1 / 22

CMS National Conference on Care Transitions

CMS National Conference on Care Transitions. December 3, 2010. Support from Hospital to Home for Elders The SHHE project at San Francisco General Hospital. Jeff Critchfield, MD Associate Professor Department of Medicine University of California, San Francisco. Objectives.

huyen
Download Presentation

CMS National Conference on Care Transitions

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. CMS National Conference on Care Transitions December 3, 2010

  2. Support from Hospital to Home for EldersThe SHHE project at San Francisco General Hospital Jeff Critchfield, MD Associate Professor Department of Medicine University of California, San Francisco

  3. Objectives • Communicate challenges faced in the Safety Net Hospitals • Share Specific efforts by SHHE to address challenges • Adaptation of prior interventions for low-income, multi-ethnic setting

  4. SHHE • Gordon and Betty Moore Foundation awarded grant to implement and evaluate a readmission initiative • Collaborate with Boston University to adapt Project RED for patients at San Francisco General Hospital • Large, academic, urban public hospital • 66-75% patients have limited health literacy

  5. SHHEPrimary Questions • Can we reduce re-admissions among low-income elders using key components of prior clinical trials? • Is telephone follow-up feasible? • Why is this population re-admitted?

  6. Study Design and Population • English, Spanish, Mandarin or Cantonese - speaking patients, age 60 or older • Admitted to medicine, family medicine, cardiology, and neurology • Transitioning to home (Hotel, shelter) • 200-patient pilot (all received intervention)

  7. Intervention Elements: In-Hospital • Dedicated SHHE nurse • Culture/ language concordance • Focus on coaching and patient goal-setting – (Motivational Interviewing) • Computer-assisted transition packet • Licensing – Engineered Care • Interface with our hospital’s IT system • Translation time/costs

  8. Intervention Elements : Post-Hospital • Follow-up telephone calls • Prescribing ability- Nurse Practitioner or Physician Assistant • Days 1-3 and 7-9 post-hospitalization

  9. Pilot ResultsCharacteristics of Patients • 81% are non-white • 46% have less than a HS education • 53% born outside the United States • 72% are single, divorced, widowed • 92% earn less than $20,000 per year

  10. Successes in the pilot • Remarkably successful connecting with patients • 80% completed at least one post-hospitalization phone call (clinical) • 98% completed 30-day follow-up interviews (evaluation)

  11. Pilot ResultsHigh access to care • 93% had PCP visit in prior 6 months • 41% ED visit in 6 months prior • 32% Hospitalization in 6 months prior

  12. Pilot Outcomes • 23% of patients were re-hospitalized within 30 days • 26% of re-admissions/ ED visits were at outside hospitals • 5.5% 30-day mortality

  13. Randomized Controlled TrialEnrolling Now Comparing usual care to usual care with SHHE 700 person RCT Primary endpoint – 30, 90, 180 day readmission Build database –psychosocial, functional (readmission factors) Current enrollment – 115 subjects

  14. Key Lessons Core of intervention is relationships Coaching – patients feel heard Teach back methods Cultural concordance Morbidity is high among this patient population Case management?! Palliative Care

  15. Discussion Points In populations with social and economic challenges what parameters must be considered to determine preventability of re-admission?

  16. Discussion Points How do you balance an evidence based approach with local needs, expertise and resources?

  17. SHHE Team • Clinical • Kara Duffy • Lizbeth Flores-Byrne • Diane Robbins • Richard Santana • Tip Tam • Barbara Walter • Catheryn Williams • Co-Principal investigators • Sue Currin • Jeff Critchfield • Operations • Barbara Walter • Michelle Schneidermann • Margarita Sotelo • Will Huen • Evaluation • Eric Kessell • Margot Kushel • Urmimala Sarkar • Liz Goldman • Edgar Pierluissi • Data collection • Eric Kessell • Aurora Hernandez • Alice Lam • Tiffany Sin • Collaborators • Michael Paasche-Orlow (Project Red) • Chris Corio (Engineered Care)

  18. For more information, contact: Jeff Critchfield, MD jcritchfield@medsfgh.ucsf.edu

More Related