Care Transition Opportunities for LTC

1. Care Transition Opportunities for LTC Naomi Hauser , RN, MPA Director Care Transitions Quality Insights of Pennsylvania August 14, 2013

2. Care Transitions • A continuous process in which a patient’s care shifts from being provided in one setting of care to another

3. Affordable Care Act • New care transition/30-day readmission reduction programs • Increase incentives to improve coordination between settings and providers that help reduce health care costs through prevented readmissions • Supporting individuals and caregivers who experience a transition in their care setting

4. Financial Incentives/Penalties • Medicare began financial incentives to reduce potentially avoidable hospital transfers through pay-for-performance initiatives, bundled payments and other strategies • October 2013

5. Facts • Avoidable rehospitalizations drivers • A failure in hospital discharge processes • Patients’ ability to manage self-care • Quality of care in the next community settings (skilled nursing facilities, home health care agencies, and office practices)

6. Facts • IHI faculty discovered that the failures in care coordination between the hospital and SNF that led to rehospitalization within 30 days after discharge fell into two main categories: • Those related to care provided within the skilled nursing facility • Those related to care provided during the transition from the hospital to the skilled nursing facility

7. Facts • Nursing home residents transferred to hospitals for acute change in their clinical condition • 1 of 4 Medicare patients admitted to SNF from hospitals • Readmitted within 30 days • 2/3 potentially avoidable

8. Opportunities • Identify improvement opportunities/RCA • Use Interact tools • Start the conversations with partners/ER • Collaborate • Transparency • Establish goals/measures/collect data/trends • Spread/sustainability interventions

9. Changing Image of LTC • Important to understand consumers’ emerging and changing needs, wants and expectations, especially concerning • Quality of their experience with providers position as • Trusted advocates in helping consumers access services and supports • While assisting consumers and their families • In navigating complex aging challenges

10. Action Steps • Identify and implement effective programs and practices • Promote safe, effective care transitions while decreasing potentially avoidable 30-day readmissions • Get started now!

11. Interventions • Hickory House COACHING

12. C.O.A.C.H.Customer Service and Education Based Elaine Doyle, BSN BA RAC- CT Mary Zebert, SW

13. What does C.O.A.C.H. mean? • Communicate Expectations • Organize Goals • Assign Coach • Continued Review • Handoff Homework

14. Team Roster • Case Manager • Coach • Rehab • Social Services • Clinical Services • Registered Dietician

15. 72-Hour Meeting • Introductions • Prior level of functioning • Our goals • Patient’s goals

16. 72-Hour Meeting • Goal is to shift the patient’s “time oriented” focus to a “goal oriented” focus • Rehab initiates the checklist and hands it off to the CM before the meeting – CM adds the nursing goals • Determine patient’s education needs and place patient on “alert charting” • Incorporate the patient’s expectations into your goal sheet then review it with patient and family • Introduce the COACH

17. Continued Communications • Update the goal sheet at the weekly rehab meeting; discuss possible need for a home assessment • Share the changes with the patient • If the patient is off track, their coach meets with the CM, CM determines if an extra meeting is needed • Nursing will monitor patient for early warning signs of change in condition using the INTERACT tools to enable early treatment of illness and avoid unnecessary hospital readmission

18. Discharge Meeting • 72 hours before discharge date • Case Manager approaches the patient regarding their safe transition home, reviews their progress and offers a general overview of what to expect as they transition from SNF to home • The Case Manager and Social Worker coordinate the logistics of the discharge; DME and transitional services are arranged • Verify that transport to home has been secured, confirm date and time of transition home • CM issues the Patient Education Handbook to the patient and explains how it will benefit the patient • CM issues printed handouts related to patient’s needs • CM instructs patient that an appointment with his PCP needs to be made in a one week

19. Day of Transition • Each team member will meet with the patient to review the Patient Education Handbook in relation to their corresponding area of expertise. Instructional notes will be made in the book • CM will review the safe transition instructions with the patient

20. Transition Follow-Up • SS places a call on day 2 or 3 to inquire about PCP appointments • SS places a second call on day 7 to 10 to find out if the appointment was made • SS places a third call on day 21 to 24 days to find out if the appointment was kept • SS places a fourth call on day 31 to find out if the patient was readmitted to the hospital

21. Results • The two months of data showed: • 22 patients had a Post-Discharge Follow-up phone call on day 2 or 3 • 20 patients were connected on day 2 or 3 with a follow-up phone call • 16 patients reported appointment made on day 2 or 3 phone call.

22. Results • The two months of data showed: • 18 patients reported keeping appointment on day 7 follow-up phone call • 17 patients were not readmitted within 30 days of hospital discharge

23. Facts • Research highlights that • Nearly one-fourth of Medicare beneficiaries discharged from the hospital to a SNF • Are readmitted to the hospital within 30 days • Cost Medicare $4.34 billion in 2006

24. QUESTIONS

25. This material was prepared by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization for Pennsylvania, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 10SOW-PA-ICPC-KD-080513. App. 8/13.