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Care transition and network activation within home supported discharge service for stroke patients in Portugal Silvina Santana, Berthold Lausen , Chariklia Tziraki ICIC13, 11– 12 April 2013. p urpose.

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P urpose

Caretransition and network activation within home supported discharge service for stroke patients in Portugal

Silvina Santana, BertholdLausen, CharikliaTziraki

ICIC13, 11– 12 April 2013


P urpose

purpose

  • to report on the use of a user-centred model and methodology, including the scale CTNAM, to assess the quality of care transition and network activation action, within a randomized control trial on home supported discharge for stroke patients in Portugal


P urpose

context - evidence

EVIDENCE

we talk a lot about integrated care, integrating care, care coordination, care continuity ....

EVIDENCE

points of discontinuity, that is, care transitions, have seldom been investigated

EVIDENCE

care transitions are problematic, dangerous and expensive for the patient, the care provider and the health and social care systems


P urpose

context - in need of a definition

  • a transition of care refers to a patient movement between care locations, providers or different levels of care within the same location as his/her condition and care needs change: the patient transits

  • it can be seen as a set of actions designed to ensure coordination and continuity of care (NTOCC, 2008): actions to assure that all goes well when the patient transits

  • but also as a point in a care process and in space, to which the time dimension is always associated (me, 2013 - I like processes! 


P urpose

context – CT as a point in a care process

in processes mapping, we would represent a care transition like this

place

implies a defined,

identifyablestate

place

a transition

e.g., discharge

about a CT, we want to know: WHAT, HOW, WHEN, WHO, other resources and WHY, in order to improve and evaluate efficiency and eficacy


P urpose

context – the Portuguese care system

  • the Portuguese health care system

    • diversity of entry points

    • no national EHR

    • difficult information flow between professionals, services and institutions

    • inadequate use of scarce and expensive resources

  • the Portuguese social care network

    • mostly run by privately owned, non-profit-making institutions (IPSS and Misericórdias), that operate close to the population


P urpose

context – the Portuguese care system

  • the RNCCI, a kind of 3rd level of care

    • launched in 2006 by the Portuguese gorvernment, it has been presented as a 3rd level of care, connecting with acute care hospitals and health centres

    • builds on partnerships among existing institutions in diverse sectors (most of them are IPSS or hospitals belonging to Misericórdias - Charities), integral planning and multidisciplinary practice

    • country wide, dedicated web-based information system available

    • home care is supposed to be one important element in this network, but implementation is low so far

    • integration outside the RNCCI (e.g., between hospitals and primary care) and between the RNCCI and other levels of care is still weak


P urpose

context – the Portuguese care system


P urpose

question

  • fromthepointoftheviewofthepatients, howisthesystemdoing, regardingtheirtransitionfromonecareprovider to another?


P urpose

methods

  • we have studied the whole patient’s course, from the admission to the stroke unit to six months after discharge

  • a methodology has been developed to assess the quality of care transitions and network activation actions

  • today we present the results from using the CTNAM, the Care Transition and Network Activation Measure


P urpose

methods

patient course in the study group

discharged directly home

Community

SU

Community

1 month from discharge

6 months

homecare team with case manager

discharged to an RNCCI inpatient unit

Community

SU

CU

Community

1 month from discharge

6 months

homecare team with case manager


P urpose

methods

4

main aspects

  • dealing with the medication at home

  • dealing with the activities of daily living

  • finding help in the community

  • dealing with the moment of discharge itself

AT THE DISCHARGE

from

the SU

the RU

self-reported patient preparedness

informationprovidedbythe hospital orthe RU

momentofdischarge

TALK ABOUT

NETWORK ACTION

  • A name or/and phone number at the hospital

  • List of medication, how and when to take

  • Written care plan, including diagnosis, ...

  • Discharge letter to be given to family doctor, nurse ...

  • MEDICATION at home: why, how, sec effects

  • DAYLY LIFE ACTIVITIES: can and cannot do

  • ALERT SYMPTOMS

  • FIND HELP IN THE COMMUNITY

  • OPTIONS THE PATIENT HAS

  • INCLUDE THE FAMILY or other informal carer


P urpose

methods

Social careentities

FHU/Healthcenter

(primarycare)

Familydoctor as gate keeper

Hospital

(acutecare)

Discharge management team

RNCCI

stillmostlyinpatient

HOME

TALK ABOUT

CHECK BEHIND

help in the community: services, tech aids, economic aid

PLAN FORWARD

discuss discharge letters

care at home and rehab

medication and exams: done

medication and exams: to do


P urpose

methods

Social careentities

Hospital

(acutecare)

Discharge management team

HOME

RNCCI

stillmostlyinpatient

Healthcenter

(primarycare)

Familydoctor

PATIENT AND IC

  • ABLE TO TAKE MEDICATION AT HOME

  • CHANGE LIFE STYLE/HABITS

  • DONE CONSULTATION and EXAMS

  • FOLLOW REHABILITATION PLAN

  • INFORMAL CARER ABLE TO DEAL WITH NEEDS

  • ABLE TO FIND SUPPORT IN THE COMMUNITY

Perceived quality of care

Satisfaction with services


P urpose

results

  • self-reported patient preparedness (1=not confident at all to 5 = very confident)


P urpose

results

  • information provided by the unit (1=none, 2=not enough, 3= all I need)


P urpose

results

12 itemsgrouped in 4 dimensions

  • moment of discharge, talk about (1=completely disagree to 5=fully agree)


P urpose

results

  • network activation (yes, no)


P urpose

results

  • primary care (family doctor) action (1=completely disagree to 5=fully agree)


P urpose

results

  • home care (1=completely disagree to 5=fully agree)


P urpose

conclusions

  • outside the RNCCI, that still handles a limited percentage of patients in need of rehabilitation after a stroke there is no integrated information system available to the providers involved in the chain of care

  • tools such as case managers or care plans are not in use

  • discharging and referring letters are the preferred way of communication between hospitals and family doctors based in health centres of family health units

  • it is not common practice to provide the patients with an anchor contact point in the discharging unit or helping the patients finding help in the community


P urpose

conclusions

  • the widely adoption of a standard framework based on a conceptual model for the measurement of care transition quality is strongly recommended

  • the measure set should include structural, process and outcome measures

  • process measures should be paired, addressing both the sending and the receiving providers in order to promote shared accountability

  • the right balance between cost and benefit must be found keeping always in mind the logic of network


P urpose

Caretransition and network activation within home supported discharge service for stroke patients in Portugal

thanks

ICIC13, 11– 12 April 2013


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