Transitions of Care
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ATRIAL FIBRILLATIONTRANSITIONS OF CAREFor the Healthcare Provider*
TABLE OF CONTENTSWhat is Transitions of Care?Efficacy of Transitions of Care ApproachProject ScopeThe Role of the ProviderThe Role of the PatientResourcesAction Requested and TimelineFeedback Survey*
BACKGROUND AND CHALLENGESMost commonly diagnosed arrhythmia disorder2.3 million people in U.S. living with AF- 160,000 new cases annuallyPatients with multiple chronic conditions can visit ~16 physicians annuallyAF is responsible for 88,000 deaths per year- $16 billion in healthcare costsChallenge of coordinating basic information (e.g., test results, prescription medications, diagnosis)Poor coordination often leads to adverse clinical outcomes, increased re-admissions, over-utilization of health care services, and untimely follow-up*
TRANSITIONS OF CARE DEFINITION
Transitions of Care refer to the movement of patients between health care locations, providers, or different levels of care within the same location as their conditions and care needs change.Specifically, they can occur:Within settingsBetween settingsAcross health statesBetween providers
CARE COORDINATION DEFINITION
Care coordination is a function that helps ensure the patients needs and preferences for health services and information sharing across people, functions, and sites are met over time. Coordination maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and high-quality patient experiences and improved healthcare outcomes.
Care coordination is important for everyoneSome populations are particularly vulnerableCare coordination measures may be appropriate at the clinician-level; others may be appropriate at the group, practice or organizational-levelPatient/family surveys are essential to measure care coordination; performed within close proximity to the healthcare event
ELEMENTS OF TRANSITIONS OF CAREMedication reconciliationFollow-up tests and servicesChanges in plan of careInvolvement of team during hospitalization, discharge, follow-up, etc.Communication Transfer of all information when site of care changesEducation of the patient and family*
NATIONAL CARE COORDINATION GOALSHealthcare organizations and their staff will continually strive to improve care by soliciting and carefully considering feedback from all patients and their families regarding coordination of their care during transitions.
Medication information will be clearly communicated to patients, family members, and the next healthcare professional and/or organization of care, and medications will be reconfirmed at each transition.
All healthcare organizations and their staff will work collaboratively with patients to reduce 30-day readmission rates.
All healthcare organizations and their staff will work collaboratively with patients to reduce preventable emergency department visits. *
EFFICACY OF TRANSITIONS OF CARE
Hospital to Home ACC & IHI national quality improvement initiative to reduce cardiovascular-related hospital readmissions and improve the transition from inpatient to outpatient status for individuals hospitalized with cardiovascular disease (e.g., heart failure)Medication managementFollow-upSymptom management*
TRANSITIONS OF CARE AND PROVIDER PAYMENTProvider payments are shifting toward the key elements of Care Quality and Care Coordination
By 2015, providers will be required to document quality improvement indicators or face decreases in reimbursement
By 2017, Medicare reimbursement will be adjusted based on documented quality outcomes for all physicians
Capturing those indicator data will aid in either enhancing existing care protocols or developing new ones
AFIB TRANSITIONS OF CARE GOAL
To develop practical resources to encourage best practices in clinical decision-making, patient-provider communication, and patient self-management.
ROLE OF THE CARE PROVIDER
Engaging Mended Hearts VolunteersMaking a referral to post-ablation patients
Review Patient Care PathwayPatient Care PlanReview Patient Discharge Checklist (provided in patient kits)Review AF Educational Resources (provided in the patient kits)
ROLE OF THE MENDED HEARTS VOLUNTEERUnderstand the Patient Care PathwayPeer-to-peer patient supportPatient Care Plan (No interpretation of orders/prescriptions)And what is it and why is this important?Patient Discharge Checklist (General)And what is it and why is this important?Atrial Fibrillation Educational Resources*
ROLE OF THE PATIENT AND CAREGIVER
Understand the Patient Care PathwayPatient Care PlanAnd what is it and why is this important?Patient Discharge Checklist And what is it and why is this important?Atrial Fibrillation Educational Resources*
PROVIDER/PATIENT KIT RESOURCESProvider Resource Kit Best practices Patient care plan elementsDischarge checklistTransition record checklistMended Hearts Info
*Patient Resource KitElements of a care planPatient discharge checklistRole of the caregiverGuide to AFib brochureAFib Patient DVDMended Hearts Info
Healthcare ProviderWeb-based / monthly survey - 4 questions
Mended Hearts VolunteerTelephone / Web-based surveys Monthly/Quarterly
PatientsPostcard / Received during visit 4 questions for 30 days post event