A U G U S T 1 5 , 2 0 1 3

MANITOWOC COUNTYCARE TRANSITION PROGRAM

Judy Rank – DirectorCathy Ley – Supervisor Care Transitions Coach

MANITOWOC COUNTY CARE TRANSITION PROGRAM

Julie Place, Director of Nursingjulieplace@manitowochrc.com

Marcia Donlon, Director of Home Health & Hospice Services mdonlon@hfmhealth.org

Judy Culligan, Social Worker/Discharge Plannerjudith.culligan@aurora.org

BUILDING THE PARTNERSHIPS

• Acute Care for the

Elderly (A.C.E.)

• Began with a grant

from The Aurora

Foundation

• Included Both Hospitals

and 6 Nursing Homes

A.C.E. TEAM

• Acute Care for the Elderly

• Team Consists of :

Hospital Staff

Nursing Home Staff

Physicians

ADRC

Home Care Agencies

Other Long-Term Coalition Members

A.C.E. TEAM

• Purpose is to coordinate cares for the elderly

to assure quality and continuity

• A.C.E. Team evolution to present

Education related to needs of patients and staff

Assisting different providers to work together

Development of pathways

Avoidable re-admissions and current issues

GETTING STARTED WITH CARE TRANSITIONS –RESOURCES OFFERED BY THE AGING & DISABILITY

RESOURCE CENTER (ADRC)

• Home-Delivered Meals

• Subsidized Transportation

• Assistance in accessing public benefits i.e.: Medicaid, Family Care & Foodshare

• Caregiver Support Programs

• Prevention Programs

• Information & Assistance

WHAT ROLE DO THE ADRC RESOURCES PLAY IN REHAB DISCHARGES?

Could the ADRC be doing more??

PARTNERSHIPS ALREADY BUILT

• Hospitals and Rehab Centers providing space for

Prevention Programs

• Staff from facilities are co-facilitating Prevention

Programs

• Long-Term Care Coalition

• Social Worker/Discharge Planner Network

STUDIED OPTIONS

• Evidence-Based

• Something to Sell/Partner to Community

• Affordable

APPROACHING THE MEDICAL COMMUNITY

• Talked with Discharge Planners

• Talked with Management Staff

• Wanted opportunity to prove the program

CARE TRANSITION INTERVENTIONTHE ERIC COLEMAN MODEL

Why Was This Model Chosen?

• Community-Based Model

• Low-Cost Intervention

• Eau Claire County was using this model and it was

successful

• One of our Community Hospitals had worked with

Dr. Coleman on a prior project

• This model would work in our community and with

our partners

THE ERIC COLEMAN MODEL

Model Consists of:

A Transition Coach who makes:

• One Hospital Visit

• One Home Visit

• 3 Follow-Up Phone Calls

The Four Pillars of the Model:

1. Medication Self-Management

2. Personal Health Record

3. Follow-Up Visit with Physician

4. Red Flags or Warning Signs of the Condition

THE ERIC COLEMAN MODEL

Transition Coach Role

“The Transition Coach’s role is based on teaching the skills,

knowledge, and attitude necessary to empower patients to

manage their own care.”

The goal is to teach people to fish, rather than just giving

them the fish.

THE ERIC COLEMAN MODEL

Transition Coach Role

• Coaching is not a replacement of any other current

provider

• It does not attempt to replace discharge planners

or home health nurses

• Coaching is intended to supplement any other

service that a consumer receives and enhance

their effectiveness in utilizing these services

• Coaching requires flexibility and letting go of rigid

agendas

THE FOUR PILLARS

1. Medication Self-Management

• The goal is that the consumer is knowledgeable

about his/her medications and has a management

system

• The management system has to be realistic and

individual to the person

• Coach is non judgmental and realistic

THE FOUR PILLARS

2. Personal Health Record (PHR)

• List of medications (dose, frequency, reason) how

they actually take it, not necessarily as prescribed

• Space for the consumer’s self-identified goal

• Space for patient’s concerns &questions for follow-

up visit with their physician

• Space for information about Red Flags/Warning

Signs

THE FOUR PILLARS

3. Follow-Up Visit With Physician

Coach will assist consumer in getting ready for their

follow-up visit with physician

o Is appointment scheduled? If not coach can work with

consumer to build skills to effectively get a quick

appointment

o Are there any barriers in getting to this appointment and if

so, what can consumer do to remove the barriers?

o Are there any questions you have for your doctor?

THE FOUR PILLARS

4. Red Flags / Warning Signs

• Consumers will identify and write down the

indications that their condition is worsening – i.e.,

“How were you feeling before you went to the

hospital? What was happening?”

• What is the consumer’s plan when they experience

these red flags/warning signs?

TRAINING PROCESS

• We participated in the Care Transition Program’s

Regional Training

• Prior to training, we needed to complete a

Readiness Assessment Tool, which is designed to

help you think through the elements of the Care

Transitions Intervention. This document covers

goals, commitment, role changes, implementation,

documentation, and ongoing support.

• Training lasted one day and occurred in Aurora,

Colorado

• Staff was trained in October 2012

PLANNING – MOVING FORWARD

• Set up meetings with our 2 hospital partners Aurora Medical Center and Holy Family Memorial to plan for implementation

• The hospitals worked together to develop a screening tool which would work for the program and both hospitals

• As a group we determined which medical diagnoses would be included

• The hospitals identified which of their staff members would complete the forms and make the referrals to us and how the referrals would get to the ADRC

• Hospital staff did a “test run” of screening tool prior to start of program, to make sure form worked smoothly

IMPLEMENTATION

Began the program in November 2012

• Did the roll-out with both hospitals simultaneously

• Made the first hospital visit on November 6, 2012

• Met with our partners more frequently in the

beginning to address any issues or questions that

came up

• Steady growth in the program since the start

FOCUS ON COMMUNITY HOSPITAL IMPLEMENTATION

STARTED WITH A.C.E. TEAM –(ACUTE CARE FOR THE ELDERLY)

• Community focus versus “competition”

• 2011 Team selected for Chamber of Commerce Award for the work done together to improve the community

• ACE Team was known and respected within hospitals

ADRC INITIATED ACTION WITH HOSPITALS

• Introduced Care

Transitions Initiative

and Plan

• Important to identify

right leads from the

start

• Included Hospitals

as Key Stakeholders

from the start to

develop the model

ATTENDED TRAINING SESSIONS IN DENVER TO LEARN ERIC COLEMAN MODEL – 4 ATTENDEES

• Information & Assistance Workers from the ADRC

who would become the actual coaches for

Manitowoc County

• Representative from Felician Village – Senior Care

Complex

• Representative from Holy Family Memorial – Why

was this important???

O C T O B E R 2 0 1 2

OUR TEAM IN DENVER

NEXT STEPS:

• Team meetings at both hospitals to educate physicians and staff on Care Transitions – I organized and facilitated

• Develop referral tool to share at meetings and get staff familiar with and use

• Communicate, communicate, communicate information

• Ask staff often how things are going with referrals

• Invite coaches to numerous meetings & events to build relationships

• Reassure that coaches will NOT impede referrals to home care or hospice service

SHARING INFORMATION

• It is important to share information back with

physicians and staff regarding the number of

referrals and outcomes – they love to hear the

stories

• Also conveys that the coaches are improving care,

and this is a partnership

• Late adapters…..- keep moving on the journey and

reinforcing positives

• Pharmacy connection

CARE TRANSITIONS PROCESS

• We identify

potential clients for

the Care Transitions

Program upon

admission and

throughout the

patient’s stay

• The tool for

Assessing

Readmission Risk &

Eligibility for the

Care Transitions

Program is used to

identify these clients

CARE TRANSITIONS PROCESS

• Once a patient is identified through the screening

process, a Care Transitions Coach at the ADRC is notified

• If we feel a particular patient would benefit from the

Care Transition Program and does not meet the criteria

on the screening tool, we will discuss the case with a

Transitions Coach to see if they can take them on

• Response time for a Care Transitions Coach to make a

hospital visit is usually on the same day the referral is

made

CARE TRANSITIONS PROCESS

• Along with the program screening tool, Coaches

are given the patient’s History & Physical, Face

Sheet with Demographics and Discharge Summary

if applicable

• The patient information is placed in a folder in a

designated area on each unit. Coaches will collect

the information from the folder so that the Social

Worker or Case Manager doesn’t have to be

present for the Coach to see the patient

CARE TRANSITION PROGRAM RESULTS NOVEMBER 3, 2012 – JUNE 30, 2013

• 138 Total Referrals from Hospitals (2 main referral sources) and a few from Nursing Homes

• 23 of the 138 declined intervention. These people were discharge prior to a Care Transition Coach hospital visit

• 102 total of the 138 received or are still receiving intervention

• 49 of the 138 declined to continue the program after a hospital visit from the Coach or receiving their personal health record

CARE TRANSITION PROGRAM RESULTS NOVEMBER 3, 2012 – JUNE 30, 2013

• 4 of out 138 were hospitalized while in the program;

all in the first month of the program – 2 of the 4 were

re-hospitalized before ever being seen at home

• 29 of the 138 fully completed the program

• 0 Re-hospitalizations within 30 days for those who

have completed the program

THE FUTURE OF CARE TRANSITION

• Current Funding

o 100% Time Reporting

o ADRC Budget Item

• Future Funding

o 100% Time Reporting

o Provider Participation

DEVELOPED PARTNERSHIPS

• Hospitals

• Nursing Homes

• Home Care Agencies

WHAT’S NEXT?

• Future Partnerships

• Future Expansion of Prevention Programs

• Marketing to Community

A YEAR AT A GLANCE

QUESTIONS?