MANAGING CARE TRANSITIONS South Country Health Alliance

February 2013

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Care Transitions: Learning Objectives

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Characterize care transitions and understand impact on older and disabled adults.

Learn methods that support members through transitions including medication reconciliation.

Review care transition process and documentation requirements.

Care Transitions 3

Transition: Movement of a member from one care setting to another as the member’s health status changes. Examples include: moving from home to a hospital

as the result of an exacerbation of a chronic condition or moving from the hospital to a rehabilitation facility after surgery.

Care Setting: The provider or place from which the member receives health care and health-related services. In any setting, a designated practitioner has ongoing responsibility for the member’s medical care. Examples include: home, home health care, acute

care, nursing facility, rehabilitation facility

30 Day Readmissions: The Problem

Nationally – 17.6% of Medicare beneficiaries discharged from the hospital are readmitted within 30 days.

More than 85% of these re-hospitalizations are unplanned.

20-40% of re-hospitalizations are possibly preventable.

64% of Medicare beneficiaries who are readmitted within 30 days do not receive any post-discharge care before readmission.

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Hospice

Hospital

Home Ambulatory Care Clinic

Skilled Nursing Facility

SNF

Rehabilitation Facility Hospice

Fundamental Disconnect…

**Dr. Eric Coleman’s slide, printed here with permission.

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Hospice

Hospital

Home Ambulatory Care Clinic

Skilled Nursing Facility

SNF

Rehabilitation Facility Hospice

And others…

Pharmacists

Specialists

Home Health

Payers 6

Hospice

Hospital

Home Ambulatory Care Clinic

Skilled Nursing Facility

SNF

Rehabilitation Facility Hospice

Opportunities for improvement?

Pharmacists

Specialists

Home Health

Payers 7

Patient Level Contributors

Non-intentional non-adherence Money financial barriers Intentional non-adherence Didn’t fill the prescription Other Subtotal

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System Level Contributors

Discharge instructions incomplete and illegible Conflicting information from different sources Duplicative prescribing Incorrect label Other Subtotal

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Care Transitions 10

Older or disabled adults moving between health care settings are particularly vulnerable to: Fragmented care due to lack of follow-up Health care providers not communicating. Unsafe care due to changes with medication

regimes or lack of understanding on new or discontinued medications.

Self-management concerns.

Goal

To promote safe/effective transitions of care as patients navigate from one provider setting to another – or one caregiver to another through proactive care coordination.

Providing a consistent person through the care transition makes a difference.

Care Coordinators are the key to prevent

problems during transitions.

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Four Pillars for Optimal Transition Medication Self-Management:

Knowledgeable about medications and has a system to manage their medications.

Personal Health Care Record: Understands and has a personal health care record.

Warning Signs: Verbalize warning signs and symptoms to watch for and how to respond.

Follow-up with Primary Care Provider: Schedules and completes a follow-up appointment with their Primary Care Provider.

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Personal Health Care Record

Facilitate communication and continuity of care planning across care settings. Member is in charge of their personal health care record.

Explain the personal health care record and its components.

Review and update any areas after any change in condition and/or setting.

Encourage the member to update and share with their Primary Care Provider and Specialists at follow-up appointments.

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Warning Signs

Member is knowledgeable about indicators that their condition is worsening and how to respond.

Discuss the signs and symptoms of potential changes in their health status.

Collaboratively develop an plan that outlines who to call and when to call them.

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Follow-up with Primary Care Provider Member schedules and completes a follow-up visits with

their Primary Care Provider and is empowered to be an active participant during the visit.

Emphasize the importance of the follow-up visits and the need to provide their Primary Care Provider an update with their current health status.

Practice and role play questions to ask their Primary Care Provider and/or Specialist.

Follow-up with the member to discuss the outcome of the visit with their Primary Care Provider and/or Specialist.

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Medication Self-Management

Discuss the importance of understanding medication and having system in place.

Reconcile medication regimen after care transitions. Identify and correct any discrepancies.

Assist with medication simplification to support a manageable system.

Answer any medication questions.

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Why Is Medication Reconciliation Important?

Most frequently occurring type of medical error: Medication errors

Most frequently cited category of root causes for serious adverse events: Ineffective communication

Most vulnerable parts of a process: Links between the steps (the “hand-offs”)

Medication reconciliation addresses all of these

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Prescribing errors known to occur when there is incomplete information about the patient

27% of hospital prescribing errors attributed to incomplete medication history on admission Reference: Dobrzanski s, Br J Clin Govern 2002; 7: 187-93

Medication discrepancies can lead to harm: 22% - in hospital 59% - after discharge Reference: Gleason KM, Groszek JM, Sullivan C, Rooney D,

Barnard C and Noskin GA. Am J Health-Syst Pharm. 2004; 61:1689-95

Why Is Medication Reconciliation Important?

Medication Reconciliation Process Medication reconciliation in home care starts

and ends with the client and involves four basic steps:

1. Identify the client; 2. Create the Best Possible Medication History

(BPMH) and identify discrepancies; 3. Resolve and communicate discrepancies;

and 4. Close the medication reconciliation loop.

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Identify and Target Members

Targeted Members: SeniorCare Complete and AbilityCare SNP (Group A) members who experience a hospitalization.

Goal: Is all members are to have a medication reconciliation visit.

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Best Possible Medication History Interview the client/family using a systematic

process to establish the clients’ medication regimen including drug, dose, route and frequency.

The information gathered will reflect what the client is actually taking versus what is prescribed.

Compare information from interview with other sources of information including physician orders, discharge and transfer information, medication labels, pharmacy lists, etc…

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Best Possible Medication History Identify any discrepancies among the sources

of information. Document any discrepancies on the

Medication Reconciliation Tool.

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Resolve and Communicate Discrepancies

Resolve appropriate discrepancies with the client/family if the changes required are consistent with the prescription.

Identify discrepancies that need to be resolved by the physician/nurse practitioner, pharmacist or other member of the client circle of care. The urgency of the reconciliation and resources available need to be considered when choosing the method of communicating the discrepancy.

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Resolve and Communicate Discrepancies Communicate discrepancies to other members

of the client circle of care via: Phone Facsimile Hand delivery by the clinician Hand delivery by the client/family Face-to-face discussion

Document actions taken to resolve discrepancies in the client record for follow up during subsequent visits if necessary and appropriate.

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Close the Reconciliation Loop

Confirm resolved discrepancies. Communicate the reconciled medication list via:

Phone discussion with the client/family or clinician.

Facsimile to the organization to communicate the discrepancy with the client/family.

Face to face discussion with the client/family. Verify the member/family understands any

changes to the medication regimen and importance of keeping the medication list up-to date.

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Goals of Medication Reconciliation Clearly delineate for the Member New medications with indications Medications to be stopped Medications with new instructions Medication to continue taking as before.

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Care Coordination Requirements Identify planned transitions – reach out to the

member prior to the admission or day of the admission.

Share essential information with the receiving setting within 1 business day of the notification of the admission.

Communicate within 1 business day of notification with providers, member and/or responsible party about the transition process and about changes in the member’s health status and care needs.

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Care Coordination Requirements

Communication with Primary Care Provider Contact within 1 business day of notification

of the transitions. Verbally, fax, or flag in an electronic system. Contact the clinic – Primary Care Provider and/or

Specialty Care Provider. Notify of admission - if not involved.

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Care Coordination Requirements Communication with Receiving Setting Contact within 1 business day of notification

or the transitions. Unit or Discharge planner, Social Worker, etc… Verbally, fax, flag in an electronic system

Contact to share: Services that are currently being received and who

provides them (i.e. home care services) Primary Care Provider and/or Specialty Care Provider

contact information, resource for current medications, chronics conditions, current treatments, etc…

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Care Coordination Requirements Communicating with the Receiving Setting is

NOT a utilization review function and does not constitute authorization of the hospital stay.

Communicate with discharge planner so they know what services are being provided (i.e. home care, EW, CADI, etc…). Determine from discharge planner if any new services and/or equipment might be needed and assist to coordinate with best possible Provider.

Determine who is arranging for services upon discharge.

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Care Coordination Requirements Communication with the Member and/or

Responsible Party Contact within 1 business day of notification

or the transitions. Talk with member and/or responsible party

(face-to-face, telephonic): what happened; changes in health status; what might occur while in hospital/nursing home;

and discharge plans leading to or delaying discharge.

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Care Coordination Requirements Communication with the Member and/or

Responsible Party Work with member and/or family, reassure

you’ll contact when they go home, reassure that you’ll be available to support them. Offer Care Coordinator’s phone number for

contact.

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Care Coordination Requirements Reach out to the member after the return to usual setting to assess

needs and prevent readmissions. Telephonic or face-to-face contact Medication changes/new prescriptions filled. Arrange for or

complete a medication reconciliation visit in-person. Follow-up appointments, transportation, services Understanding of what to do if condition changes or gets

worse. Personal health care record DME/Supplies Changes in functional needs (bathing, eating, dressing,

transfers, etc…)

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Documentation To simplify the requirement to track the care

transition process, the health plans have created a form called the Individual Transition Log

Use of this form will be required whenever a care transition has occurred.

Care Systems/Counties to develop internal process to collect & record data. One log per member – record whether the

transition was planned or unplanned.

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Individual Transition Log

Care Transitions - Summary

The Care Coordination is the key to preventing and managing care transitions by: Facilitating communication to improve member’s

health and safety Develop relationships with members, local

practitioners, hospitals, nursing facilities, etc… Monitoring those at higher risk to prevent

unplanned care transitions.

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Questions/Ideas?

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