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The Care Transitions Intervention

Transitions of Care: Helping Patients across the Great Divide. The Care Transitions Intervention. MaineHealth Learning Community PRISM 2 May 3, 2007. Care Transitions.

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The Care Transitions Intervention

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  1. Transitions of Care: Helping Patients across the Great Divide The Care Transitions Intervention MaineHealth Learning Community PRISM 2 May 3, 2007

  2. Care Transitions Definition: the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.

  3. The Care Transition Intervention* Objective: To test whether an intervention designed to encourage older patients and their caregivers to assert a more active role during care transitions can reduce re-hospitalization rates. *Coleman, E., Smith, J., Frank, J., Min, S., Parry, C. & Kramer, A. (2004). Preparing patients and caregiver to participate in care delivered across settings: the care transitions intervention. Journal of the American Geriatrics Society, 52:1871-1825, 2004.

  4. Care Transitions: The Four Pillars • Medication self-management • Use of a patient-centered record- Personal Health Record (PHR) • Primary care and specialist follow-Up 4. Knowledge of “red flags”- signs and symptoms to be reported

  5. Nurse Transition Coach The nurse transition coach improves care transitions by providing patients with tools and support that promote knowledge and self-management of their transitions as they move from hospital to home.

  6. Nurse Transition Coach Role Hospital • Establishes relationship (approx. 45 minute visit) • Introduces PHR and the Four Pillars • Visits every two days during hospital stay • Helps patient/caregiver to play a more active and informed role Skilled Nursing Facility • Visits or calls 1/week during SNF stay • Teaches patient/caregiver what to expect • Addresses each of the Four Pillars Home • Visits 24-72 hours post discharge (approx. 60 minute visit) • Calls on day 2, 7 and 14 post-discharge (calls- 5-15 minutes) • Assesses functional abilities, social support, environmental challenges & self-management capabilities and needs • Addresses each of the Four Pillars

  7. Who are the patients ? • Community-dwelling older adults (65>): • Non-psychiatric admission • Can answer brief 4-item cognitive screen or has willing proxy • Lives within predefined radius of hospital • Working telephone • With at least one of 11 diagnoses (determined by likelihood of need for SNF/ home health)

  8. CHF* COPD * Coronary Artery Disease Diabetes Stroke * Hip Fracture Peripheral Vascular Disease Cardiac Arrhythmias * Back Conditions (spinal stenosis) DVT * Pulmonary Embolism * Diagnoses * = particularly amenable to this type of program

  9. The Care Transitions Intervention Outcomes Measurements: Rates of post-discharge hospital use at 30-60-90 days. Patient/family care experience was assessed using the care transitions measure. Results: The adjusted odds ratio comparing re-hospitalization of intervention group with control group: 0.52 at 30 days, 0.43 at 90 days, .57 at 180 days. Intervention Group= 158 Control Group = 1,235 Coleman et al., 2004

  10. Care Transitions Pilot at MMC November, 2006 - April, 2007 • A collaborative effort between MaineHealth Elder Care Services, Maine Medical Center, University of Southern Maine School of Nursing and HomeHealth Visiting Nurses of Southern Maine • Two USM graduate clinical nurse specialist students were Transition Coaches and offered the program to patients on P3CD,R4,R6 and R7

  11. Care Transitions Pilot Preliminary Outcomes • Hospital re-admission rate within 30 days: 7% (N=28) • Care Transition Measures: • Self-management skills - 100% • Understanding warning signs and symptoms- 100% • Obtaining essential information for managing their condition during physician visits- 94% • Understanding their medication regime: What medications are and how to take them- 100% Side effects of all meds -94% • Would recommend Care Transitions to others- 100% • (N= 16; % of patients with increased confidence levels)

  12. Next Steps: MMC Physician-Hospital Organization Care Managers pilot underway with Greater Portland Medical Group practices Evaluate options for dissemination within the MaineHealth System The Care Transitions Intervention

  13. For more information….. MaineHealth’s Partnership for Healthy Aging 465 Congress St, Suite 701 Portland, ME 04101 207-775-1095 Pfha@mmc.org

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