Coleman Nashville January 2018.ppt · Eric A. Coleman, MD, MPH 3 Anticipatory Guidance for the Receiving Team You have done a great job of caring for this patients in the inpatient

Eric A. Coleman, MD, MPH

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An Under‐recognized Key to Improving Transitional Care: Feedback Loops


Care TransitionsThe most interesting things happen in doorways

--Inferno, Dan Brown

But Dr. Coleman, we have done everything

(c) Eric A. Coleman, MD, MPH

The Triple Aim through the Lens of Care Transitions

Better health for populations—self care as central tenet

Better care for individuals—quality and patient experience measures (HCAHPS/CTM) tied to value based purchasing

Lower costs through improvement—readmission penalties; STAR ratings, bundled payment, ACOs, MSPB and more


A Word of Caution:Checklists and Task Completion in Context


Ultimate Goal for Transitional Care

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



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Improving Cross-Setting Collaboration

(c) Eric A. Coleman, MD, MPH Loehrer S, McCarthy D, Coleman, EA Population Health Management DOI: 10.1089/pop.2015.0005

Effective Collaboration among Health Care Providers Requires:

Trusted convener

Common goals

Shared understanding--site visits and shadowing

Starting small and go after “quick wins”

Data to identify opportunities for improvement

Focus on patients’ needs and experiences

Loehrer S, McCarthy D, Coleman, EA Population Health Management DOI: 10.1089/pop.2015.0005

Improving Cross-Setting Communication


Design with the End-User (or Next-User) in Mind

Put yourself in the shoes of the next care team

Even better—reach out and ask them!

Think beyond your professional discipline

Consider how data collection might serve multiple purposes for greatest efficiency


Re-Thinking the Transfer (D/C) Form

Include expectations for transfer—what you hope or anticipate will be accomplished

Shift perspective from historical to future

Shift orientation from reporting versus action



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Anticipatory Guidance for the Receiving Team

You have done a great job of caring for this patients in the inpatient hospital—bravo! Now we ask you to consult your crystal ball If something was going to go bump in the night(s)

after discharge, what would that look like? What initial steps might you suggest to address

the problem without sending to the ED?


Carolinas HealthCare “SNF Circle Back” Questions

1. Did the patient arrive safely?

2. Did you find admission packet in order?

3. Were the medication orders correct?

4. Does the patient’s presentation reflect the info you received?

5. Is patient and/or family satisfied with the transition from the hospital to your facility?

6. Have we provided you everything you need to provide excellent care to the patient?

]Source: Emily Skinner, Carolinas Healthcare System (HRET/HEN Website)

Home Health Care Nurse Perspectives on Care Coordination for Recently Discharged Patients

HHC nurses encounter many challenges including:

1) hospital & outpatient physician accountability

2) lack of access to hospital records,

3) difficulty reaching hospital & outpatient physicians

4) payer requires that HHC orders come from MDs

5) clinician misconceptions about HHC services .

Christine D. Jones, MD, MS et al abstract presented at SHM 2016 (c) Eric A. Coleman, MD, MPH

Patient Engagement Feedback Loops

Teach Back: A Core Competency


Simulation to “Road-Test” the Care Plan


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Do We Inadvertently Foster Dependency?


Identifying when a patient crosses the “invisible line”

Persons with Chronic Illness have Predictable Relapses of Their Condition

Provide anticipatory guidance to person and family caregivers

Use simulation principles to gauge self-care capabilities of patients and family caregivers



JAMA 2014;311(3):243-244

A Patient’s Care Plan Is Our Best Guess

The care plan is rarely customized to an individual’s ability to participate in self-care

What if we could “road test” the care plan before transfer?

We could then refine and better customize the care plan



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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

Meeting Patients Where They Are:The Care Transitions Intervention

www.caretransitions.org

Key Elements of The Care Transitions Intervention

Simplicity is biggest asset and liability Unique focus on skill transfer to support self-care “Transitions Coach” is the vehicle to build skills,

confidence, provide tools all to support self-care– Model behavior for how to handle common problems– Practice or role-play next encounter


Coaching = Skill Transfer

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



Agenda Is Driven by the Patient’s Goals


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Distinguishing CTI:What It Is and What It Is Not

What CTI Is NotCTI does not attempt to replace home health care/case managementTransitions Coaches do not provide skilled careCoaches do not fix problemsCoaches do not nudge or remindCTI has no checklists


What CTI IsUnique focus on skill transfer to promote confidence in self-careTransitions Coaches have skillsTools to evaluate skill transferPatient’s goal drives agendaCTI aims to promote independence by not fixing problems for patients

Care Transitions InterventionResults from the Real World



Supporting the “Unsung Heroes”Family Caregivers


What Frightens Family Caregivers?

The answer is “many things” However an underappreciated fear is that by not

being adequately prepared, they may cause harm to their loved one

Understanding the True Contributions of Family Caregivers

46% family caregivers perform 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.

Caregiver Advise Record & Enable (CARE) Act

(1) Record family caregiver’s name on admission;

(2) Notify family caregiver when discharge is near;

(3) Include family caregiver in discharge instruction



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39 States and Territories Have EnactedThe CARE Act into Law:

Alaska, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Hawaii, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Rhode Island, Texas, Utah, Virginia, Virgin Islands, West Virginia, Washington, Washington DC, Wyoming

J Hosp Med July 5, 2016

Family Caregiver Activation in TransitionsTM

FCATTM Tool

The FCATTM tool is designed to be administered by a health professional or self-administered by the family caregiver (takes 2 minutes)

Facilitate more productive interactions and guide the care team in understanding patient and family needs and deploying appropriate resources


Illustrative FCATTM Items

I have a trusted pharmacist or pharmacy in my community that I can contact if I have medication questions

I understand which of the instructions in my loved one’s care plan are most important and need to be completed first and which instructions are less urgent

If my loved one needs help from a healthcare professional, I am confident I can insist until I get what is needed


The Joint Commission Journal on Quality and Patient Safety.2015;41(11):November:502-507.

Risk Identification



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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

3)

American Journal of Medical Quality 28(5) 383–391

What Predicts Execution of Discharge Instructions?

Hospital Admissions Risk Multiplier Screen (HARMS-8)

1. How would you rate your current health?

2. How many prescription medications are you taking?

a) How often do you decide not to take your medications?

b) How sure are you that you know the reason for taking meds?

3. Are you having any difficulty doing activities of daily living?

4. How often do you have trouble remembering or thinking clearly?

5. How many friends/relatives you could call on for help?

6. How confident are you that you can manage your conditions?

7. During the past 6 months, did you go to the emergency room?

a) Do you think you will go to the emergency room again?

8. During the past 6 months, did you stay in the hospital?

a) Do you think you will need to be hospitalized again?

Consider a Two-Step StrategyStep 1: Narrow the population to a manageable #

Predictive algorithm (e.g., LACE)

Diagnosis (e.g. the 3 publicly reported)

Prior utilization (e.g., Hospital, Obs and ED)

Step 2: Go to the bedside

Ask the patient to reflect on contributing factors

Evaluate literacy, cognition, activation, family caregiver, mental health diagnoses


Getting Started


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



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Getting Started:Huddle for Care

Huddle for Care is a virtual community of care transitions implementers exchanging innovations

Browse stories of solutions implemented by transitional care teams across the U.S.

http://huddleforcare.org/



www.caretransitions.org

We invite you to join us!

Documents

Coleman Nashville January 2018.ppt · Eric A. Coleman, MD, MPH 3 Anticipatory Guidance for the Receiving Team You have done a great job of caring for this patients in the inpatient