ADAPTING TRANSITIONAL CARE PROGRAMS WITH PERSON-CENTERED INTERVENTIONS TO IMPACT READMISSION RATES

June Simmons, MSWPresident and CEO, Partners in Care Foundation

Partners in Care Foundation

Who do we serve?

• Partners serves older adults, adults with disabilities, and medically fragile adults who require in-home supports after hospital discharge or ongoing supports to avoid institutionalization

• We offer tailored, person-centered services to patients with diverse health and psycho-social needs in English, Spanish, and Armenian across the state of California

• Most patients receive managed Medicare

Evidence-Based Transitional Care Services

Partners offers all three interventions at our CCTP* communities.

Care Transitions

Bridge Model

CTI(Coleman Care

Transitions Intervention)

HomeMeds

• In-hospital visit and post-discharge phone calls

• 30 day duration

• In-hospital and in-home visits

• 4 week duration• In-Home

Medication Review & pharmacist intervention

• One-time

*CCTP: CMS-funded Community-based Care Transitions Program

Person-Centered Care

• Partners’ staff consider which of the 3 care transitions interventions, or combination of interventions, is best suited to decreasing the likelihood of readmission for each individual patient.

When selecting an intervention with the patient, we consider the patient’s:• Personal goals• Level of health risk• Social support needs• Cognitive status• Availability of family/caregivers• Neighborhood & local resources• Personal comfort and preferences• Cultural and linguistic characteristics

InterventionsUnique to Bridge

Set up services prior to discharge

Provide discharge preparation information sheet prior to discharge

Call patient within 48 hours of discharge

Make additional calls or schedule visits to resolve identified problems

Use health record to relay information to other providers

Track patients progress and address emerging needs at 30-days post

discharge

Bridge & CTI

Pre-discharge hospital visit

Assess for and address emerging needs post-discharge

Telephone follow-up to ensure adherence to plans

Coordinate with other providers and agencies

Interventions Unique to CTI

Use Personal Health Record (PHR) tool

Conduct one home visit 24-72 hours post-discharge

Actively engage patient in medication reconciliation

Use role-playing and other tools to transfer skills

Perform 3 follow-up phone calls to reinforce coaching , self-

management, sharing PHR

Bridging the Gap

Providing flexible, tailored programming for each patient’s needs means reducing readmission risk

The Bridge Model allows us to serve patients who:• Refuse home visits due to cultural reasons or personal discomfort; • Are cognitively impaired and difficult to coach• Are still too ill to take responsibility for behavior change• Lack caregiver or are otherwise in need of social supports and incapable of making

own arrangements • Are geographically beyond our reach

Across Partners’ 3 CCTP communities, over 9,096 patients were enrolled in the Bridge Model as of 9/30/15.

Increasing Bridge Interventions12/13-9/15

Number of Bridge Cases vs CTI Cases

A UCLA Study on Partners’ Bridge Patients7/14-12/14

9.78% Readmission Rate

For further information contact:• June Simmons, CEO at jsimmons@picf.org• Or check our website: picf.org