patient-centered care transitions: helping hands · helping hands health services advisory group of...

Patient-Centered Care Transitions:Helping Hands

Health Services Advisory Group of California, Inc.–1–

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Patient-Centered Care Transitions: Helping Hands

Jennifer Wieckowski, MSG

Program Director, Care Transitions

Health Services Advisory Group of California, Inc.

(HSAG-California)

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HSAG-California: The Medicare Quality Improvement Organization

(QIO) for California QIOs are a major force and trustworthy partner for

improvement.

The QIO Program is the largest federal program dedicated to improving health quality at the community level.

QIOs in every state and territory are united in a network administered by the Centers for Medicare & Medicaid Services (CMS).

Current QIO initiatives run August 2011–July 2014.



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Objectives

Learn about current CMS national initiatives and local implementation efforts to improve care transitions. Identify common patient-centered care elements

in nationally known care transition models. Discuss the importance of coordinated care

transitions across medical and community-based providers. Identify community-based resources that can be

used to enhance patient-centered care.

(c) Eric A. Coleman, MD, MPH

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The Hospital Readmission Problem

20 percent of Medicare fee-for-service patients are readmitted within 30 days.

90 percent of those readmissions are unplanned.

The cost to Medicare for unplanned readmissions in 2004 was $17.4 billion.



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Patient Perspectives

“They overmedicated me like you wouldn’t believe [in the NH]. All they had to do was make one call to my primary care doctor.”

“The doctor did not know that there was no way my wife could take care of me.”

“A lot of times the questions don’t come until you get home.”

“You know, we are responsible for our own healthcare and it is our fault if we fall through the cracks.”



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Care Transitions Are Common

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Silos In Our Healthcare System



13© Eric A. Coleman, MD, MPH

Our healthcare system operates in “silos,” is setting centered―notpatient centered―and is incapable of reciprocal operation between organizations.

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No Provider Takes Responsibility

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Common Elements of Safe and Effective Care Transitions

Medication reconciliation occurs.

Patients and caregivers are involved and prepared.

Person-centered care plans are communicated timely across settings.

The sending provider maintains responsibility for the patient’s care until the receiving clinician/location confirms the transfer and assumes responsibility.



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Common Elements of Safe and Effective Care Transitions (cont’d)

“Rocket science is helpful, but not required.”

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However, none of these will work

unless . . .

. . . an important element is present.



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HUDSON RIVER PLANE LANDINGJanuary 15, 2009

SHARED Accountability

P r o v i d e d b y N a n c y S k i n n e r



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Hospital Readmission Penalties

Effective October 1, 2012, high-readmission hospitals will be penalized based on avoidable readmissions of patients diagnosed with CHF, AMI, or pneumonia.

Penalties are based on data from July 1, 2008, to June 30, 2011.

The penalties will increase in FYs 2014 and 2015.

CMS will finalize rules on implementation of the penalties next year.

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Community-Based Care Transitions Program (CCTP)

Section 3026 of the Affordable Care Act

Test models for improving care transitions for high-risk Medicare beneficiaries from the inpatient hospital setting to other care settings

Multiple hospitals must partner with a community-based organization (CBO) that has care transition experience.

$500 million available– Applications accepted on a rolling basis



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Hospice

Hospital

HomeAmbulatory Care Clinic

Skilled Nursing Facility

SNF

Rehabilitation Facility

Hospice

Getting Started:Convene Relevant Partners

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Getting Started:Patient-Centric, Community-Based Approach

Establish relationships with the community of providers who care for patients in your area.

Recruit and convene relevant partners.

Conduct a root cause analysis of the causes of readmissions or adverse events surrounding hospital discharge.

Choose evidence-based care transition interventions to address these causes.



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Components of Evidence-Based Care Transition Interventions These programs:

– Engage patients with chronic illnesses while hospitalized.

– Follow patients intensively post-discharge.

– Teach/coach patients about medications, self-care, and symptom recognition and management.

– Remind and encourage patients to keep follow-up physician appointments.

Approaches to achieving these goals differ across programs.

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Comparing Evidence-Based Care Transition Interventions

Care Transitions Intervention (Coleman)

– Patient-centered intervention designed to improve quality and contain costs for patients with complex care needs as they transition across care settings.

Transitional Care Intervention (Naylor)

– Patient-centered intervention designed to improve quality of life and patient satisfaction and reduce hospital readmissions and cost for elderly patients hospitalized with CHF.



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Comparing Evidence-Based Care Transition Interventions (cont’d)

Care Transitions Intervention (Coleman)– APN, RN, social worker, or occupational therapist

– 1 care coordinator per 40 patients

– Duration: 30 days following hospitalization

Transitional Care Intervention (Naylor)– Advanced practice nurses (3)

– 1 care coordinator per 39 patients

– Duration: 3 months following index hospitalization

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Comparing Evidence-Based Care Transition Interventions (cont’d)

Care Transitions Intervention (Coleman)

– Home visit post discharge: 3 follow-up calls

– Based on four pillars: medication management, patient-

centered record, primary care and specialist follow-up, and

knowledge of red flags

Transitional Care Intervention (Naylor)

– Hospital visit and home visits of varying frequency

– Comprehensive assessment in hospital• Defining priority needs and services

– Ongoing advocacy, education, and communication to

ensure plan of care



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Four Pillars

Medication self-management

Patient-centered record (PHR)

Follow-up with PCP/specialist

Knowledge of “Red Flags” or warning signs/symptoms and how to respond

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

PersonalHealthRecord



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Accessing Community Resources: Helping Hands

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Acknowledgements

Eric A. Coleman, MD, MPH

Associate Professor

Divisions of Geriatric Medicine and Health Care Policy and Research

University of Colorado Health Sciences Center



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Thank You!

Jennifer Wieckowski, MSG

Program Director, Care Transitions

HSAG-California

700 North Brand Blvd., Suite 370

Glendale, CA 91203

818-427-4378

[email protected]

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www.hsag.comThis material was prepared by Health Services Advisory Group of California, Inc., the Medicare Quality

Improvement Organization for California, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not

necessarily reflect CMS policy. Publication No. CA-10SOW-8.0-122811-01

We convene providers, practitioners, and patients to build and share knowledge, spread best practices, and achieve rapid, wide-scale

improvements in patient care; increases in population health; and decreases in health care

costs for all Americans.

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