Presenter: Rose Alfano APRN

Care Transitions from Acute Care to outpatient: Improving Patient

Experience through Best Practices

Objectives• Improve health care quality for patients by coordinating care

transitions throughout the continuum of care• Reduce avoidable cost during care transitions• Reduce preventable readmissions

Goals • Improve the patient experience• Ensure the best possible outcomes

Comprehensive Discharge Planning

Prior to discharge organize follow-up services and address barriers utilizing community resources

Stratify patients into transition pathways

Daily huddle with consistent care teams

Designated hospital staff to call patient 2-3 days after discharge.

Daily Huddle & Patient Identification

• UPON ADMISSION sort patients into four pathways

• EACH SUBSEQUENT DAY review patient progress

• FOCUS ON AVOIDABLE DAYS

Patient Sorting Criteria

•RED: Needs pallative Care

•Orange: Complex home discharge or is a readmit

•Green: Transferring to another facility after discharge

•Blue: Meet and Greet- No significant needs

Complete and timely communication of information

Providers ensure that discharge summary is issued within 2-3 days to outpatient provider

Use standard format of discharge summary

Medication Reconciliation

Reconcile medications at each transition

Check for accuracy and look for contraindications

Assess Financial Barriers

Provide up to date medication lists to patients

Prompt follow-up visit with an outpatient provider after discharge

Hospital staff schedule follow-up visits prior to discharge

Services: Ongoing symptom and medication management, 24/7 phone access

Lost Revenue

• Hospital follow up visit within 7 days of discharge: Additional $156 on top of visit charge

• Hospital follow up visit within 14 days of discharge: Additional $104 on top of visit charge

Patient/Caregiver education using the “teach back” method

Teach Back Method

“Take with meals? No problem I eat all of the time!”

Open communication between providers

Occurs between each setting and among multidisciplinary teams

Discharge provider confirms the subsequent provider received discharge summary

Successful Programs: Evidence-Based

• The Care Transitions Intervention

• The Transitional Care Model

•Project RED

Key Points• Discharge starts on admission

• All Patients are called within 7 days for medication reconciliation

• All patients have a scheduled face-to-face visit with a provider within 14 days and high risk patients within 7 days

• Discharge Summary completed within 2-3 days of discharge

Reference• Agency for Healthcare Research and Quality. (2018). Re-Engineered

Discharge (RED) toolkit. Retrieved from https://www.ahrq.gov/professionals/systems/hospital/red/toolkit/redtool5.html

• Burke, R.E. & Coleman, E.A. (2013). Interventions to Decrease Hospital Readmissions: Key for Cost-Effectiveness. JAMA Internal Medicine.

• Coleman, E.A., Parr, C., Chalmers, S. (2006). The Care Transitions Intervention: Results of a Randomized Controlled Trial. Archives of Internal Medicine 166: 1823-28.

• Jack, B.W., Chetty, V.K., Anthony, D. (2009). A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial. Annals of Internal Medicine 150(3): 178-88.

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Reference Continued

• Kim, C.S., & Flanders, S.A. (2013). Transitions of Care. Annals of Internal Medicine 58(5 part 1): ITC3-1.

• Naylor, M.D., Brooten, D.A., Campbell, R.L. (2004). Transitional Care of Older Adults Hospitalizes with Heart Failure: A Randomized, Controlled Trial. The Journal of the American Geriatrics Society 52: 675-84.

• Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalization. Cambridge, MA: Institute for Healthcare Improvement; June 2013.