care transitions: a demonstration project tim young, lcsw piedmont hospital sixty plus older adult...
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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