Care Setting Transitions and

the Primary Care Home

Stacy Moritz, RN, MBA Acumentra Health October 8, 2013

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Patient-Centered Primary Care Institute History and Development

• Launched in 2012

• Public–private partnership

• Broad array of technical assistance for practices at all stages of transformation – Learning Collaboratives

– Website (www.pcpci.org)

– Webinars & Online Learning

• Ongoing mechanism to support practice transformation and quality improvement in Oregon

Oregon’s PCPCH Model is defined by six core attributes, each with specific standards and measures:

• Access to Care – “Be there when we need you”

• Accountability – “Take responsibility for us to receive the best possible health care”

• Comprehensive Whole Person Care – “Provide/help us get the health care and information we need”

• Continuity – “Be our partner over time in caring for us”

• Coordination and Integration – “Help us navigate the system to get the care we need safely and

in a timely manner”

• Person and Family Centered Care – “Recognize we are the most important part of the care team, and we are

responsible for our overall health and wellness”

Read more: http://primarycarehome.oregon.gov

PCPCH Model of Care

Care Setting Transitions and the Primary Care Home

Stacy D. Moritz, RN, MBA

Acumentra Health

October 8, 2013

Objectives

• Identify typical transition communication failures that occur when a patient transfers across settings

• List effective strategies a primary care home can use to improve care transitions

• Translate the best practices into meeting PCPCH standards for specialized care setting transitions and for referral and specialty care coordination

Meeting PCPCH Standards 4.E.0 Continuity

• Specialized Care Setting Transitions

– Written agreement with your usual hospital providers

– Must Pass = Yes

– Points = 0

It’s a Partnership Problem

It’s a Partnership Problem

Common Fallacies About Care Transitions

• One-time task!

• One size fits all!

• Everyone is clear on their roles and responsibilities

• Medication reconciliation has been taken care of by the sending provider

• Everyone has access to the information the need

It’s All About Communication!

• Patients and families are often the only source of information

• EMRs are often not compatible

• No follow-up appointment scheduled with primary care, or it is too far out

• Discharge or transfer plan is not timely or complete

• No emergency plan, including a telephone number for whom the patient should call first!

Polling Question

How long after patient discharges from the hospital

before your clinic typically receives a discharge plan?

a. 24 hours

b. 48 hours or less

c. 72 hours or less

d. Greater than 72 hours

e. Too long to make it useful in care coordination

Best Practices

• Develop a plan for communicating with the hospital or sending provider.

– Model communication plan/agreement between hospital and medical home

• Ask your patients to bring the discharge plan and educational materials to their follow-up visit.

• Support the discharge plan!

Red, Yellow, Green

Your Goal Weight:

Green Zone: All Clear No shortness of breath No swelling No weight gain No chest pain No decrease in your ability to maintain your activity level

Green Zone Means:

Your symptoms are under control Continue taking your medications as ordered Continue daily weights Follow low -salt diet Keep all physician appointments

Yellow Zone: Caution

If you have any of the following signs and symptoms:

Weight gain of 3 or more pounds in 2 days Increased cough Increased swelling Increase in shortness of breath with activity Increase in the number of pillows needed Anything else unusual that bothers you

Call your physician if you are going into the YELLOW zone

Yellow Zone Means:

Your symptoms may indicate that you need an adjustment of your medications

Call your physician, nurse coordinator, or home health nurse.

Name: ______________________________________ Number: ____________________________________ Instructions: _________________________________ ____________________________________________

Red Zone: Medical Alert

Unrelieved shortness of breath: shortness of breath while at rest Unrelieved chest pain Wheezing or chest tightness while at rest Need to sit in chair to sleep Weight gain or loss of more than 5 pounds in 2 days Confusion

Call your physician immediately if you are going into the RED zone

Red Zone Means: This indicates that you need to be evaluated by a physician right away

Call your physician right away

Physician: ____________________________________ Number: _____________________________________

Another Example

• Patient tool from University of North Carolina Health Literacy program

– Guides patients in adjusting diuretic dosage or calling provider when weight varies from target (green)

Best Practices

• Identify early in the process the date the patient is likely to be discharged

• Consider open access for appointment scheduling

• Designate a call-in period when patients can call in to talk with their primary care provider

• Engage patients and family to be proactive in care

Roles of Ambulatory Practices

AMA report: There and Home Again, Safely: 5 Responsibilities of Ambulatory Practices in High Quality Care Transitions

5 Responsibilities for Safe Care Transitions

• Assessments

• Goal setting

• Supporting self-management

• Medication management

• Care coordination

Medication Reconciliation

Try a “brown bag” review:

• Identify a few patients to call the day before their appointment. Ask them to bring all their medicines when they come in.

• Review each item and ask them how and when they take it and for what.

• Provide written documentation for the patient.

• Discuss your findings and confirm understanding.

5 Principles

Collaborative

Person-Centered

Structured

Flexible

Iterative

Meeting PCPCH Standards 5.E.1 Coordination & Integration

• Referral & Specialty Care Coordination

– Track referrals to consulting specialty providers

– Include referral status and if consultation results have been communicated to the patient and clinicians

– Must Pass = No

– Points = 5

Referral & Specialty Care Coordination

Step 1: Improve internal office communication.

Step 2: Engage the patient in scheduling.

Step 3: Facilitate the appointment.

Step 4: Track referral results.

Step 5: Analyze data for improvement opportunities.

Step 6: Gather patient feedback.

No Place Like Home Campaign

www.noplacelikehomeor.org

• Resources

– 5 Key Areas

– Medication reconciliation

– Teach-back tools

– Primary care tools

Acumentra Health Patient Engagement Resources

www.acumentra.org

• “Resources for managing your health” – Living Well with Chronic Illness program

– Specific conditions (including heart failure patient guides)

– Smoking cessation, falls prevention, managing blood pressure and medications

– Caregiver resources

– Hospital, nursing home, home health “compare” tools

Acumentra Health Patient Engagement Resources

www.acumentra.org

• “Be a partner in your health care”

– Three questions to ask your doctor

– Patient decision aids

– Speaking up about hand washing and safety concerns

– Avoiding a return to the hospital

– Making your end-of-life wishes known

Questions?

Resources

• No Place Like Home Campaign, and specifically resources for primary care providers

• Sample hospital agreement letter

• Archives of Internal Medicine Report - Communication Discrepancies Between Physicians and Hospitalized Patients

• Exacerbation Action Plan and Protocol (Red Yellow Green sheets)

Resources

• American Medical Association (AMA) Report - There and Home Again, Safely: 5 Responsibilities of Ambulatory Practices in High Quality Care Transitions

• Medication Brown Bag Review, Health Literacy Universal Precautions for Primary Care

• Patient handout - “What can I do to live as well as I can with my health condition?” which links patients to these resources

• Patient handout “How can I partner with my doctor on my health care?” which links patients to these resources

For More Information

Stacy Moritz, RN, MBA Director of Medicare Quality Services Acumentra Health

503-382-3918 smoritz@acumentra.org “The conductor of an orchestra doesn’t make a sound. He depends, for his power, on his ability to make other people powerful.” — Benjamin Zander

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