Transcript Document

Transitional Care: Patient-Centered
Collaboration Across the Continuum
Judy Scott, BSN, RN, CCM
September 26, 2012
7/17/2015
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Objectives
• Upon completion of this session, the participant
will be able to:
– Describe how to create a business plan that
supports Transitional Care
– Explain Relational Coordination’s role in
Transitional Care
– Describe two outcome measures for Transitional
Care
– Discuss three lessons learned through
Transitional Care
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Background and Introduction
• Across the country, 20% of Medicare beneficiaries are
readmitted to the hospital within 30 days of discharge
(Healthcare Advisory Board, 2010)
• Unplanned readmissions cost Medicare $17.4 billion in
2004 (Healthcare Advisory Board, 2010)
• Avoidable readmissions accounted for $12 billion in costs
to Medicare in 2005 (Healthcare Advisory Board, 2010)
• Causes of avoidable readmissions include hospital-acquired
infections and other complications; premature discharge;
failure to coordinate and reconcile medications; inadequate
communication among healthcare personnel, and poor
planning for safe transitions of care. (Berenson, Paulus, & Kalman,
2012)
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Background and Introduction
• At IUH North Hospital, 16.5% of Medicare beneficiaries are readmitted
within 30 days
• Of patients we discharged to a Skilled Nursing Facility (SNF) in 2011,
13.06% were readmitted to our hospital within 30 days; this rate goes
up to 22% depending on the SNF
• 30-day SNF readmissions cost our hospital an estimated $268,540 in
2011
• According to the Healthcare Advisory Board (2010), Payments will soon
be bundled for episodes of care. This means we will receive one
payment to share between the physician, the hospital, and the postacute care provider.
– An episode of care is defined as 3 days prior to admissions to 30 days post-discharge
– Readmissions that occur within 30 days of hospital discharge will not be reimbursed
– This change forces hospitals and post-acute providers to work more collaboratively
together to improve patient care quality and reduce readmissions
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The Big Question
• Could we improve patient outcomes and reduce
our 30-day readmission rates if we utilized the
Transitional Care Model for patients who
discharge from our hospital to a skilled nursing
facility (SNF)?
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What is Transitional Care?
• Mary D. Naylor, PhD, RN, is the Marian S. Ware Professor in Gerontology
and Director of the NewCourtland Center for Transitions and Health at
the University of Pennsylvania School of Nursing. She has conducted
research in care transitions since 1989.
• “The Transitional Care Model provides comprehensive in-hospital
planning and home follow-up for chronically ill older adults hospitalized
for common medical and surgical conditions. The heart of the model is
a Transitional Care Nurse (TCN), who follows patients from the hospital
and into their homes and provides services designed to streamline
plans of care, interrupt patterns of frequent acute hospital and
emergency department use, and prevent health status decline.”
Retrieved August 7, 2012 from http://www.transitionalcare.info/
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Evidence Review
Keywords: Skilled nursing facility, hospital readmissions, case management, transitional
care, relational coordination
• Level II – Randomized Control Trial (RCT)
– Coleman, E.A., Parry, C., Chalmers, S., & Sung-Joon, M. (2006). The care
transitions intervention: Results of a randomized controlled trial. Archives
of Internal Medicine. 166, 1822-1828.
This study showed that tools and guidance from a transition coach reduced hospital readmissions for
patients discharged home.
• Level III – Control trial without randomization
– Williams, G., Akroyd, K., & Burke, L. (2010). Evaluation of the transitional
care model in chronic heart failure. British Journal of Nursing 19 (22),
1402-1407.
– Wong, F.KY., Chan, M.F., Chow, S., Chang, K., Chung, L., Wai-man, L. & Lee,
Rance (2010). What accounts for hospital readmissions? Journal of
Clinical Nursing 19, 3334-3346.
These studies showed that utilizing a transitional care model or community health nurses to follow-up with
patients reduced hospital readmissions.
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Evidence Review
Data Bases Searched: Medline, EBSCO, PubMed
• Level IV - Well-designed case-control and cohort studies
–
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Naylor, M.D., Bowles, K.H., & Brooten, D. (2000). Patient problems and advanced practice nurse
interventions during transitional care. Public Health Nursing, 17(2), 94-102.
Naylor, M.D. & McCauley, K.M. (1999). The effects of discharge planning and home follow-up
intervention on elders hospitalized with common medical and surgical cardiac conditions.
Journal of Cardiovascular Nursing, 14(1), 44-54.
Watkins, L., Hall, C., & Kring, D. (2012). Hospital to home: A transition program for frail older
adults. Professional Case Management, 17(3), 117-123.
The Naylor, et. al. studies supported the use of APNs to follow-up with patients post-discharge and were
successful in reducing readmissions. In the Watkins and Kring study, they proved that a hospital to
home program of patient follow-up reduced readmissions by 67%
• Level VI - Evidence from a single descriptive or qualities study
–
–
Havens, D.S, Vasey, J., Gittell, J.H., & Wei-Ting, L. (2010). Relational coordination among nurses
and other providers: Impact on the quality of patient care. Journal of Nursing Management. 18,
926-937.
Smith, S.B. & Alexander, J.W. (2012). Nursing perception of patient transitions from hospitals to
home with home health. Professional Case Management, 17(4), 175-185.
The Havens, et. al. study showed that using Relational Coordination improved patient care quality.
The study by Smith, S.B. & Alexander, J.W. showed that nurses perceive the transition of
patients from hospital to home with home care needs improvement.
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What are we trying to accomplish?
• Improve safety and clinical outcomes for
patients transitioning from our hospital to
skilled nursing facilities (SNF) and then on to
home.
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How will we know that a change is an
improvement?
• 30-day SNF readmissions will be reduced
• We will experience Medicare cost avoidance by
reducing readmissions
• Patients will report satisfaction with the
program and improved confidence in their selfcare abilities
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What changes can we make that will
result in an improvement?
• Implement Transitional Care (TC); a patientcentered approach to guide the patient and
caregiver through the care continuum.
• By adding a Transitional Case Manager (TCM),
we allow the inpatient case managers to align
their focus with that of the system to reduce
length of stay, and we allow the TCM to focus on
chronic case management.
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Building the Case for Transitional Care:
Revenue Potential
• 2011: 55 SNF readmissions within 30 days of
hospital discharge
• The literature shows that 76% of Medicare
readmissions are avoidable. For us, that meant
that 42 readmissions could have been avoided
in 2011
• Based on Medicare payment rates, this
represents $359,436 in unreimbursed care
under the new ACO model
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Revenue Potential
• Those 42 preventable readmissions account for 265
patient days (average LOS for SNF discharges was
6.3d)
• Given our overall average LOS of 3.9d, we could have
admitted an additional 68 patients during this time
period, representing over $581,944 in lost revenue
potential (based on Medicare reimbursement)
• Median Medicare Cost/Case = $4,630
• Multiplied by 68 = $314,840
• Revenue potential minus cost/case = $267,104 net
revenue potential
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Potential Return on Investment
• Net revenue potential:
267,104
• Potential lost revenue:
+ 359,436
$626,540
• Program costs:
- 120,000
• Potential ROI:
$506,540
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The Right Thing to Do
• It’s not all about the money...
• It’s about bridging communication gaps
• It’s about ensuring the safe transition of our patients
and coordinating care from one setting to the next
• It’s about taking the best possible care of our patients
to improve clinical outcomes and enhance
patient/family satisfaction...even if that means moving
beyond the hospital walls to do it.
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Executive Team Support
• IUH is evolving into an Accountable Care Organization
• Executive Team encourages innovation and creativity
• It is the right thing to do for our patients
• Culture and Maxims
• Take Ownership
• Do More
• Show Kindness
• Create Joy
• Connect Fully
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Building the Program
• Case Manager candidate selection:
– Highly motivated
– Critical thinker
– Problem solver
– Strong clinical background
– Collaborative
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Building Relationships
• Patient/Caregiver
• Advanced Healthcare Associates
• Four local Skilled Nursing Facilities; selected
based on our referral patterns
• Home Care Agencies
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Relational Coordination
• “Coordinating work across functional and
organizational boundaries through relationships
of shared goals, shared knowledge and mutual
respect, supported by frequent, timely,
accurate, problem-solving communication.”
Retrieved August 7, 2012 from: http://rcrc.brandeis.edu/rc/
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Relational Coordination
• Shared Goals: Improve patient outcomes
• Shared Knowledge: Bridge communication
gaps; patient report, clinical education, patient
education materials
• Mutual Respect: Understand the specialized
care delivered across the continuum
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Relational Coordination
• Another way to look at it:
– “While coordination is the management of
interdependencies between tasks, relational
coordination is the management of interdependencies
between the people who perform those tasks” (Gittell,
2009, p.15)
• Relational Coordination can improve communication
among colleagues who work in different areas of
expertise. It results in fewer chances for errors to
occur and will drive quality performance in a positive
direction. (Gittell, 2009)
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Post-Acute Facility Collaboration
• Began in 2010
• Learn from each other; developing mutual respect
• Provide free clinical education for post-acute care
providers
• Identified opportunity to improve communication at
time of transition to the SNF
– Developed standard Patient Report Tool
• Transitional Care Program developed in 2011;
implemented February, 2012
• Collaboration continues today
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Innovative Partnership
• In addition to clinical case management, our
Transitional Care program includes an innovative
partnership with a transitional care physician
• This former IU Health hospitalist works closely with our
case manager to meet the clinical needs of our
patients throughout their stay in the SNF
• The transitional care physician acts as the patient’s
primary care physician until discharge from the SNF at
which time, the patient’s primary care physician
resumes care of the patient
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Physician Collaboration
• Transitional Care Physician is employed by Advanced
Healthcare Associates
• TCM partners with the Transitional Care Physician to
coordinate the patient’s care throughout their SNF stay
• TCM proactively monitors the patient for any clinical
changes and engages the TCP as needed
• Early recognition of subtle changes in the patient’s
clinical condition has allowed treatment to occur in the
SNF and has prevented hospital readmissions
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Nuts and Bolts of the Program
• Training
• HIPAA Compliance
• Informed Choice
• Patient Enrollment
• Patient Visits
• Essential Functions
• Documentation
• Discharge Packet
• Home Care Plan
• Communication and Handoffs
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Training
• Johns Hopkins Nursing Institute
• Scholarships
• Guided Care Certification
– Major focus on motivational interviewing
– Patient engagement
– Medical Home Model but principles apply to
Transitional Care
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HIPAA Compliance
• Consent to participate
• Includes release of information consent so we
can access patient information in the SNF and
beyond
• Program intent and consent form were reviewed
and approved by IUH Legal Department
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Referral and Choice Process
• Introduction letter is given to the patient
• Explanation of the program offered during the
Informed Choice Process
• Patient selects post-acute facility
• Transitional case manager and physician are
notified of the referral and are given basic
patient information: name, MRN, room number,
discharge location, anticipated discharge date
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Patient Enrollment
• The TCM meets the patient in the hospital prior
to discharge
• The patient consents to participate in the
program and agrees to release their health
information
• The patient’s discharge summary is reviewed by
the TCM prior to discharge for medication
reconciliation and to clarify any information for
the SNF provider
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Patient Visits
• Multiple 1:1 patient visits in the SNF weekly
• Early identification of subtle clinical changes
• Prompt intervention
• Care coordination
• Patient education
• Ongoing medication reconciliation
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TCM Essential Functions
• Develop and nurture a collaborative partnership with the
patient/caregiver and post-acute facilities (Relational Coordination)
• Create a seamless path for the patient/caregiver; one consistent
resource to answer questions or concerns, provide ongoing
education, and navigate the patient through the care continuum
• Act as the patient’s link to all physicians (the hospitalist,
transitionalist, specialist(s), and primary care physician) as well as
other healthcare providers involved in their care
• Empower patients to be active participants in their care and
decisions regarding their care through education and action plans
• Connect the patient to community resources, home health agencies,
and health plan case managers as needed
• Conduct medication reconciliation at discharge to assure safety and
continuity
• Bridge the communication gaps that can exist when patients
transition from one care setting to another
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Documentation
• Morrisey Concurrent Care Manager (MCCM)
• Continuum Module
– Documentation occurs at the patient level rather
than the encounter level; spans the continuum
– Can view continuum notes from the acute side if
patient is readmitted
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MCCM Continuum
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Continuum Notes
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SNF Discharge Packet
• Comprehensive packet is faxed to the PCP and any specialists
involved in the patient’s care at the time of SNF discharge. Packet
includes:
• Hospital discharge summary
• Summary of events during SNF stay
• Transitional Care physician notes
• Therapy notes
• Lab and test results; resulting treatments
• Vital signs
• Diet
• Discharge medications
• Any special concerns to be followed-up by the PCP
• Post-discharge follow-up tests and appointments
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Transitional Care Home Plan
• Medications
– Patient-friendly language
– Schedule
– Reason
•
•
•
•
•
•
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Wound care as needed
Diet
Activity
Follow-up appointments
Post-SNF care as needed (HHA)
Additional information as needed
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Sample Home Care Plan – Page 1
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Sample Home Care Plan – Page 2
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Outcomes through May 2012
IUH North Hospital SNF Discharges and 30-Day Readmissions
A comparison of overall SNF readmission rates before and after implementing
Transitional Care in February 2012
600
Patient Volume
500
488
13.31%
Readm it
Rate
400
Total Cases
Readmissions
300
200
100
154
65
8.40%
Readm it
Rate
13
0
Jan11-Jan12
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Feb12-May12
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Outcomes through May 2012
• 45% Reduction in overall 30-Day SNF
readmissions since our Transitional Care
Program was implemented Feb 24, 2012!
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Cost Avoidance through May 2012
• Median Medicare Cost/Case = $4,630
• Cost of SNF Readmissions Jan11 thru Jan12 =
$300,950
• 45% cost reduction, minus program costs = $108,326
in cost avoidance thru the first 4 months
• Annualized cost avoidance = $324,978
• Estimate does not include revenue potential
from additional admissions
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Patient Satisfaction
• Tool has been developed
• Currently under review by IUH Marketing Dept.
before implementation
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Lessons Learned
• Patient hand-off from hospital to SNF needs improvement
• Medication reconciliation is a high risk area; needs improvement
• Need mechanism to notify the ED of transitional care patients, even if
they’ve been discharged home from the SNF
• SNF patient education needs improvement; patients are unprepared to care
for themselves at home
• SNF discharge process is somewhat fragmented; needs improvement
• Need mechanism to collaborate with other programs within IUH system to
coordinate patient care (i.e., GRACE, Chronic Disease Management, etc.)
• It is challenging to coordinate care for patients who have primary care
physicians outside the IUH system
• Once the patients return home from the SNF, they need continued
monitoring to assure appropriate follow-up and prevent further
readmissions (Some of our patients readmitted to the hospital from home
outside the 30-day window)
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Home Care Pilot
• Goals:
– Reduce hospital readmissions beyond 30 days postdischarge
– Improve the patient’s self-care abilities and outcomes
• Skilled nursing visit within 48hrs of SNF discharge;
then once weekly x 4 weeks
–
–
–
–
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Medication adherence
Follow-up appointments
Therapies as needed
Continued patient education
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Thank you!
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References
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Berenson, R.A., Paulus, R.A., & Kalman, N.S. (2012). Medicare’s readmissions-reduction program: A positive
alternative. The New England Journal of Medicine, 366(15), 1364-1366.
Gittell, J.H. (2009). High performance healthcare: Using the power of relationships to achieve quality,
efficiency and resilience. New York, NY: McGraw Hill.
Havens, D.S, Vasey, J., Gittell, J.H., & Wei-Ting, L. (2010). Relational coordination among nurses and other
providers: Impact on the quality of patient care. Journal of Nursing Management. 18, 926-937.
Healthcare Advisory Board (2010). Succeeding under bundled payments. Retrieved May 10,
2011
from www.advisory.com.
Naylor, M.D., Bowles, K.H., & Brooten, D. (2000). Patient problems and advanced practice
nurse
interventions during transitional care. Public Health Nursing 17(2), 94-102.
Naylor, M.D. & McCauley, K.M. (1999). The effects of discharge planning and home follow-up
intervention on elders hospitalized with common medical and surgical cardiac conditions. Journal of
Cardiovascular Nursing, 14(1), 44-54.
Smith, S.B. & Alexander, J.W. (2012). Nursing perception of patient transitions from hospitals
to home
with home health. Professional Case Management, 17(4), 175-185.
Watkins, L., Hall, C., & Kring, D. (2012). Hospital to home: A transition program for frail older
adults.
Professional Case Management, 17(3), 117-123.
Williams, G., Akroyd, K., & Burke, L. (2010). Evaluation of the transitional care model in chronic
heart
failure. British Journal of Nursing 19 (22), 1402-1407.
Wong, F.K.Y., Chan, M.F., Chow, S., Chang, K., Chung, L., Wai-man, L. & Lee, Rance (2010).
What
accounts for hospital readmissions? Journal of Clinical Nursing 19, 3334-3346.
7/17/2015
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