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The Family Caregiver ConnectionSupporting Essential Care Partners as Patients Transition to Home
Danny van Leeuwen, RN, Health Hats
MaryAnne Sterling, CEA, Family Caregiver
Geri Lynn Baumblatt, MA, Patient Engagement Expert
Amy Cain, RN, Wolters Kluwer (Emmi)
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Elder Care Transitions = Sinking of Titanic
2018 © Sterling Health IT Consulting
My Mom’s Story• 7 care transitions in 4.5 months after a fall/
broken ankle • Every care transition means starting from
scratch • No communication or coordination between
facilities • Lack of a comprehensive care plan • Only source of up-to-date medication list =
me
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2018 © Sterling Health IT Consulting
What is a Care Transition?From To
• Hospital • In-patient Rehab • Assisted Living • Nursing Home • Hospice • Home
• Hospital • In-patient Rehab • Assisted Living • Nursing Home • Hospice • Home
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2018 © Sterling Health IT Consulting
What are the components of a care transition?• Change of physical location • Medical record updates • Medication changes/reconciliation • Coordination of healthcare • Coordination of social services • Instructions/next steps • New providers to educate • Paperwork • Family caregiver chaos
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2018 © Sterling Health IT Consulting
What makes elder care transitions unique?• Frail condition of many elders • Dementia & mobility issues • Medication volume and complexity • Living situations that don’t match care
needs • Fall risk • Patient wishes vs family preferences/
abilities • Driven by what Medicare will cover
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2018 © Sterling Health IT Consulting
What Happens Today?• Overall lack of knowledge about the needs of seniors with complex health conditions • Unique aspects of elder care transitions are not factored into the equation • Healthcare and social services operate in silos • Patients and family caregivers have to figure out how to navigate the system
on their own • Discharge instructions and medication lists are written at a high literacy level
and not user friendly • Many tasks previously designated for nurses are now being handed to family
caregivers • Longterm care is not tech enabled – at all.
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2018 © Sterling Health IT Consulting
What Does NOT Happen Today?• Communication • Care planning • Evaluation of family caregiver needs • Training for patients/family caregivers • Coordination of healthcare AND social services • Accountability/reliable follow-up • Treating the WHOLE patient
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Healthcare
Community Supports
Social Services
2018 © Sterling Health IT Consulting
Result for Caregivers• Absent from work trying to find resources & coordinate care ▫ Can’t find resources in their community ▫ Can’t afford resources they do find ▫ Can’t get access to medical records
• Not prepared or trained • Neglect their own health and end up needing care • Expend their own financial resources • High likelihood their parent will make return trip to emergency dept
and the process begins again…
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2018 © Sterling Health IT Consulting
What can the “system” do?• Guide family toward services they may need and help
coordinate them • Provide clinical information in a way both patient and
caregiver understand, i.e. plain language and language of choice
• Provide access to an aggregate medical record and assistance from a pharmacist to review & adjust medications
• Help put resources in place, starting with an on-call home health nurse
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Tools to Support the Circle of Care
Geri Lynn Baumblatt, MA @GeriLynn
Disclosures
Advisor, Roobrik
Advisor, Helpsy Health
Beta Tester, Atlas of Caregiving CareMap app
Consultant, Active Daily Living
Concerns• Safely providing care • Skills • Understanding • Finances
@gerilynn
@gerilynn
• Social Isolation • Family strife • Injuries to self • Care coordination • Their job/employment • Their health
What they don’t know…
1. Haley et al, 2009; 2 Cuijpers, 2005; 3. Girgis el al, 2013; 4. Spillman et al, 2014; 5, Slgado-Garcia et al 2015; 6. Dassell@ Carr, 2014 & Steinberg et al, 2010; 7 Darragh et al, 2015; 8. Capistrant 2012 $ Ji et al 2012; 9. George & Gwyther, 1986, Selzer & Li, 2000, Skaff & Perrin 1992; 10. Haley et al, 2009
@gerilynn
http://www.oncologynurseadvisor.com/oncology-nursing/including-informal-caregivers-in-discharge-planning-beneficial/article/651627/
Including Informal Caregivers of Elderly in Discharge Process Reduces Readmission Risk
25% reduced risk of readmit within 90 days
24% reduced risk of readmit within 180 days
@atlasofcare
lungchicago.org
lungchicago.org
@careDOTcoach
©2017.Allrightsreserved.
Example InteractionAvatar = human + software
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@careDOTcoach
©2017.Allrightsreserved.
The Avatar SolutionThe best of human & software intelligence
CORE
ProviderPortal
FamilyPortal
CareAvatar
HealthAdvocates
ClinicalAlgorithms
inpatientin-home
⬆self-management
⬇readmissions
⬇delirium⬇EDvisits/admissions
⬆wellness
⬆patientsatisfaction
⬇falls
⬆value-basedcare$$$coaching
observing reporting
engage
ment
24x7personalizedsupport
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@careDOTcoach
©2017.Allrightsreserved.
ROI from Avoiding ReadmissionDe-identified patient data shown
Email+phonealerttriggeredbycontextualresponse:
PreventedReadmission$13,000costavoidance
byinformingclinicalteamtoadjustmedications
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• Passively tracks day-to-day activity of the care recipient in their living space • Activity and inactivity compared against defined criteria and daily living patterns • If activity falls outside normal patterns, caregivers receive alerts
In-homecomponents Simplesetupwithtelephonesupport Smartphonedisplay
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CAPTURES INFORMATION • Motion • Door status • Bed/Chair occupied • Pill box access • Stove left on
ANALYZES DATA and compares to selected safety criteria
Caregivers Select Alert & Notification Criteria
Caregiver Installs DevicesCaregivers Receive
Actionable Information
SafeinHome
ALERTS Immediate Attention
OBSERVATION on Demand
Tracking of multiple days
activity
TREND ANALYSIS Identifies changes
71% of caregivers interested in technology
… only 7% use it
• Don’t know which tech to use • No time to learn new tech • Clinicians need to suggest friendly tech
AARP 2016
Why Not?
EmpoweringPatients&CaregiversAfterDischarge
Titleofpresentation
Inanidealworld–patientsandcaregiverswouldleaveanyepisodeofcare
understandingeverythingtheyneedtoknowtogetbetter,staywell,
attheirhighestleveloffunctionandhaveaccesstoallthetoolstheyneed
forsuccess.
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Titleofpresentation
TechnologytoMaintainConnection
▪ Keeppatientatthecenter▪ Drivepatientstotherightactions▪ Includefamilyandcaregivers▪ Personalized▪ Deliversconsistentmessageinreliablemanner▪ Deliversresultsforproviders
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Titleofpresentation
ExtendingReach
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Titleofpresentation
EmmiTransition®
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• Proactive,scalableandautomatedcallcampaigns• Helpspeopletransitionfromhospital-to-home• Reinforceskeymessagestoindividualsandfamily• Tracksanddocumentsactivityandrecovery• CorrespondingEmmiEngage®programs
EngageswithEmmi’sempatheticvoice
Collectsvitalinformationfromusers
Providesdailyreportsonrecoverystatus
NotifiesStaffofpeopleat-riskofreadmission
Titleofpresentation
UniqueApproach–UnderstandsPeople
BuiltonBehavioral&EducationalScience
▪ Triggers▪ Habits▪ Motivators▪ PositivePsychology▪ ActionPlanning
HumanCenteredDesign
▪ Intuitive▪ Non-disruptive▪ Empathetic▪ Normalize&De-stigmatize▪ ReduceAnxiety
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Ifyourdoctor’sofficecan’tgetyouinsoon,makesuretheyknowyouwerejustinthehospitalandweretoldyouhaveheartfailure.
PROPRIETARY & CONFIDENTIALPROPRIETARY & CONFIDENTIAL
Day 1
Day 3
Day 4
Day 5
Day 6
Day 7
Transportation to follow-up appointment?
Day 2
Day 8
Day 9
Day 10
HeartFailureHarry–45daysofconnection
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