Seamless Transitions of Care: Strategies for Successful Outcomes · 2019-04-23 · 4/12/2019 1 Seamless Transitions of Care: Strategies for Successful Outcomes Susan LaGrange, RN,

4/12/2019

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Seamless Transitions of Care: Strategies for Successful Outcomes

Susan LaGrange, RN, BSN, NHA, CDONA, FACDONA, CIMT, IP-BC

Director of Education

Pathway Health

Objectives

1. Describe the elements of the discharge planning process from admission to discharge to home

2. Identify helpful transition tips for a successful discharge

3. Assist family and resident with preparation to discharge home

4. Understand person-centered care planning requirements

This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.

A Little History


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Why focus on transition of care?

• Can lead to adverse events

• Higher readmission rates

• Higher costs

• Miscommunication

• Can occur from any setting

• Patient satisfaction

Transitions of Care

What are transitions of care?

Movement of patients from one health care practitioner or setting to another as their condition and care needs change

Transitions of Care

Occurs at multiple levels• Between settings: Hospital ↔

Sub-acute facility/SNF, Hospital ↔ Home

• Within settings: ICU ↔ Ward

Across Health States• Curative care ↔ Palliative

care/Hospice

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Common Care Transitions

Key Components of Care Transitions

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HRRP, SNFVBPThis presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice

with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.

Quality


OIG-Office of Inspector General

https://oig.hhs.gov/oei/reports/oei-02-09-00201.pdf


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https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

CMS State Operations Manual


Transitions of Care Begins with Discharge Planning

F624 Orientation for Transfer or Discharge

“A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand.”


Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf


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https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf


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Sufficient Preparation and Orientation

• Providing a good explanation of the location of discharge and the reason

• Ensuring resident’s belongings go with the resident (or safeguard)

• Staff provide services to prevent or minimizes anxiety

• Resident is provided preparation for transfer in a manner that they can understand

• Document resident understanding of the discharge


Guidance/Guidance/Manuals/downloads/som107ap_p

p_guidelines_ltcf.pdf


F660 Discharge Planning Process

“The facility must develop and implement an effective discharge planning process that focuses on the resident’s discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions.”



F660 Discharge Planning Process

Discharge needs are identified

Include regular re-evaluation

Involve the Interdisciplinary

Team

Consider caregiver availability, capacity

and capability

Involve the resident/resident

representative

Goals and treatment

preferences

Interest in receiving information on returning to the

community

Assistance with selection of

another provider

Complete and timely

documentation

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som10

7ap_pp_guidelines_ltcf.pdfThis presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice


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F660

“If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.”

“For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data..”

“The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident’s goals of care and treatment preferences.”


Definition

“Discharge Planning”:

A process that generally begins on admission and involves identifying each resident’s discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident’s stay to ensure a successful discharge.

CMS Discharge Critical Element Pathway-CMS

20132 (11/2017)

https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html


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https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

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Section Q of the MDS

• Appropriate and adequate supports

• Resident/Resident Representative Involvement

• Referral to Local Contact Agency

• Not all residents can be discharged to another setting


Discharge Care Planning


Policy/Procedures for Discharge Planning

Example:• Policy: It is the policy of

this facility that an effective discharge planning process will be conducted with the resident and/or resident representative as active partners, focusing on the resident’s goals and preparation for resident centered care following discharge


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Procedure

Procedure:

• Resident comprehensive assessment

• Person-centered discharge care plan developed

• Referrals

• IDT to re-evaluate

• Selection of destination

• Documentation

• Discharge Summary


Discharge Plan

Interdisciplinary Team + Resident + Resident Representative


A Good Discharge Plan Starts At the

Time of Admission


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Destination-Home


Resident Admission

Creating a Person-Centered Approach to Transition of Care!


Admission

Gather information on:

• Prior living setting

• Plans for discharge

• Assistance needs and availability


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The First Step to Success

Make sure that you and the

resident/patient are on the same page

Discover

Needs

Goals

Preferences

Expectations

Does the resident and their caregivers/family

members have the same goals


Begin The Assessment Process!


RAI PROCESS

MDS

CATs

CAAs

CARE PLAN

CAA SUMMARY

CARE ASSESSMENTS RESIDENT INTERVIEWSThis presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice


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Steps for a Safe Transition

Home!


Transition Care Plan

• Do you have a formal transition of care plan?

• Is there consistent education across shifts?

• Is there a process for communication with all members of the care team ?

• Are you confident you have documentation to substantiate progress and process?


The Home Environment

• Do you have a process to discuss the home environment with the resident and their caregivers?

• Have you completed a home visit to identify:• Safety needs/barriers?• Mobility needs/barriers?• Resident motivation?

*Develop an individualized plan to overcome any barriers and opportunities for successful transition!


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Preparing for Medical Management

• Education in chronic disease management

• Understanding of medical conditions • Signs and

symptoms of trouble

• Communication with Providers • When to call, who

to call • Health monitoring

• E.g. blood glucose monitoring

• Medical treatments • E.g. nebulizer,

wounds, etc.This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice


Managing Social Care Needs

• Financial needs

• Support structure

• Access to care- Transportation

Assess social aspects of health

• Local Area Agency on Aging

Have resources available to

describe resources in the

community


Discharge Planning

Resident Teaching• Medications

• Treatments

• Devices

• Routines

• Etc.

• Functional Interventions

• Resident Representative Teaching


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Considerations

Resident Cognition

Function

Motivation

Endurance

Available Support


Cognitive Health

• Does this individual have a dementia diagnosis or a mental health diagnosis

• Education of the caregiver

• Referral to resources

• Alzheimer’s Association

• Caregiver support groups

• Booklets on behavioral management

• Local groups for the individual to get involved with


Practice and Repetition


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Start Education Process-ASAP!

• Education of your resident (and caregivers) is key to their success

• Education must be coordinated and consistent

• Start teaching now • A little every day

• This is an advantage to our setting


Plan-Medication Teaching

• Name

• Dose

• Time

• Route

• Special instructions

• Side effects or special considerations


Key education topics

• Their medical conditions

• Key warning signs • Medications

• Key side effects

• Mobility • Safety

• Etc.


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Day of Discharge


Tasks for the Day of Discharge

• Communicate with the Medical Provider in the Community

• Give contact info to the resident (e.g. nurse case manager or social worker)

• Assist with scheduling follow up appointments

• Provide educational packets• Medication information• Disease specific

information• Treatment instructions• Etc.

• Ensure that everything you have planned for is in place • Transportation • Support• Home health • Durable medical

equipment • Medication list • Mobility aides • Etc.


Discharge Instructions-MDS 3.0

• Identification

• Contact information

• Advance Directives

• Physician Name

• Pharmacy

• Care Provider Contact

• Medical History

• Medications

• Treatments

• Durable Medical Equipment

• Housing

• Transportation

• Follow-up appointments

• Contact information at Nursing Facility

• Medication education

• Disease management education

• Who to call in an emergency

MDS 3.0 RAI Manual, Pages Q-9-10This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.

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Post-Discharge Follow-Up

Your Role


Follow Up Is Essential!

• Ensure that the individual has connected with their primary care provider and/or specialist

• Ask about symptoms, concerns, and medications-coaching approach

• Is the plan working?

• Are they accessing the necessary community resources ?

• Is their caregiver showing up?

• Do they feel safe?

• Does the caregiver have questions?


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Coaching Approach

Coach the resident/resident representative through solving the issue themselves:

• Provide guidance, reassurance and encouragement

• Encourage them to access services and resources that have been discussed

• Empower them to master the management of their health


Providing Follow Up

• Ensure that the resident and their caregivers know this individual before discharge

Have a designated person in charge of follow up

• Formal hand-off of medical care

• Review of course of care at your facility

• Key medication/treatment changes

Provider at the Nursing Home

should also follow up with

the Community medical provider


F661 Discharge Summary


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Discharge Summary Inclusions

(i) A recapitulation (or concise summary) of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.

(ii) A final summary of the resident's status, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative

(iii).Reconciliation of all pre-discharge medications with the resident’s post discharge medications (both prescribed and over-the-counter).

(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services.


• Identification and demographics

• Customary Routine

• Cognitive Patterns

• Communication

• Vision

• Mood and Behavior Patterns

• Psychosocial Well-being

• Physical functioning and structural problems

• Continence

• Disease diagnoses and health conditions

• Dental and nutritional status

• Skin Condition

• Activity Pursuit

• Medications

• Special Treatments and Procedures

• Discharge Planning

• Documentation of Summary Information

• Documentation of Participation in Assessment

F661: Final Summary of Resident status




Timing of Discharge Summary


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Employee Education


Against Medical Advice


Post Discharge Process

• Determine formalized process

• Care Navigation

• Transition of Care model

• Other

• Communication

• Coordination with care team (full continuum)

• Collaboration with partners

• Documentation

• Monitor outcomes

• QAPI

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Summary - Facility Planning

Policies and Procedures

01Identify available services and contacts in your community

02Education

03


Questions?


References and Resources

• Centers for Medicare & Medicaid Services State Operations Manual, Appendix PP – Guidance to Surveyors for Long Term Care Facilities (Rev. 173, 11-22-17): https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

• LTC Survey Pathways (Download)

https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/nursing-homes.html


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https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/nursing-homes.html

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• Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.16. October 2018: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html

• Agency for Healthcare Research and Quality: Chartbook on Care Coordination. Transitions of Care: https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure1.html



• Medicaid.gov: Improving Care Transitions: https://www.medicaid.gov/medicaid/quality-of-care/improvement-initiatives/care-transitions/index.html


Disclaimer

“This presentation provided is copyrighted information of Pathway Health. Please note the presentation date on the title page in relation to the need to verify any new updates and resources that were listed in this presentation. This presentation is intended to be informational. The information does not constitute either legal or professional consultation. This presentation is not to be sold or reused without written authorization of Pathway Health.”


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https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html

https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure1.html

https://www.medicaid.gov/medicaid/quality-of-care/improvement-initiatives/care-transitions/index.html

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Seamless Transitions of Care: Strategies for Successful Outcomes

Susan LaGrange, RN, BSN, NHA, CDONA, FACDONA, CIMT, IP-BC

Director of Education

Pathway Health

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Documents

Seamless Transitions of Care: Strategies for Successful Outcomes · 2019-04-23 · 4/12/2019 1 Seamless Transitions of Care: Strategies for Successful Outcomes Susan LaGrange, RN,