Care Transitions: Chasms, Bridges

NH-VT ACP Chapter Meeting October 2013

Julius Yang, MD, PhD Medical Director of Health Care Quality Beth Israel Deaconess Medical Center

Boston, MA

Care Transitions: Definition

• “…occur when information about or accountability for some aspect of a patient’s care is transferred between two or more health care entities or is maintained over time by one entity.”

– Across settings (e.g., hospital to physician’s office)

– As coordination needs change (acute episodes and chronic disease management)

Care Coordination Measures Atlas

Care Transitions

A view into the chasm

Patient’s Experience

Adverse Events after Discharge: Occurred in almost 1/5 of discharges

• 2/3 classified as adverse drug events • 1/3 deemed preventable, 1/3 deemed ameliorable

Care Transition Success or

Failure

System-Level

Condition-Specific

Patient-Level

Medication Management

Care Transition: Risk and Complexity

System-level Risks

Discharge Disposition: A broader view

System-level Risks

• Provider discontinuity (hospitalists, specialists, PCPs)

• Non-compatible electronic health records

• Unreliable information transfer amongst providers

• Pending results at discharge

• Ambiguous provider responsibility

41% of discharges included pending test results • Of these, 9% deemed “potentially actionable”

• Of these: • 62% of MDs were unaware of the result • 33% of MDs were unaware that test had been ordered

“Take as directed”

Medication-level Risks

Medication-level Risks

• Medicare patients typically discharged with high number of different medications

• Hospital-to-home medication reconciliation

• Multiple prescribing and dispensing sources

• Safety monitoring

• Medication list accrual

• High-risk: anticoagulants, insulin, antipsychotics

Condition-level Risks

Condition-level Risks

• Heart failure

• COPD

• Diabetes mellitus

• Active cancer

• End-stage renal disease

• End-stage liver disease

Patient-level Risks

Patient’s Experience

Patient-level Risks

• Activation

• Health care literacy

• Caregiver support

• Mental illness

• Financial resources

• Transportation/mobility

• Food options

• Recovering from acute illness – “perturbed physiologic systems”

• Stress – Sleep deprivation – Disruption of normal circadian rhythms – Poorly nourished – Have pain and discomfort – “…confront a baffling array of mentally challenging situations” – Receive medications that can alter cognition and physical function – Can become deconditioned by bed rest or inactivity

• Lead to impairments in the early recovery period – Inability to fend off disease – Susceptibility to mental error

Transitional Care

Building bridges

• A broad range of time-limited services designed to: – Ensure health care continuity

– Avoid preventable poor outcomes among at-risk populations

– Promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another.

– Complementary to but not the same as primary care, care coordination, discharge planning, disease management, or case management

Transitional Care: Definition

Health Affairs, 30, no.4 (2011):746-754 The Importance Of Transitional Care In Achieving Health Reform

Mary D. Naylor, Linda H. Aiken, Ellen T. Kurtzman, Danielle M. Olds and Karen B. Hirschman

Transitional Care

Health Affairs, 30, no.4 (2011):746-754 The Importance Of Transitional Care In Achieving Health Reform

Mary D. Naylor, Linda H. Aiken, Ellen T. Kurtzman, Danielle M. Olds and Karen B. Hirschman

Health Affairs, 30, no.4 (2011):746-754 The Importance Of Transitional Care In Achieving Health Reform

Mary D. Naylor, Linda H. Aiken, Ellen T. Kurtzman, Danielle M. Olds and Karen B. Hirschman

Transitional Care

Health Affairs, 30, no.4 (2011):746-754 The Importance Of Transitional Care In Achieving Health Reform

Mary D. Naylor, Linda H. Aiken, Ellen T. Kurtzman, Danielle M. Olds and Karen B. Hirschman

Transitional Care

Transitional Care

Health Affairs, 30, no.4 (2011):746-754 The Importance Of Transitional Care In Achieving Health Reform

Mary D. Naylor, Linda H. Aiken, Ellen T. Kurtzman, Danielle M. Olds and Karen B. Hirschman

“3026”

• Section 3026 of the Affordable Care Act of 2010 : Community- Based Care Transitions Program. The program

• $500 million from 2011 to 2015 to health systems and community organizations that provide at least one transitional care intervention to high-risk Medicare beneficiaries.

• Interventions may include – Initiation of services no later than twenty-four hours prior to patients’

hospital discharges – Timely postdischarge follow- up services to patients and their family

caregivers; – Assistance to ensure productive and timely interactions between

patients and postacute and outpatient providers – Assessment and active engagement of patients and their

familycaregivers through self-management support – Comprehensive medication review and management.

Health Affairs, 30, no.4 (2011):746-754 The Importance Of Transitional Care In Achieving Health Reform

Mary D. Naylor, Linda H. Aiken, Ellen T. Kurtzman, Danielle M. Olds and Karen B. Hirschman

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

Hospital Readmissions Reduction Program

http://www.kaiserhealthnews.org/stories/2013/august/02/readmission-penalties-medicare-hospitals-year-two.aspx

http://www.caretransitions.org/documents/CTMspecs.pdf

Patient Satisfaction Surveys

Transitional Care Models

Exemplars

For Whom: • Hospitalized elders hospitalized with specific diagnoses with at least one risk factor for poor discharge outcome By Whom: • Gerontological Advanced Practice Nurses (APNs) Intervention Protocol: • Initial APN visit within 48h of hospital admission • APN visits at least every 48h during hospitalization • APN home visit within 48h after discharge • APN home visit 7-10 days after discharge • Additional APN home visits based on patients’ needs • APN telephone availability 7 days/week • APN-initiated telephone contact with patients/caregivers,

at least weekly

Patient experience: • Often unprepared for self-management in the next care

setting • Receive conflicting advice regarding chronic illness

management • Often unable to reach an appropriate health care

practitioner who has access to their care plan when questions arise • Have minimal input into their care plan

For Whom: • Community-dwelling elders hospitalized with one of 11

specific conditions By Whom: • Advanced Practice Nurses (APNs) as Transition Coaches

(TCs) Intervention Protocol: • Personal health record (PHR) • TC visit during hospitalization (establish rapport,

introduce PHR, arrange home visit) • TC visits/calls to SNF weekly • TC home visit 48-72h after discharge

• Medication management • Communication coaching and PHR reinforcement • Contingency planning

• TC telephone follow-up x 3 next 28 days

For Whom: • Adults admitted to medical teaching service By Whom: • Nurse Discharge Advocates (DA), Pharmacists Intervention Protocol: • DA visit during hospitalization

• Education • Create After-Hospital Care Plan (AHCP)

• DA transmits discharge summary to PCP • Pharmacist phone call 2-4 days after discharge

Building a Transitional Care Program

What type of bridge to build?

Building a Transitional Care Program

• Which patients need transitional care?

• What are the critical actions/interventions?

• Who should perform each action?

• Where should those providers be based?

• What is the source of funding for those providers?

Who is the target population?

• All patients leaving the hospital

• Those with specific “high-risk” conditions

• Those with “high-utilization” patterns

• Affiliations with primary care practices

• Based on payer incentives/penalties

Assessment of Post-hospital Needs

Patient/Caregiver Education/Activation

Medication Reconciliation

Post-discharge Outreach

Communication with Ambulatory Providers

Post-discharge Follow-up Appointments

Post-discharge Logistics Support

Post-discharge Condition Monitoring

Contingency Management

Coordination of Ambulatory Providers

Coordination of Hospital-based Providers

Post-discharge Medication

Reconciliation

Post-discharge Education/Activation

Chronic Disease Care Management

Post-discharge Follow-up Visit

What are the critical actions/interventions?

Standardized Discharge Communication

Who will be providing the care?

• Physicians

• Clinical Nurses

• Social Workers

• Pharmacists

• Case managers

• Community health workers

Where are these providers based?

• Hospital

• Primary care clinic/Patient-centered medical home

• Specialty clinic (Cardiology, Oncology)

• Provider organization

• Payer

What is their source of funding?

• Penalty avoidance (Readmissions)

• Quality incentives

• Global payment model (ACO)

• Research/development grant

Lessons from the field

• “It’s not just what you do, it’s how you do it”

• Telephone outreach: Careful how you ask

• Post-discharge follow-up:

– Sooner not always better than later

– PCP or specialist

• “Who’s calling me now?”

Care Transitions

“Team Play”

Care Transition: More than a handoff?

“Handoff” o Unidimensional, instant o Independent of conditions

“Pass” o Linear, unidirectional o Trajectory/target o Dependent on fixed conditions o Coordination between passer and receiver

“Team Play” o Non-linear o Dynamic conditions o Anticipatory coordinated action o Iterative steps towards a common goal