Coleman Midas Tucson May 2015.ppt Session... · Eric A. Coleman, MD, MPH 2 Framing Remark—Saying Doing Does discharge begin on admission? Really? If so how might we design and operationalize?

Eric A. Coleman, MD, MPH

1

A Multifaceted Approach to Improve Quality and Safety during Care Transitions

Eric A. Coleman, MD, MPH, AGSF, FACP

Professor of Medicine

Director, Care Transitions Program

www.caretransitions.org (c) Eric A. Coleman, MD, MPH

Roadmap

I. Framing remarks

II. Considering the national health policy landscape

III. Strategies that appear to be not working to ensure safety and quality at transitions

IV. Promising strategies to ensure safety and quality at transitions

(c) Eric A. Coleman, MD, MPH

Part I: Framing Remarks

Ultimate Goal for Transitional Care

To create a match between the individual’scare needs and his or her care setting


Misalignment

Patient identified needs

Payment requirements

Professional gratification

Regulatory requirements


Is Our Vocabulary Holding Us Back?

Time to eliminate the word “discharge”?



2

Framing Remark—Saying Doing

Does discharge begin on admission? Really?

If so how might we design and operationalize?

Where do the end-users (or next) fit into the plan?

What 5 things would you want to include in an admission assessment that would directly impact quality and safety of discharge?

(c) Eric A. Coleman, MD, MPH (c) Eric A. Coleman, MD, MPH

Part II: Considering the nationalhealth care policy landscape

Making the Shift from Encounters to Episodes to Populations

Penalties for hospitals with excessive readmissions

Codes to pay physicians for post-hospital discharge care coordination provided to Medicare beneficiaries

Payment mechanism for community organizations to bill Medicare for transitional care

Bundled payment for episodes of care

Accountable care organizations


Yes But--Many Readmissions Occur for Reasons Outside of My Hospital’s Control

Timing of PCP follow up

Patient’s unaddressed treatment preferences

Patient’s transportation

Patient’s finances

Patient’s substance abuse

Access to community mental health professionals


By now you may be thinking…



3

Part III:Strategies that appear to be not working

to reduce readmissions


Observations of What Appears Not to Be Working

1. Relabeling discharge planning and case management

2. Taking a provider-centric interpretation of “patient engagement”

3. Branding readmitted patients as “non-compliant”

4. Believing the solution must lie within the EHR

5. Having too many coordinators, too many assessments, too many care plans, too many follow-up phone calls

6. Resisting invitations to partner with CBOs


Part IV:Promising strategies to reduce

readmissions


Strategy #1:Fostering Greater Patient Engagement



Show of Hands—who has been non compliant? Time to Retire the Term….

“Non-compliant”

© Eric A. Coleman, MD, MPH


4

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Functional and Clinical Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model


Getting Started: A Simulation Lab….For Patients

North Mississippi Health System—Lee Greer, MD

Opportunity to “road test” the discharge care plan for heart failure patients and modify based on performance

Simulation lab in dedicated unit with multiple stations

Reduction in 30-day readmission rate from 17% to 13%

JCOM 2014;21(11):1-5 (c) Eric A. Coleman, MD, MPH

Self-Care Support for the “Silent” Care Coordinators

By default, patients/family caregivers perform a significant amount of their own care coordination

They do this without skills, tools and confidence to be effective


Getting Started: The Care Transitions Intervention

Low-cost, low-intensity, adapt to different settings One home visit, three phone calls over 30 days “Transitions Coach” is the vehicle to build skills,

confidence and provide tools to support self-care– Model behavior for how to handle common problems– Practice or role-play next encounter or visit– Elicit patient’s health related goal– Create a “gold standard” medication list


Coaching = Skill Transfer


5


Teach Patients to Fish or…..Move in with Them!

Persons with chronic health conditions live with them 24/7 or 168 hours per week

Fixing problems for patients represents an implied promise that you will be back to fix the problem again should it arise

Doing for patient puts the patient in the back seat

Educating puts the patient in the passenger’s seat

Coaching puts the patient in the driver’s seat



Care Transitions Intervention (CTI)Summary of Key Findings

Significant reduction in 30-day hospital readmits (time period in which Transition Coach involved)

Significant reduction in 90-day and 180-day readmits (sustained effect of coaching)

Net cost savings of $300,000 for 350 pts/12 mo

Adopted by over 935 health care organizations in 44 states nationwide

Strategy #2:Fostering Family Caregiver Engagement


Two Extremes

Either family caregivers are perceived to be “dysfunctional” and “annoying”

Or they are simply invisible and ignored


Understanding the True Contributions of Family Caregivers

46% of family caregivers performed medical/nursing tasks

78% of family caregivers managed medications

53% of family caregivers served as care coordinators

Source: S. Reinhard, C. Levine, S. Samis. Home Alone: Family Caregivers Providing Complex Chronic CareAARP/UHF Publication October 2012.



6

Getting Started: Improving the Discharge Experience

Schedule discharge instructions at a time when family caregivers can participate


Getting Started: Resources for Family Caregivers: Next Step in Care

United Hospital Fund of New York

Materials to support family caregivers

www.nextstepincare.org


Strategy #3:Fostering Greater Physician Engagement

and Accountability


Define Accountability During Transitions

Patients experiencing transitions want to know who is the accountable professional overseeing their care


Journal of Hospital Medicine 4(6):364-370 July/August 2009


7

Following Patients Across Sites of Care

Hospitalists follow patients from hospital to SNF (growing number of groups)

Using technology and incentives to promote PCP participation in advance care planning in hospital (British Columbia)

Incentives for PCP to visit patients in hospital (Excellus Rochester)


Strategy #4:Building Professional Competency


A Gap in Training

Most health care professionals had little exposure to strategies that promote effective care coordination in a single setting much less across multiple settings


Led by Mark Williams, MD

Comprehensive intervention and toolkit

Mentoring component

Model significantly reduces readmissions

www.hospitalmedicine.org/BOOST

INTERACT

Designed to improve quality of nursing home care by providing tools and resources to reduce avoidable acute care transfers– Early identification of resident change in status

– Improve documentation for change in condition

– Enhance communication with other providers

http://interact2.net/


8

Sokol PE and Wynia MK, writing for the AMA Expert Panel on Care Transitions. There and Home Again,

Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical

Association, Chicago IL 2013. Available at: www.ama‐assn.org/go/patientsafety

Strategy #5Forging Cross-Continuum Care Teams


Building and Fostering Cross Continuum Teams (CCT)

Acknowledge interdependence to serve population

Define priorities and write an aim statement

Agree on population metrics that define success

Identify common data sources plus story-telling

Emphasize the local community element


Building a Cross Setting TeamSetting the Ground Rules

What level of participation is required to be an active member in the collaborative?

What elements of care will we continue to compete on versus those that we will not?

Where will we meet? (hint—the hospital cafeteria may seem attractive but be careful)


Getting Started: Building Your Team

(c) Eric A. Coleman, MD, MPH (c) Eric A. Coleman, MD, MPH

Who Might You Invite to Join Your CCT?

Hospitals

Outpatient physician practices

Skilled Nursing Facilities

Home Health Agencies

Hospice and palliative care providers

Health plans

Dialysis facilities


9


Adult Day Health Centers

Area Agencies on Aging (AAAs)

Mental Health Providers

Emergency Medical Services

Pharmacies

Quality Improvement Organizations (QIO)

Who Might You Invite to Join Your CCT? Getting Started: Patient Education

Agree on common set of teaching materials

Ask patient how s/he best learns—then document and share with next care team

Perform teachback across the continuum


Getting Started: Consolidate Follow Up Phone Calls

Patients may receive 4-6 follow up phone calls

Confusing, frustrating, diminishes trust, disengage

Ideally need to consolidate to a single professional with skills + accountability

Marketing calls can wait a week or more


Getting Started:Community Transitions Conferences

Invite a broad array of stakeholders

Have patients and families share their experiences

Focus on poorly executed transitions

Focus on well executed transitions

Opportunity for constructive non-blaming discussion


Strategy #6Improving communication


Reinventing the Transfer Summary

Gain consensus between senders and receivers for a single format within a given community

• Design with the receiver in mind• Essential elements• Perspective (historical vs. future)• Orientation (reporting versus action)• Mode of communication• Timeliness of communication



10

Audience Poll—The Big Five?

Imagine you could only ask the patient 5 assessment questions

What 5 things would you want to include in an admission assessment that would directly impact quality and safety of discharge?


Maybe it’s not Mabel’s heart that is responsible for her HF admits…

1) Health literacy

2) Executive cognitive function

3) Activation/locus of control

What Predicts Execution of Discharge Instructions?

Coleman EA, et al. Understanding and Executing Discharge Instructions. Am J Med Qual 2013;28(5):383-391.


What 5 Things Would You Include in the Admission Assessment?

?(c) Eric A. Coleman, MD, MPH

1. Patient goals and preferences

2. Baseline physical & cognitive function

3. Family caregiver status

4. Health literacy status

5. Activation score


What 5 Things Would You Include in Admission Assessment—Eric’s List


www.caretransitions.org

We invite you to join us!

Documents

Coleman Midas Tucson May 2015.ppt Session... · Eric A. Coleman, MD, MPH 2 Framing Remark—Saying Doing Does discharge begin on admission? Really? If so how might we design and operationalize?