Facts - Pennsylvania Health Care Association

Care Transition Opportunities for
Naomi Hauser , RN, MPA
Director Care Transitions
Quality Insights of Pennsylvania
August 14, 2013
Care Transitions
 A continuous process in which a patient’s care shifts
from being provided in one setting of care to another
Affordable Care Act
 New care transition/30-day readmission reduction
 Increase incentives to improve coordination between
settings and providers that help reduce health care
costs through prevented readmissions
 Supporting individuals and caregivers who experience
a transition in their care setting
Financial Incentives/Penalties
 Medicare began financial incentives to reduce
potentially avoidable hospital transfers through payfor-performance initiatives, bundled payments and
other strategies
 October 2013
 Avoidable rehospitalizations drivers
– A failure in hospital discharge processes
– Patients’ ability to manage self-care
– Quality of care in the next community settings (skilled
nursing facilities, home health care agencies, and office
 IHI faculty discovered that the failures in care
coordination between the hospital and SNF that led
to rehospitalization within 30 days after discharge fell
into two main categories:
– Those related to care provided within the skilled nursing
– Those related to care provided during the transition from
the hospital to the skilled nursing facility
 Nursing home residents transferred to hospitals for
acute change in their clinical condition
 1 of 4 Medicare patients admitted to SNF from
– Readmitted within 30 days
– 2/3 potentially avoidable
 Identify improvement opportunities/RCA
 Use Interact tools
 Start the conversations with partners/ER
 Collaborate
 Transparency
 Establish goals/measures/collect data/trends
 Spread/sustainability interventions
Changing Image of LTC
 Important to understand consumers’ emerging and
changing needs, wants and expectations, especially
– Quality of their experience with providers position as
• Trusted advocates in helping consumers access services and
• While assisting consumers and their families
– In navigating complex aging challenges
Action Steps
 Identify and implement effective programs and
 Promote safe, effective care transitions while
decreasing potentially avoidable 30-day readmissions
 Get started now!
 Hickory House
Customer Service and Education Based
Elaine Doyle, BSN BA RAC- CT
Mary Zebert, SW
What does C.O.A.C.H. mean?
 Communicate Expectations
 Organize Goals
 Assign Coach
 Continued Review
 Handoff Homework
Team Roster
 Case Manager
 Coach
 Rehab
 Social Services
 Clinical Services
 Registered Dietician
72-Hour Meeting
 Introductions
 Prior level of functioning
 Our goals
 Patient’s goals
72-Hour Meeting
 Goal is to shift the patient’s “time oriented” focus to a
“goal oriented” focus
 Rehab initiates the checklist and hands it off to the CM
before the meeting – CM adds the nursing goals
 Determine patient’s education needs and place patient on
“alert charting”
 Incorporate the patient’s expectations into your goal
sheet then review it with patient and family
 Introduce the COACH
Continued Communications
 Update the goal sheet at the weekly rehab meeting;
discuss possible need for a home assessment
 Share the changes with the patient
 If the patient is off track, their coach meets with the CM,
CM determines if an extra meeting is needed
 Nursing will monitor patient for early warning signs of
change in condition using the INTERACT tools to enable
early treatment of illness and avoid unnecessary hospital
Discharge Meeting
72 hours before discharge date
Case Manager approaches the patient regarding their safe transition home, reviews their
progress and offers a general overview of what to expect as they transition from SNF to home
The Case Manager and Social Worker coordinate the logistics of the discharge; DME and
transitional services are arranged
Verify that transport to home has been secured, confirm date and time of transition home
CM issues the Patient Education Handbook to the patient and explains how it will benefit the
CM issues printed handouts related to patient’s needs
CM instructs patient that an appointment with his PCP needs to be made in a one week
Day of Transition
 Each team member will meet with the patient to
review the Patient Education Handbook in relation to
their corresponding area of expertise. Instructional
notes will be made in the book
 CM will review the safe transition instructions with
the patient
Transition Follow-Up
 SS places a call on day 2 or 3 to inquire about PCP
 SS places a second call on day 7 to 10 to find out if the
appointment was made
 SS places a third call on day 21 to 24 days to find out if
the appointment was kept
 SS places a fourth call on day 31 to find out if the
patient was readmitted to the hospital
 The two months of data showed:
 22 patients had a Post-Discharge Follow-up phone call
on day 2 or 3
 20 patients were connected on day 2 or 3 with a
follow-up phone call
 16 patients reported appointment made on day 2 or 3
phone call.
 The two months of data showed:
– 18 patients reported keeping appointment on day 7 followup phone call
– 17 patients were not readmitted within 30 days of hospital
 Research highlights that
– Nearly one-fourth of Medicare beneficiaries discharged
from the hospital to a SNF
– Are readmitted to the hospital within 30 days
– Cost Medicare $4.34 billion in 2006
This material was prepared by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization for
Pennsylvania, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of
Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 10SOW-PA-ICPCKD-080513. App. 8/13.

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