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Transitions in Care -- Page 1 - University of Iowa Health Care
Transitions in Care -- Page 1 Transitions in Care for Older Adults Disclosure Statement I, Marianne Smith, PhD, RN, FAAN do not have any financial interests or relationships with any manufacturers of products or providers of services I might be discussing in my presentation. I have no financial relationships with any of the companies supporting this educational event. I will not discuss any pharmaceuticals, medical procedures, or devices that are investigational or unapproved for use by the FDA. Marianne Smith, PhD, RN, FAAN UI College of Nursing Goals for today Objective 1. Changing Landscape Review Age-related the landscape of factors that contribute to care transitions Discuss common challenges related to transitions between care settings Review online resources designed to promote quality transitions Identify “simple” solutions that promote quality changes in health, function, and social support result in varied needs Health-related services: Care & treatment of chronic and acute illnesses Living-related services: Assistance with ADLs; IADLs; medical, social needs Social services: Financial assistance; benefits/ social insurance management Not practical to think ONLY of health services! Older adult care is NOT static! Services used change over time Living Older environments and health services both exist on a continuum Senior apartment/ Independent living Home alone Home with family Senior group home Residential care/Assisted living Board & care Senior foster care Intermediate nursing facility/Nursing home Skilled nursing facility Many living settings for older adults today! people move “up and down” the continuum depending on their needs Home health services Adult day health services General practice outpatient Urgent care clinics Ambulatory surgery Specialty practice outpatient Acute care hospitals Emergency services Chronic care hospitals Health service settings are also growing! Transitions in Care -- Page 2 Many interactions, too! Home alone Senior apartment/ independent living residence Home with family Senior group home Residential care/ assisted living Senior foster care Intermediate facility /nursing home Skilled nursing facility Adult day health services Home health services Urgent care clinics General practice outpatient Specialty practice outpatient Ambulatory surgery Emergency services Hospitalization Transitions are common… Change in status often triggers transitions Original home to . . . Assisted living/residential care: Living OR Respite Nursing home: Living OR Rehabilitation Hospital: treatment of an acute episode of illness/injury Hospital to . . . Home: with or without home health care/family support Assisted living/residential: Living OR Rehab Nursing home: Living OR Rehab Nursing home to . . . Home: live alone, with family/friends Assisted living/residential care And commonly pose challenges! Objective 2: Common Challenges Too Communication often complicated by lack of accurate, adequate, timely information Admission Discharge Transfer within settings Outpatient generalist to specialist (visa versa) Outpatient to hospital (visa versa) Inpatient hospitalist to PCP Problems for patients care instructions Problems for providers care issues issues Inadequate patient & family education Limited/inconsistent care coordination Medication changes/discrepancies Gaps in service access Focus here is on hospital to community but issues apply to nearly ALL transfers! Hospital to community . . . Hospital to community, cont. Common problems areas include Communication issues Inadequate Failure to include caregiver(s) in care plan Language/ethnicity barriers not addressed Health literacy not considered Transfer summary/instructions inadequate/too late Not available to PCP for follow-up visit=75% Restricted PCP’s follow-up care=24% patient & caregiver education Use of medical jargon Lack of adequate time in teaching Reliance on verbal (vs. printed) instruction Printed instruction unclear, too long, wordy Use of yes/no questions Failure to use “teach-back” to promote understanding of instructions Transitions in Care -- Page 3 Hospital to community, cont. Hospital to community, cont. Limited/inconsistent Limited/inconsistent care coordination Lack of communication/coordination within the hospital: Emergency to inpatient unit Lack of timely follow-up/coordination at discharge Wrongful assumptions that PCP knows what happened before/during hospitalization Key providers are in agreement on the care management plan A provider who KNEW the person would take care of them in the transition care coordination Lack of referrals at discharge Lack of coordination among providers in multiple settings Are all really aware of complex patient’s needs? Services provided by others? Medications used (prescribed and OTC)? Patient’s readiness to engage in self-care? Family’s readiness to support, assist, supervise? Facility’s readiness to continue needed treatments or services? Hospital to community, cont. Hospital to community, cont. Medication Gaps changes & discrepancies Nearly half of hospital medication errors occur when ordering admission & discharge medications; errors often related to Lack of accurate & comprehensive history Multiple changes made during hospitalization Substitutions based on formulary restrictions Use of short-acting agents to gain tight control New meds intended for short-term (delirium) Failure to reconcile at time of discharge!! Costs translated to policy Increased health care costs Rapid readmissions following hospitalization Emergency transfers/services Adverse drug events management Time/resources to establish optional plan of care emotional/psychological costs to patients & families Costs deemed “avoidable” in service access between discharge & first follow-up Lack of a “key contact” once the person leaves No one is “in charge” of the transition No clear way to solve unexpected questions, problems, or find additional help or services Instructions to contact PCP, whether or not PCP was involved in hospital care or has a summary to guide responses Costs translated to policy 2012 policy changes focused on transitionrelated problems Unnecessary http://www.foxbusiness.com/personal-finance/2012/10/02/feds-crackdown-on-medicare-readmissions/ Transitions in Care -- Page 4 Costs translated to policy Affordable Care Act 1 in 5 Medicare patients are readmitted within one month of discharge Return trips cost more than $17 billion since 2004 Section 3025 of the Affordable Care Act Included provisions to improve hospital care Readmission penalty Specifics determined by Centers for Medicare & Medicaid Services Final rule announced August 1, 2012 Readmissions: A stubborn problem More policy implications Being an ACO member has implications for community providers Discharge too soon? Inadequate post-hospital treatment? OR lack of appropriate discharge planning, patient education, and transfer of relevant information??? http://www.foxbusiness.com/personal-finance/2012/10/02/feds-crack-downon-medicare-readmissions/ Accountable Care Organizations ACO agreements Provide Select coordinated care and chronic disease management Dual focus Improve quality Reduce costs preferred providers across the continuum to achieve “triple aim” Deliver high quality care Improve patient outcomes Decrease costs Improve communication & coordination across the care continuum http://www.innovations.cms.gov/initiatives/ACO/index.html Right care, right location, right time, at the right cost Transitions in Care -- Page 5 ACO agreements Big More policy implications question Which providers have the “right stuff” to be “preferred” (aka a member /partner with the ACO)?? http://partnershipforpatients.cms.gov/ Example of resources available through Partnerships for Patients Transitions in Care -- Page 6 Objective 3: Online resources Online resources Many Goal resources available to promote quality/reduce transfer-related problems Common themes relate to challenges Improve communication Enhance patient/family education & involvement in care planning Promote care coordination Reduce medication mishaps Encourage “point of contact” during transitions http://www.ihi.org/resources/ here is not to be comprehensive, but instead offer some options/choices!! No one “right” solution!! Individualized decisions are essential Check out what makes best sense for you Some federal (AHRQ; CMS) Some private (Interact) http://www.nextstepincare.org/ Free Guides and Checklists for both family and health care providers Endorsed by AARP http://www.ihi.org/resources/Pages/Tools/HowtoGuideImprovingTransitionstoR educeAvoidableRehospitalizations.aspx http://www.ahrq.gov/professionals/ http://caretransitions.org/ Resources endorsed by the Agency for Health Research and Quality (AHRQ) Many free materials http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy4/index.html Alternative program/materials recommended by IDEAL (AHRQ) Transitions in Care -- Page 7 “The INTERACT quality improvement program is designed to improve the early identification, evaluation, management, documentation, and communication about acute changes in condition of residents in nursing homes, assisted living facilities and home health care.” -- Overview, Implementation Guide https://interact2.net/ * Development and testing of INTERACT was support by NIH, CMS, The Commonwealth Fund, The Retirement Research Foundation, the Patient Centered Outcome Research Institute, Medline Industries, and Westcom, Inc. ** See Ouslander, J.G., Bonner, A., & Herndon, L. (2014). The Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement Program: An Overview for Medical Directors and Primary Care Clinicians in Long Term Care. JAMDA, 15, 162-170. Transfers to acute care are addressed in the context of overall quality of care Interact tools help nursing home and assisted living providers improve care to reduce transferrelated problems Primary focus on Communication Communication within the Nursing Home Stop and Watch: Early Warning Tool SBAR Communication and Change in Condition Progress Note Medication Reconciliation Worksheet for PostHospitalization Focus Early identification of problems!!! Transitions in Care -- Page 8 Communication tools build on established principles Many resources to promote quality Objective 4: “Simple” changes Telephone contact Using telephone communication at the time of transfers is widely cited as an effective means to both promote effective acute care AND reduce risks of rehospitalizations Many resources and tools available today Key themes/ideas are common to most Need to address “challenges” identified IMPROVE Communication Care coordination Patient & family education/involvement REDUCE Errors, complications Cost of care http://www.healthaffairs.org/ Kind, A., Jensen, L., Barczi, S., Bridges, A., Kordahl, R., Smith, M., &Asthana, S. (December, 2012). Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital. Health Affairs, 31(12), 2659-2668. doi: 10.1377/hlthaff.2012.0366 Key Elements from the Abstract: 1) The Coordinated Transitional Care (C-Trac-C) Program was designed to improve care coordination & outcomes among veterans with high-risk conditions that were discharged to community care from the VA hospital in Madison, WI 2) Patients worked with nurse care managers on care and health issues before and after discharge, with contacts made by phone after discharge 3) Patients receiving C-Trac-C experienced 30% fewer rehospitalizations, producing an estimated $1225 saving/ patient Telephone contacts Additional ideas . . . NH calls hospital to assure information sent was adequate; followed patient to unit NH identifies “key contact” to take report at the time of discharge Promotes direct transfer of information & opportunities for questions Avoids misunderstanding/miscommunication by less knowledgeable staff Hospital identifies “key contact” to answer questions re: progress/discharge needs Transitions in Care -- Page 9 Benefits of telephone follow-up Improve education/instructions Outcomes reported in the literature Enhanced patient satisfaction Increased medication adherence Reduced preventable ADEs Decreased subsequent ER/ED visits Decreased hospital readmissions Thought-FULL Improve accuracy Build a team Adoption Quality of standardized transfer forms Reduced risk of “oversights” Increased emphasis on critical issues Rapid reconciliation of pre-post transfer medications; better outcomes with Involvement of nurse leaders Inclusion of clinical pharmacists Rapid/accurate transfer summary to key providers: PCP, NH, home care My point… to Providers have MANY opportunities to enhance transitions between care and treatment settings As simple as a phone call! Enhanced provider-to-patient education Increased provider-to-provider communication/care coordination Recent policy changes mandate change, BUT leadership will be critical to success! use of printed information Easy-to-read and follow Avoid long lists/pages of information that only have 1 or 2 relevant points Include number to call if questions AFTER discharge (and provider is ready to respond!) Check for understanding using openended questions Teach-back Patient explains in his/her own words what they will do based on discharge instructions improvement relies on leadership! Change champions to oversee processes Educators to promote understanding of best practices Facility and corporate leaders that are committed to implementation Staff that are involved, understand the value of methods and buy-in Ask: What barriers exist to process improvements?? Summary We are in the midst of a care “revolution” Pay close and thought-FULL attention to transition-related processes How can you/the care team improve transitions to/from the designated setting of care? Nursing home to hospital, assisted living, home? Hospital to nursing home, assisted living, home? Transfers within the care setting (unit-to-unit)? Transitions in Care -- Page 10 Summary Reduce the NEED for transfers by promoting early identification/treatment of problems Understand challenges, then address with practice change Collaborate with the care team to implement more effective approaches Identify/use key resources and materials Remember: No one right way or solution! On-going process!!
