Transitions of Care Coordination of Care Across Settings Mark Hawk, MSN, ACNP Carla Graf, MS, CNS...

Transitions of CareTransitions of CareCoordination of Care Across SettingsCoordination of Care Across Settings

Mark Hawk, MSN, ACNP Mark Hawk, MSN, ACNP

Carla Graf, MS, CNSCarla Graf, MS, CNS

Bree Johnston, MDBree Johnston, MD

ObjectivesObjectives Identify all potential acute care setting Identify all potential acute care setting

disciplines/departments that are involved in the care disciplines/departments that are involved in the care of this population.of this population.

Explain current evidence-based research regarding Explain current evidence-based research regarding “models of care” for transitions across acute “models of care” for transitions across acute settings/units.settings/units.

Identify all potential disposition avenues (SNF, rehab, Identify all potential disposition avenues (SNF, rehab, home, etc.) for acutely hospitalized elders.home, etc.) for acutely hospitalized elders.

Recognize common obstacles in providing seamless Recognize common obstacles in providing seamless transitions between acute care settings/providers.transitions between acute care settings/providers.

Transitions of CareTransitions of Care

InsuranceInsurance Placement needsPlacement needs Need for SNF with on-site dialysisNeed for SNF with on-site dialysis Support SystemSupport System Occupying inpatient med-surg bedOccupying inpatient med-surg bed Unable to schedule elective surgeryUnable to schedule elective surgery Patient outcomePatient outcome

Discontinuity ErrorsDiscontinuity Errors

3 types of errors:3 types of errors: Medication continuityMedication continuity Test result follow upTest result follow up WorkupWorkup

49% had at least one error49% had at least one error

(Moore JGIM 2003; 18: 646-51)(Moore JGIM 2003; 18: 646-51)

TransitionTransition

Passage from one place, state, stage of Passage from one place, state, stage of development to another; also the period or development to another; also the period or place where such a change is effected place where such a change is effected (Fletcher 2005)(Fletcher 2005)

What is “Transitional Care”?What is “Transitional Care”?

……a set of actions designed to ensure the a set of actions designed to ensure the coordination and continuity of health care as coordination and continuity of health care as patients transfer between different locations or patients transfer between different locations or different levels of care within the same different levels of care within the same location.location.

(Coleman, 2003)(Coleman, 2003)

Transitional CareTransitional Care

Encompasses both sending and receiving Encompasses both sending and receiving aspects of transferaspects of transfer

Appropriate information sharingAppropriate information sharing Logistical arrangementsLogistical arrangements Education of patient and caregiversEducation of patient and caregivers Coordination among varied HCPCoordination among varied HCP Absolutely NECESSARY for those with Absolutely NECESSARY for those with

comp,ex care needs (Fletcher, 2005)comp,ex care needs (Fletcher, 2005)

An 82 yr old with a hip fracture in An 82 yr old with a hip fracture in an acute hospital setting sees…an acute hospital setting sees…

ParamedicsParamedics Emergency PhysicianEmergency Physician NursingNursing Orthopedic SurgeonOrthopedic Surgeon Hospitalist/IntensivistHospitalist/Intensivist PT/OTPT/OT Social ServicesSocial Services NutritionNutrition

This 82 yr old with a hip fracture then is This 82 yr old with a hip fracture then is “transitioned” to a Skilled Nursing “transitioned” to a Skilled Nursing

Facility where he/she sees…Facility where he/she sees…

SNF PhysicianSNF Physician SNF NursingSNF Nursing SNF PT/OTSNF PT/OT

Then they are “transitioned” home where Then they are “transitioned” home where they see…they see…

Home Care NursesHome Care Nurses Home Care PT/OTHome Care PT/OT PCPPCP PCP NursePCP Nurse PC PharmacistPC Pharmacist

What is the common thread?What is the common thread?

The patientThe patient

And the caregiversAnd the caregivers

What breaks the common thread?What breaks the common thread?

From the patients’ perspective:From the patients’ perspective: Deficiencies in preparing caregivers and the Deficiencies in preparing caregivers and the

patient themselves for the transitionpatient themselves for the transition Transferring of information across settingsTransferring of information across settings Supporting self-management of chronic conditionsSupporting self-management of chronic conditions No encouragement to express own preferences of No encouragement to express own preferences of

the patient or caregiverthe patient or caregiver


Patient PerspectivePatient Perspective

According to a California Health Care According to a California Health Care Foundation survey, patients rated transition to Foundation survey, patients rated transition to home lower than ANY other health care home lower than ANY other health care experienceexperience

Qualitative studies suggest that patients often Qualitative studies suggest that patients often don’t understand medication SEs, whom they don’t understand medication SEs, whom they should direct questions to, what warning signs should direct questions to, what warning signs to look for, or when to resume normal to look for, or when to resume normal activitiesactivities

What breaks the common thread?What breaks the common thread?

From the caregivers’ perspective:From the caregivers’ perspective: Lack of preparation in “what to expect” and how Lack of preparation in “what to expect” and how

to respond to the changing needs of their loved to respond to the changing needs of their loved ones moving between settingsones moving between settings


Often, all that is needed is 1 Often, all that is needed is 1 or 2 more days of acute care!or 2 more days of acute care!

Transitional Care for LearnersTransitional Care for Learners

Helps address the systems based practice (and Helps address the systems based practice (and possible practice based learning) competencypossible practice based learning) competency

May help move learners beyond the culture of May help move learners beyond the culture of rewarding all discharges rewarding all discharges ““You’re awesome - you diuresed the service!You’re awesome - you diuresed the service! (but with what patient outcomes?)(but with what patient outcomes?)

May help learners see patients in the context of May help learners see patients in the context of their own livestheir own lives

PrevalencePrevalence

In 2000 for every 1000 people aged 65 and In 2000 for every 1000 people aged 65 and over they averaged:over they averaged: 400 ambulatory care visits400 ambulatory care visits 300 emergency department visits300 emergency department visits 200 hospital admissions200 hospital admissions 46 SNF admissions46 SNF admissions 106 home care admissions106 home care admissions



2001 Harris Poll commissioned by Robert 2001 Harris Poll commissioned by Robert Wood Johnson FoundationWood Johnson Foundation

On average, older people with one or more On average, older people with one or more chronic conditions sees how many different chronic conditions sees how many different physicians over the course of one year?physicians over the course of one year?

Eight!Eight!



23% of hospital patients aged 65 and over are 23% of hospital patients aged 65 and over are discharged to another institution.discharged to another institution.

11.6% are discharged with home care.11.6% are discharged with home care. 19% of SNF patients are transferred back to an acute 19% of SNF patients are transferred back to an acute

care hospital within 30 days, 42% within 24 months.care hospital within 30 days, 42% within 24 months. Ma, et al (2002) studied 920 community dwelling Ma, et al (2002) studied 920 community dwelling

elders DCed from hospital to SNF/Rehab…elders DCed from hospital to SNF/Rehab… Nearly 50% had four or more additional institutional Nearly 50% had four or more additional institutional

transitions over a 12 month period.transitions over a 12 month period.


Why do poor transitions happen?Why do poor transitions happen?

Fragmented CareFragmented Care Institutional isolation from one anotherInstitutional isolation from one another Lack of financial incentivesLack of financial incentives RegulatoryRegulatory Medicare directed towards each “setting” Medicare directed towards each “setting”

rather than each “episode” of carerather than each “episode” of care Few quality indicators to measure performanceFew quality indicators to measure performance Professional barriersProfessional barriers

Why do poor transitions happen?Why do poor transitions happen? Multiple providers unfamiliar with “scope of Multiple providers unfamiliar with “scope of

care/services” at receiving facilitycare/services” at receiving facility PCP doesn’t have privileges at receiving facilityPCP doesn’t have privileges at receiving facility Conflicting recommendations about chronic condition Conflicting recommendations about chronic condition

managementmanagement Confusing medication regimens-error and duplicityConfusing medication regimens-error and duplicity Lack of follow-up careLack of follow-up care Inadequate preparation of patient and caregiver for Inadequate preparation of patient and caregiver for

receiving care at next facilityreceiving care at next facility Passive Role of the patient/caregiverPassive Role of the patient/caregiver Transitions often urgent and unplannedTransitions often urgent and unplanned

Care Transitions Intervention-Four Care Transitions Intervention-Four “Pillars”“Pillars”

Medication self-managementMedication self-management A patient-centered recordA patient-centered record

Personal Health RecordPersonal Health Record Use of a Transition CoachUse of a Transition Coach

Primary care and specialist follow-upPrimary care and specialist follow-up Knowledge of “red flag” warning symptoms or Knowledge of “red flag” warning symptoms or

signs indicative of a worsening conditionsigns indicative of a worsening condition

(Coleman et al, 2004)(Coleman et al, 2004)

Medication ReconciliationMedication Reconciliation

2001 Harris Poll for RWJ Foundation…2001 Harris Poll for RWJ Foundation… 16 million adult Americans with chronic 16 million adult Americans with chronic

illness revealed that their pharmacist told them illness revealed that their pharmacist told them that medications prescribed by one or more of that medications prescribed by one or more of their physicians had their physicians had potentially harmful potentially harmful interactions. interactions.


Medication ReconciliationMedication Reconciliation

Forster et al, 2003-19% of patients discharged Forster et al, 2003-19% of patients discharged from a hospital experienced an associated from a hospital experienced an associated adverse event within 3 weeks.adverse event within 3 weeks.

66% of those were adverse drug events66% of those were adverse drug events

2006 JCAHO National patient 2006 JCAHO National patient Safety GoalsSafety Goals

Goal 8A:Goal 8A: Implement a process for obtaining and Implement a process for obtaining and

documenting a complete list of the patient’s documenting a complete list of the patient’s current medications upon the patient’s admission current medications upon the patient’s admission to the organization and with the involvement of the to the organization and with the involvement of the patient. This process includes a comparison of the patient. This process includes a comparison of the medication the organization provides to those on medication the organization provides to those on the list.the list.

Goal 8B:Goal 8B: A complete list of the patient’s medications is A complete list of the patient’s medications is

communicated to the next provider of service communicated to the next provider of service when a patient is referred or transferred to another when a patient is referred or transferred to another setting, service, practitioner or level of care within setting, service, practitioner or level of care within or outside the organization.or outside the organization.

Anatomy of a “good transition”Anatomy of a “good transition”

Communication of vital elements of the care planCommunication of vital elements of the care plan A Common Plan of CareA Common Plan of Care The patient’s goals and preferencesThe patient’s goals and preferences An “updated” list of problems, baseline physical and An “updated” list of problems, baseline physical and

cognitive functional status, current medications and cognitive functional status, current medications and allergiesallergies

Contact information for the patient’s caregiver and Contact information for the patient’s caregiver and PCPPCP

Preparation of the patient and caregiverPreparation of the patient and caregiver

Anatomy of a “good transition”Anatomy of a “good transition”

Reconciliation of medication list “pre” and Reconciliation of medication list “pre” and “post” transfer“post” transfer

Transportation of the patientTransportation of the patient Completion of Follow-up care with a Completion of Follow-up care with a

practitioner and/or diagnostic studiespractitioner and/or diagnostic studies Availability of diagnostic resultsAvailability of diagnostic results Availability of advance care directivesAvailability of advance care directives ““warning signs” and contact informationwarning signs” and contact information

Why Coordinate Care?Why Coordinate Care?

Advance “patient-centered” careAdvance “patient-centered” care Support for shared decision-makingSupport for shared decision-making Promote patient safetyPromote patient safety

Medication use/errorsMedication use/errors Control Medicare costsControl Medicare costs Reduce unnecessary utilization/redundancy of Reduce unnecessary utilization/redundancy of

carecare JCAHOJCAHO

What needs to be done?What needs to be done?

System level performance measurementSystem level performance measurement Process measuresProcess measures

Is the patient prepared for transfer?Is the patient prepared for transfer? Is the appropriate information promptly transmitted?Is the appropriate information promptly transmitted? Reconciliation of “pre-” and “post”- transition care Reconciliation of “pre-” and “post”- transition care

regimensregimens Information technologiesInformation technologies

What needs to be done?What needs to be done?

Intervention from “oversight” levelIntervention from “oversight” level MedicareMedicare JCAHOJCAHO

Change payment policiesChange payment policies Financial incentives for institutions/providersFinancial incentives for institutions/providers Coding and Billing ChangesCoding and Billing Changes

ResearchResearch

How to best integrate patient and caregiver How to best integrate patient and caregiver into interdisciplinary care teaminto interdisciplinary care team

How to foster collaborationHow to foster collaboration How to identify those patients at high risk for How to identify those patients at high risk for

poor transition-related outcomespoor transition-related outcomes Development of performance indicators to Development of performance indicators to

track quality of transitionstrack quality of transitions

What does work?-A “Bridging” What does work?-A “Bridging” ModelModel

Use of APNs to identify those at high risk for Use of APNs to identify those at high risk for re-admission, follow them through re-admission, follow them through hospitalization and then after discharge to hospitalization and then after discharge to home.home.

APNs assume responsibility for APNs assume responsibility for comprehensive care in collaboration with the comprehensive care in collaboration with the PCP for 4 weeks post dischargePCP for 4 weeks post discharge

Transition CoachTransition Coach

Usually Nurse or NPUsually Nurse or NP Prepares patient for what to expectPrepares patient for what to expect Provides toolsProvides tools

Follows patient to home or nursing facilityFollows patient to home or nursing facility Reconciles pre- and post- discharge medicationReconciles pre- and post- discharge medication Practices role play of next MD visitPractices role play of next MD visit

Phone calls after dischargePhone calls after discharge Reinforce plan, ensure follow upReinforce plan, ensure follow up

Tools for transitional careTools for transitional care

Medication Discrepancy ToolMedication Discrepancy Tool Personal Health RecordPersonal Health Record Care Transitions MeasureCare Transitions Measure

CARE TRANSITIONS MEASURE (CTM-3) 1. The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital.

Strongly Disagree Disagree Agree Strongly Agree N/A/dont’ know

2. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.


3. When I left the hospital, I clearly understood the purpose for taking each of my medications.


What does work?-Other ModelsWhat does work?-Other Models

APNs enhancing and encouraging the patient’s & APNs enhancing and encouraging the patient’s & caregiver’s participation in their care managementcaregiver’s participation in their care management

Staff from “receiving” facility visits the patient in Staff from “receiving” facility visits the patient in hospital and initiates the transitionhospital and initiates the transition

Extended Care PathwaysExtended Care Pathways Program for All-Inclusive Care of the Elderly Program for All-Inclusive Care of the Elderly

(PACE)(PACE) www.SFGetCare.comwww.SFGetCare.com www.sfgov.org/daaswww.sfgov.org/daas (Dept of Aging and Adult (Dept of Aging and Adult

Services)Services)

In SummaryIn Summary

Problems related to transitional care are Problems related to transitional care are commoncommon

There is evidence that enhanced focus on There is evidence that enhanced focus on transitional care improves outcomestransitional care improves outcomes

Multiple tools are available that can help us Multiple tools are available that can help us improve our transitional careimprove our transitional care

In Summary: In Summary: High Quality Transitional CareHigh Quality Transitional Care

Reliable information on transferReliable information on transfer Clear instructions about pending tests, follow Clear instructions about pending tests, follow

up visits, follow up tasks, and medicationsup visits, follow up tasks, and medications Preparation of patient, family, and caregiverPreparation of patient, family, and caregiver Empowerment of patient to assert preferencesEmpowerment of patient to assert preferences

ReferencesReferences

Coleman EA. (2003). Falling through the cracks: Coleman EA. (2003). Falling through the cracks: challenges and opportunities for improving challenges and opportunities for improving transitional care for persons with continuous transitional care for persons with continuous complex care needs. complex care needs. Journal of the American Journal of the American Geriatrics SocietyGeriatrics Society. 51: 549-555. 51: 549-555

Coleman et al. (2004). Preparing patients and Coleman et al. (2004). Preparing patients and caregivers to participate in care delivered across caregivers to participate in care delivered across settings: the care transitions intervention. settings: the care transitions intervention. Journal Journal of the American Geriatrics Societyof the American Geriatrics Society. 52: . 52: 1817-1817-18251825

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