TARGET POPULATION IMPA T - Jefferson
1
The Transions Program breaks the cycle of primary and repeated hospitalizaons or instuonalizaon in the years prior to death. Provides physicians and other healthcare providers evidence- based prognosc tools to recognize when their paent is at risk for using the hospital for a primary or secondary admission for decompensaon care. Engages paents and caregivers in proacve disease management using disease-specific ancipatory guidance for adults. Improves paent safety by reducing risks of hospital-acquired disabilies. Fulfills fiduciary ethics by lowering the cost of care across the healthcare system. Transions took the best of the hospice model and integrated those components into work process and structure, through highly coordi- nated, team-based care, focusing on paent values, preferences and cultural background. PURPOSE INTERVENTION Pillar 1 Evidence-based, in-home medical management Give paent, family and caregiver knowledge and skill-set to proacvely manage the disease Match the medical/ psychosocial intervenons within lifestyle Improve compliance with medical plan Avoid healthcare acquired disabilies by keeping people home and out of hospital Improve end of life care— earlier use of hospice Pillar 3 Caregiver Support Idenfy caregiver needs and support reduce emoon- al and physical strain to care Giver Improve quality of life in Caregiver Improve caregiver sasfac- on Help caregiver care for their loved one and cope with the oſten difficult responsibility of doing so Validate that caregiver can respect paent wishes Pillar 4 Goals of Care Conversaon Create roadmap for all future care and inter- venons Improve communicaon and establish agreement between paent, family and caregiver on end-of life wishes Improve surviving family/ caregiver sasfacon Pillar 2 Evidence-Based Medical Prognoscaon Ulize evidence-based prognoscaon methods to provide accurate survival and event esmates Prepare paent, family and caregiver for inevitable disease manifestaon process Allow paent to make informed decisions about their goals of care while family and caregiver are reconciled and paent has capacity PERSON CENTERED CARE TEAM Home visits by RN, and MSW from start of care unl hospice ready Pharmacist Consultant for medicaon review, adjustments, focus on reducing number of medicaons 24/7 access to RN through hospice Clinical Call Center IDT meengs every 2 weeks facilitated by CMO Outpaent Palliave Medicine Paents sll see their PCP/Specialist and have access to “disease modifying care” Partner with Medical Group Populaon Health teams to coordinate referrals MD RN MSW SCC Pharm Patient ’ s Home A comprehensive concurrent care model designed to manage paents with late stage illness in their preferred environment of care, using the experse of skilled healthcare providers through an interdisciplinary team approach. Idenfied populaon: Disease specific, under maximum medical thera- pies, and at risk of using the ED or hospital for symptom management or “decompensaon” care. Congesve Heart Failure COPD Demena Frailty Advanced stage cancer Advanced liver disease Neuromuscular degenerave diseases Program Caveat: Engaged champion specialty physicians to introduce program philosophy, help develop disease specific criteria, paent selecon and referral process. Funding: Medicare Advantage plans and ACO’s contracted with Sharp HealthCare medical groups. TARGET POPULATION IMPACT TRANSITIONS Community - Based Palliative Care Program Daniel R. Hoefer, MD Suzi K. Johnson, MPH, RN
Transcript of TARGET POPULATION IMPA T - Jefferson
The Transitions Program breaks the cycle of primary and repeated hospitalizations or institutionalization in the years prior to death.
Provides physicians and other healthcare providers evidence-based prognostic tools to recognize when their patient is at risk for using the hospital for a primary or secondary admission for decompensation care.
Engages patients and caregivers in proactive disease management using disease-specific anticipatory guidance for adults.
Improves patient safety by reducing risks of hospital-acquired disabilities.
Fulfills fiduciary ethics by lowering the cost of care across the healthcare system.
Transitions took the best of the hospice model and integrated those components into work process and structure, through highly coordi-nated, team-based care, focusing on patient values, preferences and cultural background.
PURPOSE
INTERVENTION
Pillar 1
Evidence-based, in-home medical
management
Give patient, family and caregiver knowledge and
skill-set to proactively manage the disease
Match the medical/psychosocial interventions within lifestyle
Improve compliance with medical plan
Avoid healthcare acquired disabilities by keeping people home and out of hospital
Improve end of life care—earlier use of hospice
Pillar 3
Caregiver Support
Identify caregiver needs and support reduce emotion- al and physical strain to care Giver
Improve quality of life in Caregiver
Improve caregiver satisfac-tion
Help caregiver care for their loved one and cope with the often difficult responsibility of doing so
Validate that caregiver can respect patient wishes
Pillar 4
Goals of Care Conversation
Create roadmap for all future care and inter- ventions
Improve communication and establish agreement between patient, family and caregiver on end-of life wishes
Improve surviving family/ caregiver satisfaction
Pillar 2
Evidence-Based Medical
Prognostication
Utilize evidence-based prognostication methods to provide accurate survival and event estimates
Prepare patient, family and caregiver for inevitable disease manifestation process
Allow patient to make informed decisions about their goals of care while family and caregiver are reconciled and patient has capacity
PERSON CENTERED CARE TEAM
Home visits by RN, and MSW from start of care until hospice ready
Pharmacist Consultant for medication review, adjustments, focus on reducing number of medications
24/7 access to RN through hospice Clinical Call Center
IDT meetings every 2 weeks facilitated by CMO Outpatient Palliative Medicine
Patients still see their PCP/Specialist and have access to “disease modifying care”
Partner with Medical Group Population Health teams to coordinate referrals
MD RN MSW SCC Pharm
Pa t i e n t ’ s H o m e
A comprehensive concurrent care model designed to manage patients with late stage illness in their preferred environment of care, using the expertise of skilled healthcare providers through an interdisciplinary team approach.
Identified population: Disease specific, under maximum medical thera-pies, and at risk of using the ED or hospital for symptom management or “decompensation” care.
Congestive Heart Failure
COPD
Dementia
Frailty
Advanced stage cancer
Advanced liver disease
Neuromuscular degenerative diseases
Program Caveat: Engaged champion specialty physicians to introduce program philosophy, help develop disease specific criteria, patient selection and referral process.
Funding: Medicare Advantage plans and ACO’s contracted with Sharp HealthCare medical groups.
TARGET POPULATION IMPACT
TRANSITIONS Community-Based
Palliative Care Program
Daniel R. Hoefer, MD Suzi K. Johnson, MPH, RN
