Strategies to Improve Healthcare Transitions: Patient & Caregiver Engagement and Activation

1. Strategies to Improve Healthcare Transitions:Patient & Caregiver Engagement and Activation Sara Butterfield, RN, BSN, CPHQ, CCM New York State Wide Senior Action Council, Inc. 2011 Annual Convention October 11, 2011

2. Centers for Medicare & Medicaid Services (CMS) • Leads a national healthcare quality improvement program, implemented locally by an independent network of Quality Improvement Organizations (QIOs) in each state • IPRO • The federally funded Medicare Quality Improvement Organization (QIO) for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS).

3. CMS GoalsNational & Statewide Level Six Priorities • Making care safer • Promoting effective coordination of care • Assuring care is person and family-centered • Promoting the best possible prevention and treatment of the leading causes of mortality, starting with cardiovascular disease • Helping communities support better health • Making care more affordable for individuals, families, employers and governments by reducing the costs of care through continual improvement

4. National Perspective 17.6% of Medicare beneficiaries are re-hospitalized within 30 days of discharge, accounting for $15 billion in spending Estimates show that 76% of these readmissions may be preventable Of Medicare beneficiaries re-admitted within 30 days, 64% receive no post-acute care between discharge and re-admission Source: MedPAC:June 2007 Report To Congress: Promoting Greater Efficiency in Medicare

5. New York State Perspective

6. Consumer Perspective AARP Report: Chronic Care: A Call to Action for Health Reform According to the results of the patient survey: • Nearly one in four patients reported experiencing a medical error, and 61 percent of this subgroup said they had experienced a major problem as a result; • About one in five reported that their health care providers did not communicate well with each other about the their individual condition or treatment, which some said compromised their health; • Nearly one in seven said they didn't get a follow-up appointment after they were discharged or, if they did, it was more than four weeks later; and • Almost one in five said their transitional care was not well coordinated.

7. Contributing Factors Patients are more chronically ill, more frail, and have more complex care needs Multiple diagnoses May see several physicians Average 13-16 medications per day May be cognitively impaired May not have a Primary Care Physician Lack of involving a caregiver for safe transition to home Access to and/or lack of community services

8. Other Contributing Factors Not remembering / understanding physician instructions Difficulty communicating with health professionals Unrealistic expectations Difficulty arranging for assistance Finances/affordability Not enough time for competing demands Loss of mobility Language barriers (Source: Beyond 50.09 Chronic Care: A Call to Action for Health Reform, AARP, March 2009)

9. Dilemmas Focus is on discharge versus transition No ownership of transition Burden of coordination is placed on patient Caregiver may not be available / involved at discharge Absence of common medical record Absence of cross setting medication reconciliation Lack of advance directives & screening for palliative care No reassessment of patient and goals at each transition Communication gaps exist between disciplines and health care settings

10. The Driving Forces…. American Geriatrics Society Health Care Systems Committee Position • Clinical professionals must prepare patients/caregivers to receive care in the next setting & actively involve them in decisions related to the formulation & execution of the transitional care plan • Bi-directional communication between clinical professionals is essential to ensuring high quality transitional care • The opportunity to collaborate with a coordinating health professional functioning across health care settings to reduce care fragmentation may enhance the care that these professionals deliver Source: J Am Geriatric Soc 51:556-557, 2003

11. Centers for Medicare & Medicaid Services Care Transitions Initiative August 2008-July 2011

12. New York Care Transitions Target Community • Five county region in Upper Capital Region of New York State with integrated referral patterns incorporating urban, suburban and rural communities within 84 zip codes • Warren, Washington, Saratoga, Rensselaer & Saratoga • Fifty providers • Hospitals (6), Home Health (6), Skilled Nursing Facilities (28), Hospice (5), Dialysis Centers (5), Multiple Physician Practices • Impacting 68,206 Medicare Fee for Service (FFS) beneficiaries

13. Where We Began Our Journey…

14. The Paradigm Shift: Discharge Versus Care Transition Cross-Setting Partnerships“Our Patient” “Patient Within Our Community”

15. Targeted Opportunities for Improvement Assessment of patient / caregiver understanding of discharge medications & instructions using Teach-Back Method Identification and referral of high-risk readmission patients for follow-up care Inclusion of 7-day follow-up physician visit appointment in discharge instructions with follow-up phone call Cross setting medication reconciliation & education Support of patient / caregiver learning for self-management (signs / symptoms / red flags / action) Improved cross setting partnerships and communication for care coordination and management Streamlined and standardized cross setting information transfer 15

16. Patient Engagement / Activation The person’s ability to manage their health and health care • Self efficacy in managing their behavior • Readiness to change - motivation • Knowledge, skill, beliefs, and behaviors • Linked to the person’s health outcomes

17. Patient Engagement / Activation Patients who were not interested or less involved in care tended to: • Have more problems with transitioning between care settings • Reported more problems with care • Less confident with there ability to manage their chronic condition • Worse health status and more chronic conditions • Required more assistance to arrange for care (Source: Beyond 50.09 Chronic Care: A Call to Action for Health Reform, AARP, March 2009)

18. Key Practices Leading to Results Collaborated with target community providers and stakeholders to identify sites where seniors gather for social and health activities • Senior Centers , Housing Units, Independent & Assisted Living Facilities, Churches, Libraries Organized one hour beneficiary outreach sessions at each site • 20 educational sessions completed to date reaching over 315 Medicare beneficiaries in community • 3 community caregiver outreach exhibits with over 160 attendees • 2 senior health fairs with over 150 attendees Developed large font, fifth grade level educational materials to share and reference during each session: • Hospital Discharge Planning “Golden Rules” • Medication Management “Golden Rules” • Personal Health Record • Caregiver Resource Handout • United Hospital Fund Next Step In Care Resources Opened sessions by asking seniors to share their health care experiences and then used their stories in conjunction with the educational materials to discuss importance of self empowerment & self-management skills Shared beneficiary feedback & perceptions with target community providers

21. Heart Failure Zones

23. Next Step In Care Guides and Checklistshttp://www.nextstepincare.org • Discharge • Family Caregivers’ Guide to • Medication Management • Going Home: What You Need to Know Next Steps • A Guide to the ER • When the Next Step Is Home Care: A • Family Caregiver’s Guide • When the Next Step Is Rehab: A • Family Caregiver’s Guide Admission HIPAA: Questions and Answers for Family Caregivers Your Family Member’s Personal Health Record Medication Management Form A Family Caregiver’s Guide to Advance Directives Planning for Discharge The Next Step in Care: What Do I Need as a Family Caregiver? Hospital-to-Home Discharge Guide

24. Medicare Beneficiary Feedback Following IPRO Care Transitions Outreach Sessions After attending this session I now feel more prepared to…. Source: IPRO Medicare Beneficiary Outreach Program Evaluations

25. Medicare Beneficiary Feedback on IPRO Care Transitions Outreach Sessions • I am a retired public health nurse that practiced before the times of Medicare and Medicaid. I think the guidance you shared here with us today on how to navigate the health care system and take charge of managing our health information has been very helpful. It is not our way to ask questions of the people who provide us health care…we often feel we do not have the right and quite often when we do our questions and concerns go unanswered. Thank you for giving us permission to become empowered! • After participating in this session I am now aware of today’s health care environmental routines/personnel and the fact that I need to be more aware of the details of my health care. • The information shared will be very helpful to organize my health information. I feel more comfortable knowing it is okay to ask the health care team questions to enable me to become more involved in my care. • Before today I never thought about involving my Pharmacist to answer questions and concerns I have about my medications. Thank you for the suggestion! • I was so anxious in the hospital I did not even think about what I needed to plan for once I got home. This information and my experience over the past year will help me plan ahead next time. • The information you provided regarding the Hospitalist role was very helpful. I had never heard about that before and had no idea that my doctor I have gone to for the past 16 years may not even know I was in the hospital to be involved in my care

26. Our Destination…… Ten New Rules to Redesign & Improve Care • Care is based on continuous healing relationships • Care is customized according to patient needs and values • The patient is the source of control • Knowledge is shared and information flows freely • Decision making is evidence-based • Safety is a system property • Transparency is evident • Needs are anticipated • Waste is continuously decreased • Cooperation among clinicians is a priority Source: Adapted from the Institute of Medicine, 2001

27. For more information Sara Butterfield, RN, BSN, CPHQ, CCM 518 426-3300 x104 sbutterfield@nyqio.sdps.org http:caretransitions.ipro.org CORPORATE HEADQUARTERS 1979 Marcus Avenue Lake Success, NY 11042-1002 REGIONAL OFFICE 20 Corporate Woods Boulevard Albany, NY 12211-2370 www.ipro.org This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-NY-AIM8-11-07