Care Transitions: A Demonstration Project

Tim Young, LCSW

Piedmont Hospital

Sixty Plus Older Adult Services

The Journey

2006 - Eric Coleman article

Summer 2007 – Geriatric Work Session

Fall 2007 - Awarded an 18 Month CMS/HHS demonstration grant (July ’08 through December ’09)

January 2008 - Hosted Transitions training with Eric Coleman

July 2008 - Transitions Demonstration Project launched

Fall 2008 – Project BOOST Pilot Project Launched

Strategic Work Team

Areas of Opportunity Identified Discharge Planning

End of Life Issues

Focus on Geriatric Care in ED

Medication Reconciliation

Communication Flow

Eric Coleman’s Model

4 Pillars Personal Health Record

Medication Reconciliation

Red Flags

Medical Follow up

Desire to Expand Transitions Concept Challenge

Selling community partners on concept

Barriers Overworked staff

Resistance to taking on more work

Transitions Work Team

Hospitalists Services Sixty Plus Older Adult Services Patient Care Coordination Nursing Services Emergency Department Pharmacy NICHE (Nurses Improving Care for Hospitalized

Elderly) Palliative Care Cardiovascular Services Visiting Nurse Health Systems (VNHS)

Piedmont’s Transitions Model

The Must Haves

Sustainability

Communication and Collaboration are key

Multidisciplinary teams who are accountable, will take risks and will not accept status quo

Strong executive staff and physician advocates

Ability to initially adapt project to support the existing culture, processes and work flow of your organization

Lessons Learned

Realistic timelines

Expectations

Data and outcomes

Process improvement and/or research

Utilize “teachback” technique with patients to gauge their understanding of discharge plan

Teach Back

Using simple language

Ask patient/family to repeat her understanding of concept

Identify and correct misunderstandings

Ask patient/family to demonstrate understanding again

Repeat above until convinced of comprehension or inability to do so

Phase I – Exploring the Process

Hospital-based transitions coach Provide Personal Health Record

Begin educational process

Community-based transitions coach Review medications

Continue educational process

Phase I - Success

Discovered barriers

Home Health Companies Difficult to train multiple “teams” Patients often not receiving skilled nursing

Medication Reconciliation Belief was that medications were “100%

reconciled”

Reviewed internal and external

Partnership with VNHS

Why hospital and home health agency partnership?

We are truly in this together!

No duplication of effort/contact – a natural fit

On-going contact with patient/family/physician

Processes in place to “catch” bouncebacks and clinically determine reason for readmission – swat team approach

Improve processes when problem identified

Phase II – Implementation

Hospital Discharge Planners Limited to 4 units to reduce staff (2 BOOST)

Limited to Medicare primary patients

3 Counties most served by hospital

Appropriate for home health services

Home Health Provider - VNHS Committed 2 SW’ers as coaches

Phase II - Barriers

Under utilization of home health

Medication reconciliation Discrepancies noted by pharmacy

Phase II - Success

Increased education about home health “homebound status”

Order for “RN to eval and treat”

Identified more psychosocial issues affecting ability to manage post discharge

Higher visibility of SW’ers for home health has led to increase in referrals

Criteria

Medicare as primary coverage

Age 70 or over

Inpatient stay on 6 Center, 6 North, 6 South or 5 Center

Patient is identified for project by IMS Team, Patient Care Coordinator – physician orders home health

Meets criteria for home health

Lives within designated geographic area (3 counties)

Patient or POA choose to participate and signs consent

Project Goals

Reduce 30 day readmission rate

Reduce ED visits

Increase patient/family satisfaction

Develop/implement a sustainable model

Address process improvement opportunities

Build broad base of community partners

Align with the Piedmont’s leadership’s strategic plan (cost reduction, quality, etc.)

For BOOST patients, IMS indicates CT

appropriate.PCTC reviews

patient list for non-BOOST CT

appropriate (70 +, on designated units, Medicare primary,

lives at home)

VNHS Intake Coordinator sends email to VNHS CT team; HH SOC visit scheduled within 24 hours

CT Patient Discharged

CT Patient HH Non-admit; VNHS to notify PCTC via email of non-admit; SOC clinician to notify PCP of

non-admit

VNHS RN/PT completes SOC visit within 48 hours

Legend

BOOST - Piedmont's better outcomes for older adults through safe transitions programBB - BouncebackCNS - Clinical Nurse SpecialistCT - Care TransitionsCTBS - Care transitions bounceback surveyCVS - Coach visit surveyED - Emergency DepartmentGCM - Geriatric Case ManagerHH - Home HealthIMS - Internal Medicine ServiceIP - In-PatientOBV - ObservationPCC - Patient Care CoordinatorPCP - Primary Care Physician PCTC - Piedmont CT Coordinator PDFC - Post-discharge follow-up callPOC - Plan of careSOC - Start of careVCTL - VNHS CT LiaisonVTM - VNHS Team Manager

PCC checks Quest for CT

orders

PCTC consents patient to CT program with VNHS as HH

provider; PCTC gives patient CT

portfolio

Coach Visit within 48 hours of SOC visit.: 4 pillars;

completes CVS; faxes CVS to PCTC; refers to Sixty Plus GCM for complex cases

CT Patient refuses Coach

Visit; Coach notifies VTM; VTM to notify PCTC of coach

refuse by email

Continue POCHH Clinical Visits 60 day

services

Piedmont BB(ED/OBV or IP)

within 30 days/90 days

CT HH Discharge; VNHS notify PCTC of any unmet patient needs

PDFC within 48 hours.For BOOST CT patients,

IMS nurse calls.For non-BOOST CT

patients, PCTC calls.

CT HH 60-day recert

PCC Logistics receives HH referral from physician and writes orders; VCTL meets with CT patient to answer

questions, explain HH program, verify payment

source

CT HH Resumption

of Care

CT BB VNHS PDFC

Completes CTBS

VNHS follow-up call to confirm patient attended MD appointment at 14 days post-

discharge

PCTC identifies BB based on daily report and notifies BB

team via email.

BB clinical review by CNS. Huddle meeting BB case review; identify as avoidable or unavoidable. If

avoidable, interventions identified with plan.

If patient did not attend MD

appointment, notify HHTM

CT Patient under VNHS Care

CT Patient under Piedmont Care

CT Patient HH Non-Admit

CT Patient BB High Risk

For BOOST patients, IMS indicates CT

appropriate.PCTC reviews patient list for non-BOOST CT appropriate (70 +, on

designated units, Medicare primary,

lives at home)

CT Patient DischargedPCC checks

Quest for CT orders

PCTC consents patient to CT program with VNHS as HH

provider; PCTC gives patient CT portfolio

PCC Logistics receives HH referral from

physician and writes orders; VCTL meets with CT patient to answer questions,

explain HH program, verify payment source

Care Transitions in Hospital

Identify as appropriate Screen for cognition and depression Educate on intervention and obtain signed

consent Home health liaison provides additional

education Follow up appointments scheduled prior to

discharge

VNHS Intake Coordinator sends email to VNHS CT team; HH SOC visit

scheduled within 24 hours

CT Patient Discharged

CT Patient HH Non-admit; VNHS to notify PCTC via email of non-admit; SOC clinician

to notify PCP of non-admitVNHS RN/PT completes SOC

visit within 48 hours

Coach Visit within 48 hours of SOC visit.: 4 pillars; completes CVS;

faxes CVS to PCTC; refers to Sixty Plus GCM for complex cases

CT Patient refuses Coach Visit; Coach notifies VTM;

VTM to notify PCTC of coach refuse by email

Continue POCHH Clinical Visits 60 day

services

CT HH Discharge; VNHS notify PCTC of any unmet patient needs

PDFC within 48 hours.For BOOST CT patients,

IMS nurse calls.For non-BOOST CT patients,

PCTC calls.

CT HH 60-day recert

VNHS follow-up call to confirm patient attended MD

appointment at 14 days post-discharge

If patient did not attend MD appointment, notify HHTM

Care Transitions in Home Health

Start of care (SOC) within 48 hours Hospital notified of non-admissions Coach visit made by social worker within 48

hours of SOC For on-going psychosocial issues, referral

may be made for GCM Confirm that patient kept the follow up

appointment with MD

Piedmont BB(ED/OBV or IP)

within 30 days/90 days

CT HH Resumption of

Care

CT BB VNHS PDFC

Completes CTBS

PCTC identifies BB based on daily report and notifies BB team via email.

BB clinical review by CNS. Huddle meeting BB case review; identify as avoidable or unavoidable. If avoidable, interventions

identified with plan.

Bounceback Protocol

Receive notice of bounceback within 60 days

Alert team members of reencounter

Notify discharge planner of need for resumption of home health orders

Meet weekly to discuss these cases

Implement strategies to address avoidable reencounters

Case Study - Mrs. H

88-year-old female

Admitted with pancreatitis, s/p cholecystectomy, and a pseudocyst

History of HTN, DM, afib, upper GI bleed, pulmonary HTN, CHF, breast cancer, and UTI

Widowed, lives with daughter

Ambulatory with cane/walker

Dependent in ADL’s (bathing, meals, transportation, meds)

Hospitalizations

12/22 through 12/24 4th IP stay in 2 months

Seen in ED

Started on TPN at discharge with home health

2/7 through 2/18 Bounceback discussion

Discharged on home hospice

TreatmentGroup 1

Demographics – 70 + and Medicare primary insuranceNon-BOOST in-patient or OBVDischarged to homeReceives HH via VNHS (coaching visit, clinical, possible telemonitoring); PCTC follow-up call

TreatmentGroup 2

Demographics – 70 + and Medicare primary insuranceBOOST in-patient or OBVDischarged to homeReceives HH via VNHS (coaching visit, clinical, possible telemonitoring); BOOST follow-up phone call

Control Group 3

Demographics – 70 + and Medicare primary insuranceEither BOOST or non-BOOST in-patient or OBVDischarged to homeMay/may not receive HH; may /may not receive BOOST follow-up phone callNon-CT patients

Care Transitions Group Differences Research Design

Patient Universe – 70 +, Medicare primary insurance, in-patient or observation, any presenting diagnosis, possible discharge to home (HH orders), SNF or assisted living

Patient Sample – 70 +, Medicare primary insurance, in-patient or observation, discharged to home

Group Differences Measurable Outcomes

1. Group differences in 30-day In-Patient Readmit Rates2. Group differences in 30-day ED/obv Rates3. Group Differences in Avoidable 30-day Piedmont Re-encounter (ED, OBV, IP) Rates4. Group differences in Average Length of Stay during readmit5. Group differences in Average Number of Days from Discharge to Readmit6. Group differences in Average Number of Days from Discharge to Next ED Visit7. Group differences in HH admit/HH non-admit patients 30-day Piedmont Re-encounter Rates (ED, OBV, IP)

CT Diagnosis Categories Evaluated

Cardiac and CHF

COPD

Pneumonia

Renal Failure

Procedure

Stroke (CVA)

Urinary Track Infection

Syncope

Clotting (DVT,PE)

Cellulitis

Altered Mental State

Infection

GI Issues

Other

Infection

COPD

Pneumonia

Other

Cardiac/CHF

0 5 10 15 20

CT Patients Chief Complaints Upon Admission

Medicare 30-Day Readmit Rates

18%

13%

17%

0%

5%

10%

15%

20%

25%

National (65+) Piedmont (65+) CT Consented (70+ &Homebound

Care Transition Patients with Home Health Care

72% 70%

28% 30%

100% 100%

Total Care Transitions PTs Bounceback PTs

PT with HH

PT without HH

Total

Patient Reasons for Bouncebacks

25%

8%

18%

31%

11%8%

39%

54%

7%

0%0%

10%

20%

30%

40%

50%

60%

Unavoidable Avoidable

Self-manage-ment Issues

InadequateSupport System

MedicationIssues

UnaddressedCo-morbidConditions

Procedure

Transitions in the ED

Transitions Care Coordinator in ED

Priority Patients: Those already enrolled in Transitions

Frequent flyers

Previously seen by Sixty Plus

Identified high risk Dementia Limited social support

Transitions in the ED - Process

Receive notification of repeat encounter

Screen for cognition and depression

Ask if patient talked with health care provider before coming to the ED

Begin education on Care Transitions pillars from the ED

Follow up post discharge

Transitions in the ED - Success

Developed electronic tool to highlight repeat encounters

Increased screening for cognitive issues and/or depression

Started education about discharge planning while in the ED

Increased referrals to home health services from the ED