Destination Safe Care Transitions – Staying on TrackHiloni Bhavsar, MDAssistant Professor, General Internal MedicineUH Quality Institute LiaisonPhysician Informaticist, UHCare

Chrissie Blackburn, MHAPrincipal Advisor, Patient and Family EngagementUniversity Hospitals & UHCMCInstitute for Healthcare Quality and Innovation

Nancy DeSantisManager, Patient Access Services

Khaliah Fisher-Grace, MSN, RN, CPHQ, PCCNSenior Quality Improvement NurseInstitute for Healthcare Quality & InnovationUniversity Hospitals Case Medical Center

Stefan Gravenstein, MD, MPHProfessor of MedicineInterim Chief, Division of Geriatrics and Palliative CareCenter for Geriatrics and Palliative CareCase Medical Center

Mary Ann Gravenstein, MD

Faisal A. Khan, Esq.Assistant General Counsel

Jonathan S. Lever, MPH, NREMT-PSenior Clinical Data AnalystInstitute for Healthcare Quality & InnovationUniversity Hospitals Case Medical Center

Edmundo Mandac, MDDepartment of Emergency MedicineInterim Chair - UHCMC

Lee Manning Schoeppler, RN, MSN, MBA, NEA-BC Agency Administrator, Director of Clinical Integration University Hospitals Home Care & Hospice

George V. Topalsky MD, F.A.C.P.UH Internal Medicine CenterCo medical director Southwest RegionSite director UH Independance health center

Laura Wilson, BSN, RNClinical System Liaison, Electronic Medical Records (EMR)/ UHCareUH Conneaut Medical Center

Cynthia B.R.Zelis, MD, MBAVice President Clinical IntegrationUniversity Hospitals Cleveland

Corinne Hurley, RN, MSNDirector, Institute for HealthCare Quality and InnovationPhysician Office Based Care

Elizabeth Ingram BSClinical Application AnalystUHCare Ambulatory EMR

Disclosures

• Speakers in this presentation have no disclosures.

Objectives

• Identify and describe national and local best practices in transitions

of care through experts and patient perspective

• Understand the resources available within the UH system today

• Understand the implications of poor transitions of care on patient

experience, readmissions, and reimbursement

• Attendees will write an “I will…” statement at the end of the

presentation to apply one transition of care best practice to their

current workflow

Overview

• Background information on transitions of care

• Best practices

• Case: Dr. Mary Ann Gravenstein

• Workshop

• Large group discussion

Clinical Integration

“The Key to Health Care Reform”

-American Hospital Association, Feb 2010

“Clinical Integration is the extent to which patient care services

are coordinated across people, functions, activities, and sites

over time so as to maximize the value of services delivered to the

patient.”

-S Shortell, R Gilles, D. Anderson

- Remaking Health Care in America, 2000

Patient

Primary Care Provider

Laboratory

Specialty Providers

Radiology

Post Acute Care

Therapy

Home Health Care

Acute Care Hospitals

Emergency Dept.

Clinical Integration is a TEAM

EffortWHY CLINICAL INTEGRATION?

• Quality• Communication• Patient

Experience• Work Flow

Efficiency• Lower Litigation

Risk • Cost Reduction• System

Revenue

Transitions of Care: Potential Consequences

• Quality

• Communication

• Patient Experience

• Work Flow Efficiency

• Litigation Risk

• Readmission• Prolonged Length of

Stay• Duplication of tests• Inaccurate treatment

• Poor Patient Satisfaction• Decreased patient

loyalty• Increased work for staff• Incomplete

documentation• Risk of Joint Defense

ED/Urgent Care Best Practices: RECIPROCITY

Visit Timeline ED/UC/SNF/Hospital Best Practice Community Physician

At intake • Notify PCP about hospital utilization • Provide clinical info when referring patients for ED/UC evaluation

During visit • Invite PCP to participate in EOL discussions• Provide patient with effective education• Provide patient with written d/c instructions• Provide patient with f/u phone #• Perform medication reconciliation• Schedule outpatient f/u appointment

• Provide ED/UC/Hospital with phone access to outpatient staff who can answer clinical questions

• Provide ED/hospital with access to outpatient clinical info

At discharge • Provide PCP with hospital contact info• Provide PCP with summary clinical info

• Confirm receipt of hospital d/c info

After discharge

• F/U with high risk pts via phone• Conduct outpatient f/u• Perform outpatient med reconciliation

Communication of Key Info(Based on Evidence and local input)

Community Physician’s

Office

ED/UC/ SNF/Hospital

48-Hour Readmission Review Pilot (UH Case)

• 136 patient readmitted within 48 hours, November 2014 – March 2015

• 39 reviews completed

Measure % Yes

All-or-none and standard of care met 2.6

Notify community MD office about observation/admission 74.6

Provide receiving MDs with hospital clinicians contact info 58.5

Patient education prior to discharge 92.4

Written discharge instructions prior to discharge 87.9

Follow-up phone number prior to discharge 72.3

Medication reconciliation 95.4

Schedule follow-up appt 87.7

Provide PCP office with patient summary 75.4

PCP participated EOL discussions during visit 96.8EOL=end of life

Practices and PolicyBest Practice UH Policy

Notify community physician office about hospital admission N/A

Provide receiving clinician’s with hospital clinicians contact information prior to discharge

GM-68

Provide patient with effective education prior to discharge CP 24, G 846 (Nursing Practice Manual)

Provide patient with written discharge instructions prior to discharge

CP 24, GM 68, G 846 (Nursing Practice Manual)

Provide patient with follow up phone number prior to discharge G 846 (Nursing Practice Manual)

Perform medication reconciliation prior to discharge CP 24, CP 112

Schedule outpatient follow up appointment prior to discharge G 846 (Nursing Practice Manual)

Provide community physician office with summary clinical information at discharge

N/A

Invite primary care physician to participate in end-of-life discussions during hospital visit

N/A

Best Practices

• In an ideal world….

• Presenting diads

• Think about the practices during the case presented

• Use the practices at your table to apply them to the case

THEME then best practices by setting1 Notify of PCP of encounter and disposition

Hospital to PCP Notify community MD office about outpatient observation and hospital admission

Hospital to SNF Notify community MD office about encounter and disposition

SNF to ED/Hospital Notify community MD office about encounter and disposition

PCP to ED/Hospital N/A

ED/UC to PCP Notify community MD office about encounter and disposition

ED/UC to Hospital Notify community MD office about encounter and disposition

Coaching Patient/caregiver write contact information in PHR of each provider through care transitions

Introduction

Case Presentation

Patient falls at home

Arrives in EDX-ray shows

comminuted fx

Ortho MD attempts closed reduction

without pain meds

Admitted inpatient

Patient gets long-leg cast

Admit med rec is not correct

Discharged to acute rehab

Pain control inadequate

Discharged to home with home

health

Home health monitors INRs

PCP appt. madeScheduling amb

= can’t go to PCP office

No appt. = no opiates or INR management

Rehab doc fills opiates

Follow up with ortho

Eventually gets PCP follow up

Workshop

Group Discussion