Patient-Centered Medical Homes: Managing Patient Transitions of Care

1. Patient-Centered Medical Homes: Managing Patient Transitions of Care Marge Houy Senior Consultant Bailit Health Purchasing, LLC

2. Objectives • Provide background information about Massachusetts’ PCMH Initiative • Provide examples of how practices are developing the infrastructure to successfully manage transitions of care • Provide an opportunity to share experiences and learn among themselves

3. Background • 49 adult and pediatric practice sites participating in EOHHS-sponsored PCMH Initiative • Undergoing intensive 2-year training to: • Implement population management approach to providing evidence-based care • Create team-based care with each team member performing “at the top of their license” • Integrate primary care and behavioral health services • Partnership with patient in managing health conditions • Provide patient-centered practice – enhanced access, cultural sensitivity, etc.

4. Key Measures of Success Practices have opportunity to share savings generated from reduced inpatient days and ED visits while meeting key quality benchmarks

5. Transitions of Care Infrastructure/Processes • Identify nursing resources to function as practice-based care manager • Key functions • Work with practice teams to stratify patients and identify high risk patients: necessarily includes patients with ED or IP admission • Create high risk patient registry; outreach and engage patients • Contact discharged patients within 2 days of discharge and bring in for f/u visit, as appropriate • Contact patients with chronic condition-related ED visit within 2 days and bring in for f/u visit as appropriate • Work with patients to promote self-management skills • Function as member of patient’s care team

6. Example and Discussion • Lee Family Practice

7. Key Changes to Achieve an Ideal Transition from Hospital (or SNF) to Home • Perform Enhanced Assessment for Post- Hospital Needs • Provide Effective Teaching and Enhanced Learning • Conduct Real-Time Patient and Family-Centered Handoff Communication IV. Ensure Post-Hospital Care Follow-Up:

8. Completing the Transition into Care Settings within the Community

9. Aligning PCMHI and STAAR STAAR Program PCMHI Initiative Empanelment Primary care practitioner takes responsible for knowing his/her panel of patients and managing care across the care continuum Perform an Enhanced Assessment of Post Hospital Needs • Involve the patient, family, caregiver(s) and community providers(s) as full partners in completing a needs assessment of the patient’s home-going needs. • Reconcile medications upon admission • Identify the patient’s initial risk of readmission • Create a customized plan of care and discharge plan based on the assessment

10. Aligning PCMHI and STAAR STAAR Program PCMHI Initiative Patient-Centered Care Make sure the patient understands and agrees to care Team-based Care Maximize provider-term communication Tracking of care transitions Provide Effective Teaching and Facilitate Enhanced Learning • Identify and involve all learners on admission • Customize the patient education process for patients, family caregivers, and providers in community settings • Redesign patient education process and patient teaching print materials • Use Teach Back daily in the hospital and during follow-up calls to assess the patient’s and family caregivers’ understanding of discharge instructions and ability to perform self-care

11. Aligning PCMHI and STAAR STAAR Program PCMHI Initiative Care Coordination Two-way communications with other providers Tracking of care transitions Transitional care within 48 hours Enhanced Access Planned care at every visit Provide Real-Time Handover Communications • Give and review with patient and family members a patient-friendly post-hospital care plan which includes a clear medication list. • Provide customized, real-time critical information to next clinical care provider(s)., • For high-risk patients, a clinician calls the individual(s) listed as the patient’s next clinical care provider(s) to discuss the patient’s status and plan of care.

12. Aligning PCMHI and STAAR STAAR Program PCMHI Initiative Care Coordination Two-way communications with other providers Tracking of care transitions Ensure Post-Hospital Care Follow-up • Reassess the patient’s medical and social risk for readmission • Prior to discharge, schedule timely follow-up care and initiate clinical and social services as indicated from the assessment of post-hospital needs.

13. How-to Guide:Completing the Transition to the Clinical Office Practice

14. Getting Started Step 1. Form a Team Step 2. The Team Identifies Opportunities for Improvement Step 3. Develop an Aim Statement

15. Getting Started Step 1. Form a Team Consider choosing team members from the following: • Patients and family members • Physicians • Nurse practitioners • Nurses • Office managers • Schedulers

16. Getting Started Step 2. The Team Identifies Opportunities for Improvement • Diagnostic review of the last 5 patients from your practice that were rehospitalized within 30 days of discharge • Review patient satisfaction data regarding communication and preparations for self care

17. Getting Started Step 3. Develop an Aim Statement • Analyze data • Select target patient population • Write an aim statement

18. Clinical Office Practice Key Changes 1. Provide Timely Access to Care Following a Hospitalization • Review on a daily basis information received from the hospital about admissions and anticipated discharges. • Provide appropriate level and type of follow-up for high risk, medium risk and low risk discharged patients

19. Clinical Office Practice Key Changes 2. Prior to the Visit: Prepare Patient and Clinical Team • Review discharge summary • Clarify outstanding questions with sending physician • Make reminder call to patient or family member • Coordinate care with home health care nurses and case managers if appropriate

20. Clinical Office Practice Key Changes 3. During the Visit: Assess Patient and Initiate New Care Plan or Revise Existing Plan • Ask the patient about his/her goals for visit; what factors contributed to hospital admission or ED visit; and what medications he/she is taking and on what schedule • Perform medication reconciliation with attention to the pre-hospital regimen • Determine need to adjust medications or dosages, follow-up have on test results, do monitoring or testing; discuss advance directives; discuss specific future treatments • Instruct patient in self-management; have patient repeat back • Explain warning signs and how to respond; have patient repeat back • Provide instructions for seeking emergency and non-emergency after-hours care

21. Clinical Office Practice Key Changes 4. At the Conclusion of the Visit: Communicate and Coordinate on-going Care plan • Print reconciled, dated, medication list and provide a copy to the patient, family caregiver, home health care nurse, and case manager (if appropriate.) • Communicate revisions to the care plan to patient, family caregiver, home health care nurse, and case manager (if appropriate.) • Ensure that the next appointment is made, as appropriate

22. Model for Improvement Use Model for Improvement to test changes • Aims • Measures • Changes - Plan-Do-Study-Act Implement Spread