“COACHING THE FRAIL EDLER THROUGH CARE …€¢ Discern how coaching is different from discharge...

2008 Summer Nursing Conference Arizona Geriatrics Society

The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.

© 2008 Arizona Geriatrics Society. All Rights Reserved

54

“COACHING THE FRAIL EDLER THROUGH CARE

TRANSITION”

Heidi M. Kramer, RN, CNS, ND

Objectives:

• Describe what is "coaching"

• Discern how coaching is different from discharge planning and case management in usual practice

• Describe and discuss the four pillars

DISCLOSURE Heidi M. Kramer, RN, CNS, ND does

not have a significant financial interest or other relationship with manufacturer(s) of

commercial product(s) and or provider(s) of commercial services discussed in the

presentation.




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Slide 1

Preparing Patients and Caregivers to Preparing Patients and Caregivers to

Participate in Care Delivered Across Settings: Participate in Care Delivered Across Settings:

The Care Transitions InterventionThe Care Transitions Intervention

Heidi Kramer, RN, CNS, ND

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Slide 2

2

The IndividualThe Individual’’s Role is Now Criticals Role is Now Critical……

Otherwise, life

expectancy

expected to

drop!3

Be CEO of their

own health and

health care

IndividualsPrevent/manage

chronic condition

Today

Life expectancy

up 12% from

67 yrs in 1950 to

75 years in 2000 2

Show up

Doctors Acute intervention

(pcn, surgery)

1940s – 1980s

Life expectancy

jumps 43% from

47 years in 1900

to 67 years in

1950 1

Nothing

Public Health

agencies

Clean up water,

sewage

Early 20th

century

What HappensWhat

Individuals Do

Who Drives

ResultsWhat WorksWhen

ElderWeb, 1900-2000: Changes in Life Expectancy in the United States, http://www.elderweb.com/history/?page OD-2838 (17 January 2006.)

IbidS. Jay Olshansky et al, “Potential Decline in Life Expectancy in the United States in the 21st Century,” New England Journal of Medicine, 17 March 2005.Source: Elizabeth L. Bewley © 2008. All rights reserved.

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Slide 3

Qualitative StudiesQualitative Studies

� Inadequately prepared for next setting

�Conflicting advice for illness management

� Inability to reach the right practitioner

�Repeatedly completing tasks left undone

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56

Slide 4

The The ““SilentSilent”” Care CoordinatorsCare Coordinators

� By default, older patients and family caregivers

function as their own care coordinators

� First line of defense for transition related errors

� Model explicitly recognizes their role as

integral members of the interdisciplinary team

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Slide 5

Care Transitions Are CommonCare Transitions Are Common……

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Slide 6

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Slide 7 The Care Transitions Intervention:The Care Transitions Intervention:

Designed to encourage older patients and

their caregivers to assert a more active

role during care transitions

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Slide 8

Key Elements of InterventionKey Elements of Intervention

� “Transition Coach” (Nurse or Nurse Practitioner)

– Prepares patient for what to expect and to speak up

– Provides tools (Personal Health Record)

� Follows patient to nursing facility or to the home

– Reconciles pre- and post-hospital medications

– Practices or “role-plays” next encounter or visit

� Phone calls 2, 7 and 14 days after discharge

– Single point of contact; reinforce, ensure follow up

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Slide 9 The Four PillarsThe Four Pillars

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Slide 10 My Medications are:Medication Dose______________________________

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______________________________Allergies: _____________________

Reason Side Effects______________________________

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____________________________________________________________Remember to take this Record with youto all of your doctor visits

PersonalPersonal

HealthHealth

RecordRecordThe Personal Health Record of:

Josephine Patient

Personal Information:

Address:

Home Phone#:

Birth Date:

Patient ID#

PCP Name:

Advanced Directives?:

Hospitalization Information:

Admitted: _/_/_ Discharged: _/_/_

Reason for Hospitalization:

___________________________________________

Caregiver Information:

Name:

Phone #:

Relation to Patient:

Personal History

Please check any illnesses or health

problems listed below that you have

ever experienced.

� Arthritis

� Abnormal Heart Rhythm

� Cancer

� Diabetes

� Hardening of the Arteries

� Heart Disease

� Heart Failure

� High Blood Pressure

� Hip Fracture

� Lung Disease

� Medical/Surgical Back conditions

� Pneumonia

� Stroke

� Other: ____________________

After I leave the hospital…

1. I will write down questions I have about my condition.

2. I will take all bottles of medicine I

am using to each doctor visit.

3. I will call _________________

immediately at (XXX) XXX-XXX if I

experience any of the following:

• Temperature above 101°F

• Uncontrollable pain

• Increased confusion

• Increased redness or d

drainage around wound

• Questions about which

medications to take

Before I leave the hospital….

� I have the instructions I need to keep my health condition from becoming worse.

� I know what symptoms to watch out for.

� I know the name and phone number of who to call if I see any of these symptoms.

� My family or someone close to me knows what I will need once I leave the hospital.

� I know what medications to take, how to take them, and possible side effects.

� I will schedule a follow up appointment with my primary care doctor.

� I will have a clear and complete copy of my discharge instructions.

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Slide 11

Four PillarsFour Pillars

1. Personal Health Record (PHR)

2. Medication Management

3. Red Flags

4. Follow up

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Slide 12

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Slide 13

Randomized Controlled TrialRandomized Controlled Trial

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Slide 14

0.2426.430.3Sad or Blue (%)

0.317.16.8Chronic

Disease Score

0.9930.830.9Lives alone (%)

0.1712.916.5CHF (%)

0.6118.517.0COPD (%)

0.0219.012.8Arrhythmia (%)

0.8113.514.1CAD (%)

0.2353.858.2Married (%)

0.5276.476.0Age (years)

0.2652.348.2Female (%)

P-ValueControlInterventionVariable

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Slide 15 0.3626.129.3Prior Hosp (%)

1+ past 6 mo

0.6938.940.3Prior ED (%)

1+ past 6 mo

0.71

52.9

25.9

19.3

1.9

50.8

24.7

21.0

3.5

D/C Destin.

Home (%)

Homecare (%)

SNF (%)

Other (%)

0.4816.514.6Friday D/C (%)

P-ValueControlInterventionVariable

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Slide 16

0.2831 %26 %Re-hospitalized

w/in 180 days


w/in 90 days


w/in 30 days

Adjusted

P-valueControlInterventionVariable

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Slide 17

0.185 %3 %Readmit for Same Dx

w/in 30 days


w/in 180 days


w/in 90 days

Adjusted

P-valueControlInterventionVariable

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Slide 18

Anticipated Cost SavingsAnticipated Cost Savings

For 350 chronically ill older adults with

an initial hospitalization, anticipated

net costs savings over 12 months:

US$ 295,594US$ 295,594

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61

Slide 19

Goal AttainmentGoal Attainment

“What is one personal goal that is

important for you to achieve one

month after you get home?”

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Slide 20

Response CategoriesResponse Categories

1. I have not worked on it

2. I have not met that goal, but am working on it

3. I have met the goal as well as I expected

4. I have met the goal better than I expected

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Slide 21

FindingsFindings

Patients who worked with the Transition

Coach were more likely to achieve

their goals around symptom control

and functional status

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Slide 22

Medication SafetyMedication Safety

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Slide 23 Introducing the Medication Introducing the Medication

DiscrepancyDiscrepancy Tool (MDT)Tool (MDT)

� Patient-centered

� Applicable across a variety of health settings

� Identify patient- and system-level factors

� Items need to be actionable at point of care

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Slide 24

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63

Slide 25

NonNon--Intentional NonIntentional Non--ComplianceCompliance

� Prior to hospitalization, a patient was

prescribed Digoxin 0.25 mg daily

� The patient’s discharge instructions read,

“Digoxin 0.125 mg daily”

� The patient had only the pre-hospitalization

0.25 mg Digoxin pills and had been taking

these since discharge

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Slide 26

Intentional NonIntentional Non--ComplianceCompliance

� A patient was admitted to the hospital for

COPD exacerbation

� Following discharge, he was not using his

maintenance steroid inhaler because he

believed that “that medication makes my

breathing worse”

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Slide 27 D/C Instructions D/C Instructions

Incomplete or IllegibleIncomplete or Illegible

� The patient’s hospital discharge instructions

were written as follows:

� “KCl 10 mEq BID”

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Slide 28 14 Percent Experienced 14 Percent Experienced

1+ Med Discrepancies1+ Med Discrepancies

� 62 percent experienced one

� 25 percent experienced two

� 8 percent experienced three

� 5 percent experienced four or more

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Slide 29

PatientPatient--Level Contributing FactorsLevel Contributing Factors

51%Subtotal

1%Other

5%Didn’t fill prescription

5%Intentional non-adherence

6%Money/financial barriers

34%Non-intentional non-adherence

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Slide 30

SystemSystem--Level Contributing FactorsLevel Contributing Factors

49%Subtotal

7%Other

4%Incorrect label

8%Duplicative prescribing

15%Conflicting info from different sources

16%D/C instructions incomplete/illegible

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Slide 31

3030--Day Hospital ReDay Hospital Re--Admit RateAdmit Rate

6.1%Patients with no identified med discrepancies

14.3%Patients with identified med discrepancies

P=0.041

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Slide 32

The lack of quality measures for The lack of quality measures for

care transitions remains a care transitions remains a

significant barrier to quality significant barrier to quality

improvementimprovement

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Slide 33 Brief History of the Brief History of the

Care Transitions Measure (CTM)Care Transitions Measure (CTM)

� Qualitative studies shaped items

� Transition-specific items => Common set of items

� Items discriminate among facilities

� CTM endorsed by NQF in May 2006

Supported by The National Institute on Aging

and The Commonwealth Fund

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Slide 34 CTM ItemsCTM Items

� The hospital staff took my preferences and

those of my family or caregiver into account

in deciding what my health care needs would

be when I left the hospital

� When I left the hospital, I had a good

understanding of the things I was responsible

for in managing my health

� When I left the hospital, I clearly understood

the purpose for taking each of my medications

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Slide 35 Relationship Between CTM scores Relationship Between CTM scores

and Return to the EDand Return to the ED

.0044.679CTM Score

.833.045Age

.2251.486Co-morbidity

Score (Deyo)

.685.166Intercept

.0133.040Model

SignificanceF statistic

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Slide 36

Demand for the CTMDemand for the CTM

� Over 1400 requests for permission to use

from 15 Countries

� Adopted by WHO multi-national (Europe)

hospital quality collaborative

� Highmark Blue Cross Blue Shield P4P

� Maine to vote on statewide public reporting

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Slide 37

Intervention DesignIntervention Design

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Slide 38

Key Elements of InterventionKey Elements of Intervention

� Conceptual Elements

– The 4 “Pillars” (conceptual domains)

� Instrumental Elements

– Transition Coach

– Personal Health Record (PHR)

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Slide 39

Four PillarsFour Pillars

�Medication self-management

�Patient-centered record (PHR)

�Follow-up with PCP/Specialist

�Knowledge of “Red Flags” or warning

signs/symptoms and how to respond

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Slide 40

Transition Coach RoleTransition Coach Role

� Nurse, nurse practitioner, social worker, etc.

– Prepares the patient for what to expect

– Prepares and role-plays with the patient about

how to get questions answered & communicate

with providers

– Provides Tools (Personal Health Record)

– Uses the 4 pillars as a guide for coaching tasks

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Slide 41 Key Attributes of the Key Attributes of the

Transition CoachTransition Coach

� Ability to shift from a “doing” role to a

coaching role

� Skill and knowledge to manage and

reconcile medications

� Strong enough sense of empowerment to

empower a patient and/or caregiver

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Slide 42 My Medications are:Medication Dose______________________________

______________________________

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______________________________

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______________________________

______________________________

______________________________

______________________________Allergies: _____________________

Reason Side Effects______________________________

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____________________________________________________________Remember to take this Record with youto all of your doctor visits

PersonalPersonal

HealthHealth

RecordRecordThe Personal Health Record of:

Josephine Patient

Personal Information:

Address:

Home Phone#:

Birth Date:

Patient ID#

PCP Name:

Advanced Directives?:

Hospitalization Information:

Admitted: _/_/_ Discharged: _/_/_

Reason for Hospitalization:

___________________________________________

Caregiver Information:

Name:

Phone #:

Relation to Patient:

Personal History

Please check any illnesses or health

problems listed below that you have

ever experienced.

� Arthritis

� Abnormal Heart Rhythm

� Cancer

� Diabetes

� Hardening of the Arteries

� Heart Disease

� Heart Failure

� High Blood Pressure

� Hip Fracture

� Lung Disease

� Medical/Surgical Back conditions

� Pneumonia

� Stroke

� Other: ____________________

After I leave the hospital…

1. I will write down questions I have about my condition.

2. I will take all bottles of medicine I

am using to each doctor visit.

3. I will call _________________

immediately at (XXX) XXX-XXX if I

experience any of the following:

• Temperature above 101°F

• Uncontrollable pain

• Increased confusion

• Increased redness or d

drainage around wound

• Questions about which

medications to take

Before I leave the hospital….

� I have the instructions I need to keep my health condition from becoming worse.

� I know what symptoms to watch out for.

� I know the name and phone number of who to call if I see any of these symptoms.

� My family or someone close to me knows what I will need once I leave the hospital.

� I know what medications to take, how to take them, and possible side effects.

� I will schedule a follow up appointment with my primary care doctor.

� I will have a clear and complete copy of my discharge instructions.

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Slide 43

The Personal Health RecordThe Personal Health Record

� Record of patient’s medical history

� Red flags, or warning signs

� Medication list and allergies

� Advance Directives

� Structured Checklist of critical activities

(instructions, f/u appointments)

� Space for patient questions and concerns

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Slide 44

PHR: Key PrinciplesPHR: Key Principles

� Portable

� Readable

� Easy to Locate

� Easy to Update

� Patient-Centered

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Slide 45

Structure of the InterventionStructure of the Intervention

� Visits

– Hospital visit

– Home visit

– *SNF visit

� Calls

– 2-day

– 7-day

– 14-day

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Slide 46 First Interaction First Interaction

(Hospital or Home Visit)(Hospital or Home Visit)

� Hospital Visit– Introduce the Program

� Structure of the intervention: visits and calls

� Role and purpose of the coach

� Accessibility of the coach

– Introduce the Personal Health Record

– Review discharge checklist

– Prepare for follow-up� Introduce notion that follow-up visits will need to be scheduled

after discharge

� Remind patient to call coach after discharge

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Slide 47 First Interaction First Interaction

(Hospital or Home Visit)(Hospital or Home Visit)

� Home Visit

– Introduce the Program

� Structure of the intervention: visits and calls

� Role and purpose of the coach

� Accessibility of the coach

– Introduce the Personal Health Record

� Patient and coach complete PHR together

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Slide 48

Home Visit, cont.Home Visit, cont.

– Reconcile pre- and post-hospital medications

� Patient updates medication list in PHR

� Patient is knowledgeable about medication purpose,

how to take medications, side effects, who to call if problems arise

– Prepare for follow-up

� Practice and “role-play” upcoming calls and visits

– Review red flags and assure patient can identify

and respond to warning signs

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Slide 49

2, 7 and 142, 7 and 14--Day Phone CallsDay Phone Calls

� The phone calls ensure follow-up and create continuity via a single point of contact

� 2-day call

– Initial follow-up and scheduling of home visit.

� 7 and 14-day calls

– Follow-up on issues discussed during prior contacts

– Review the Four Pillars as they apply to patient and

his/her stage in the transition (see Intervention

Activities Checklist)

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Slide 50

Intervention Activities ChecklistIntervention Activities Checklist

� Think of the the checklist as a menu

� Your goal is to assure coverage of the 4

pillars as appropriate for the patient at the

stage of intervention

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Slide 51

Geriatric Dosage HandbookGeriatric Dosage Handbook

Semla, TP, Beizer JL, Higbee MD

10th Anniversary Edition

© 2005 by Lexi-Comp

ISBN 1-59195-104-6

Price: ~$35

N.B.: The training team does not receive any royalties

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Slide 52 Patient Perspectives Patient Perspectives

on the CTIon the CTI

� Patients cited the Transition Coach/Home

Visit as the #1 aspect of the intervention.

– Expertise

– Security/Support

– Accessibility

– Continuity

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Slide 53 Patient Comments about the Patient Comments about the

Transition CoachTransition Coach� Accessibility

– “There was somebody I could go to if I needed, if I had

any questions, I knew I had somebody I could call.”

� Security

– “I was pretty skeptical about it. But it turned out to be

a real beneficial thing…the program gives you a real

inner comfort—when you’ve confirmed that you’re doing it right and you know what to expect.”

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Slide 54

Patient Perspectives, cont.Patient Perspectives, cont.

� The PHR

– Of those who needed a system for recording

and managing medications, 75% of patients

adopted the PHR as a tool to help with

managing their medications and health care

encounters

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Slide 55

One Last PatientOne Last Patient

– Male with multiple chronic conditions, recent CVA

– Wife/caregiver very anxious, resulting in frequent ER

visits

– Upon discharge for CVA, the transition coach worked

w/wife to:

� Write down questions for the doctor

� Successfully advocate for her husband

� Recognize signs his condition was worsening and what action to

take

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Slide 56

One Last Patient Cont.One Last Patient Cont.

� After f/u visit w/physician, the coach rec’d call from the

doctor reporting a very successful visit

� During the visit, wife pointed out to doctor that her

husband had been much more tired than usual

� Doctor listened to complaint, took a blood test, discovered

the reason for fatigue, treated as an outpatient

� End result: prevention of ER visit

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Slide 57

www.caretransitions.orgwww.caretransitions.org

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“COACHING THE FRAIL EDLER THROUGH CARE …€¢ Discern how coaching is different from discharge...

Documents

Transcript of “COACHING THE FRAIL EDLER THROUGH CARE …€¢ Discern how coaching is different from discharge...