5 Did you receive a phone call from anyone at CDH regarding the patient? If yes, please state who called – staff nurse, ED case manager, case manager, etc.

Note: NO responses to questions 1-3 will be immediately directed the Tammy Cole-Poklewski or Nancy Sunflower for follow up by the Case Manager. Additional Comments:

#3: Lack of Medication Reconciliation at each transition point#3: Lack of Medication Reconciliation at each transition point

• Include updated/up to the minute medication list on discharge summary paperworkp p

• Complete medication reconciliation at time of hospital transition

Universal Transfer Form – CDH Test of ChangeCDH Current Discharge Paperwork 4 pages– cut & paste pieces are missing

pieces on CDH form that are part of the DPH Universal form

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Mass DPH Proposed Universal Transfer Form – STAAR Team tested this form, identifying gaps. Need for updated medication list at time of discharge identified and included in new form.

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#4:Lack of standardized patient education material across #4:Lack of standardized patient education material across settingssettings

• Cross continuum team created standardized education/teaching tool to be initiated at the hospitalp

• Education/teaching tool utilized across all settings

Name:_____________________

Date: _____________________

CONGESTIVE HEART FAILURE SIGNS AND SYMPTOMS

♥ Your weight is stable♥ You have no trouble breathing♥ You can do your usual activities♥ Your symptoms are under control

NORMAL WEIGHT ● You are doing well - Continue to: ● Take your medications as ordered ● Write down your weight each morning ● Follow a Heart Healthy Low Sodium diet ● Plan activities and get enough rest ● Keep all doctor appointments

Green Zone Means:

YELLOW ZONE: CALL FOR INSTRUCTIONS WHEN: Yellow Zone Means:

CALL FOR INSTRUCTIONS

HOW YOU FEEL WHAT YOU DO

What is Congestive Heart Failure?Congestive Heart Failure (CHF) means that your heart can't pump blood as well as it should.

GREEN ZONE: YOU ARE DOING WELL WHEN:

1 Teaching

3636Revised 8/09

♥ Your weight goes up ____ pounds in _____ days♥ You have new swelling in your feet, ankles, hands or abdomen♥ You feel winded or have increased shortness of breath♥ You have a problem breathing when you're laying down♥ You feel more tired or have less energy than usual♥ You have a dry, harsh cough that does not go away

● CALL FOR INSTRUCTIONS: Home Doctor ___________________________ Phone ___________________________ VNA office

RED ZONE: MEDICAL ALERT WHEN: ♥ You have severe shortness of breath ♥ You feel palpitations or a "racing heart" ♥ You have chest pain that does not go away ♥ You have increased restlessness or nervousness ♥ You feel like fainting or passing out Call 911 immediately

Red Zone Means:

●You need to be evaluated ♥ Call 911 Immediately

gTool

used for all Hampshire

County

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Acute Care Hospitilization

28%

24%

20%

25%

30%

2009 2010

0%

5%

10%

15%

45%

57%

40%

50%

60%

Oral Meds2009 2010

0%

10%

20%

30%

40%

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Readmission RateReadmission Rate

UCL 12.211

10.135

11.135

12.135

13.135

Rat

e

CDH % Inpatient Readmit to Acute Care within 30 Days (CDB919) Care Transition Coach

initiated

CL 9.180

LCL 6.148

5.135

6.135

7.135

8.135

9.135

Jan

2009

Feb

2009

Mar

200

9

Apr

200

9

May

200

9

Jun

2009

Jul 2

009

Aug

200

9

Sep

2009

Oct

200

9

Nov

200

9

Dec

200

9

Jan

2010

Feb

2010

Mar

201

0

Apr

201

0

May

201

0

Jun

2010

Jul 2

010

Aug

201

0

Sep

2010

Oct

201

0

Nov

201

0

Dec

201

0

Jan

2011

Feb

2011

Mar

201

1

Apr

201

1

May

201

1

Rea

dmit

R

Coaching Networking BreakfastCoaching Networking Breakfast

Lessons LearnedLessons Learned

• Improve communication with referral sources

• Develop a relationship with dischargeDevelop a relationship with discharge planners

• Cross-continuum teams• Medication reconciliation• Teaching materials

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History of the ProjectHistory of the Project

• Home Care Alliance of Massachusetts

• Elevation of Transitions to a Priority Issue with Policy Makers , Payers and Providers

Transitions as a Priority IssueTransitions as a Priority Issue

• “Massachusetts Strategic Plan for Care Transitions”

• STARR Project• STARR Project

• PPACA and hospital non payment for readmissions

• Nursing Home INTERACT

Home Care is the Answer ? Home Care is the Answer ? Home healthcare is the component of the

healthcare industry best positioned to bridge gaps in care between hospitals and homegaps in care between hospitals and home,

especially for high risk groups such as older adults coping with multiple health

problems.”(Naylor, 2006)

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“Home health is likely the (only) truly scalable infrastructure for improving quality and access for the low-

mobility, high risk Medicare beneficiaries who drive the majority of program expenditures and suffer the most---1st

step in impacting quality for this group may be

Home Care is the Answer ?Home Care is the Answer ?

step in impacting quality for this group may be conceptualizing home health as THE central architecture/ platform to deliver transitional, post-acute, and primary care/ chronic care management for these individuals.”

Dr Steve Landers, Cleveland Clinic, 2009 CMS Briefing on HHQI

Premise Behind Alliance Premise Behind Alliance OPTOPT--In Project In Project

Home health agencies need to do a better and more aggressive job of:• making care transitions policy conversations about

helping hospitals (and especially the new breed of h it li t) i i l i t hhospitalist) in screening people into home care

• helping referral sources to understand what they can expect from a home care referral in terms of skilled and supportive care, medication reconciliation and management and patient teaching etc .

Alliance’s Transitions of Care GroupAlliance’s Transitions of Care Group

How do we…• get “home health care” to the discussion table?• prove we are the experts in home health care?• prove we are the experts in home health care?• illustrate are importance in the continuum of

care?• Acknowledge that…

• Home Care is the Answer

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OPTOPT--InIn

OPTimum Performance StandardsOPTimum Performance StandardsOPTimum Performance Standards OPTimum Performance Standards for Patient Centered Transitions to for Patient Centered Transitions to

and from Home Health Careand from Home Health Care

What is OPTWhat is OPT--IN IN

• A set of standards for the home care industry and its partners across all health care sectors• Promote seamless care transitions• Advance positive outcomes • Reduce risks found to cause patient

re-hospitalizations.

Seven OPTSeven OPT--In StandardsIn Standards

• Development from Home Health Care regulatory frameworkregulatory framework• COPs• OASIS-C

• Based on industry quality practices

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Standard I Standard I ReferralReferral

HHA collaborate with referral sources to achieve smooth transition

• Timely admission to home health care• MD specified admission--• Same day/ 24 Hrs• No later than 48 Hrs

Standard II Standard II Initial Home AssessmentInitial Home Assessment

Each patient receives patient specific, comprehensive assessment that accuratelycomprehensive assessment that accurately reflects the patient’s current health status includes information to establish the POC

Initial Home AssessmentInitial Home Assessment

Assess clinical, functional, service needs, home environment

Multi factor Falls riskMulti-factor Falls risk

Hospitalization risk

Depression screening (PHQ-2) Pfizer

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Initial Home AssessmentInitial Home Assessment--ContinuedContinued

Reconcile meds- follow up with MD in 1 calendar dayAbility to manage self-careAbility to manage self careAssess for HHA, other disciplinesAssess social supports, psycho-social needsPatient specific goals

Standard IIIStandard IIICollaborate with Patient and Collaborate with Patient and

Physician to Establish the POCPhysician to Establish the POC• Following discussion of pt’s condition

with MD, clinician incorporates specific Best Practices into POC• Based on OASIS-C process measures

(M2250-M2400)• Face to Face Encounter

Standard IVStandard IVPlan of Care/CoordinationPlan of Care/Coordination

• POC provides an inter-disciplinary approach for providing SN, PT, OT, ST, HHA, MSW, as needed, ,

• Evidenced-based practice• Case conferencing & ongoing care coordination

(MD/specialists)• Close coordination amongst therapy disciplines• Referral to disciplines/resources as needed

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Standard VStandard VHealth Coaching, Teaching and Health Coaching, Teaching and

Enhanced LearningEnhanced Learning

• Personalized teaching –for patients to better manage their chronic illness

PersonalizedPersonalized teachingteaching• Customize education- (Cultural and health

literacy considerations)• Red Flags …“Call Me First”• Medication Management• Self- Management tools… “Teach Back”• Goal setting…identify obstacle to reach goal

Standard VIStandard VIReRe--AssessmentAssessment

• Ongoing re-assessment of each patientpatient

But no less than 60 days/or as often as condition requiredTherapy Regulations: Minimum of every 30 days, 13th and 19th therapy visits

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ReRe--AssessmentAssessment

Continue need for home health care

Meet pt’s medical, nursing, rehab, and psycho/social needs

Discharge planning for smooth transition for patient self-care

Standard VIIStandard VII

Discharge Planning/Transition toDischarge Planning/Transition toDischarge Planning/Transition to Discharge Planning/Transition to Another FacilityAnother Facility

Standard VIIStandard VII (continued) (continued)

Discharge PlanningDischarge Planning

Transitional coaching completed/DC initiatedinitiatedo Personal Health Record/Med Listo Physician/Specialists follow-upo Who/when to call …Self-management

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Standard VIIStandard VII (continued) (continued)

Transition to Another FacilityTransition to Another Facility

Deteriorating medical condition/family unable to provide care/planned follow-up d i iadmissiono “Hand over” to another facility

Terminal illnesso Palliative Care/Bridgeo Hospice

Home Care IS the Answer…Home Care IS the Answer…

Expert PanelExpert Panel• The following individuals contributed to the content of OPT-In document:

• Kathleen Aubert, RN • Colleen Bayard PT, MPA • Keren Diamond, RN • Meg Doherty MSN ANP BC MBA• Meg Doherty, MSN, ANP-BC, MBA• Merrily Evdokimoff, RN MSN,• Cheryl Pacella DNP(c), HHCNS-BC, COS-C, CPHQ • Patricia O’Brien, RN, MBA• Helen, Siegel, RN, MSN• Jeanne M. Ryan, MA, OTR, CHCE, COS-C• Laurie Rubin• Jean Zalenski, PT, DPT, MEd.•

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Contact InformationContact Information

• cbayard@thinkhomecare.org• jeanne_ryan@cooley-dickinson.org

ReferencesReferences• www.caretransitions.org• www.ihi.org• Massachusetts Health Care Quality and Cost Council• Massachusetts Coalition for the Prevention of Medical Errors• National Transitions of Care Coalition, • www.qualityforum.org

QuestionsQuestions