Transcript Slide 1

A Collaborative Approach
to Transition Management
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Manage the Discharge from
One Care Setting to Another
Transition:
Movement of a member/patient from one
care setting to another as the member’s/
patient’s health status changes.
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Care Transition Management
Objectives:
By the end of this presentation you should:
• Understand the care coordinator’s role
and accountability with transition support
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Care Transition Management
Objectives:
• Be familiar with Transition of Care
(TOC) Collaborative Improvement
Project
• List the Four Pillars of Optimal Transition
management than can impact avoidable
readmissions
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Care coordinators
Who are they?
• Licensed Registered Nurse or Social
Worker
What do they do?
• Communicate with members/patients and
their health care providers
• Coordinate services
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Care coordinator’s role
• Communicate, support, educate, arrange
services
• Provide effective transition support
• Communicate with individuals involved in
the discharge process
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Care coordinator’s role
• Identify and note current services and
needed changes
• Assess issues known to impact
readmissions
• Update care plan
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Improving
Transitions of Care (TOC)
After Hospitalizations
Goal:
To reduce hospital readmissions by
improving member/patient support for the
transition from hospital to home or a health
care setting
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Improving Transitions After
Hospitalizations
Health plans want to reduce:
• Fragmented care
• Unsafe care
• Readmissions
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Improving Transitions After
Hospitalizations
• Three year improvement project
• Train care coordinators
• Promote member/patient and family
involvement
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Key Interventions:
• Improve Transition of Care (TOC) Log
• Train care coordinators in use of TOC Log
• Annual audits of TOC Logs
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TOC Log
Tool care coordinators use as a process to:
• Prompt communication
• Educate member/patient and family
• Manage the transition process
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TOC Log
Tool care coordinators use as a process to:
• Prevent or reduce unplanned or avoidable
transitions
• Meet regulatory requirements for
managing care transitions
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Improving the TOC Log
Revision Process:
• Gather care coordinator’s input
• Focus Groups
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Improving the TOC Log
Revised the TOC Log to:
• Incorporate care coordinators’ requests for
value-added tool
• Use as a standardized communication tool
with prompts for the Four Pillars for
Optimal Transition
• Auditable tool for CMS and Project
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Questions and Answers
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New to TOC Log
Four Pillars for Optimal Transition:
• Timely follow-up visit
• Medication self-management
• Knowledge of red flags
• Use of personal health record
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Timely Follow-up
Appointment
• Did the member/patient schedule the
appointment (appt)?
• Assist with making the appt, as needed
•
How will they get to the appt?
•
Stress the importance of keeping the appt
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Medication
Self-management
Determine whether member/patient/
responsible party have an understanding of
current medication regimen.
Does the member/patient:
• Have medications (meds) changes?
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Medication
Self-management
• Have their meds?
• Remember to take their meds?
• Need help with med set-up or taking them?
• Questions/Concerns about their meds?
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Knowledge of Red Flags
Indicate whether the member/patient/
responsible party are aware of symptoms that
indicate problems with healing or recovery.
Does the member know:
• What are the warning signs/symptoms?
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Knowledge of Red Flags
• What action should they take if symptoms
appear?
• Who and when to call with questions or
concerns?
• Do they have phone numbers available?
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Use of a
Personal Health Record
Indicate whether member/patient/responsible
party uses a personal health care record for
tracking health history and current medication
regimens.
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Use of a
Personal Health Record
An organized account of personal health
information that the member/patient can
self-record and bring to appointments.
Use to increase member/patient engagement
and self-management
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Personal Health Record
Typical PHR topics:
• Personal & caregiver contact information
• Healthcare providers & contact information
• Medical history
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Personal Health Record
• Medications
• Warning signs
• Questions for practitioners/list of
appointments
• Personal goals
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Personal Health Record:
Example
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Personal Health Record:
Example
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New to TOC Log
As a result of this transition discussion:
• Have you updated the member’s/patient’s
care plan?
⃞ Yes
⃞ No
If No, explain
• Services started, stopped, changed
and/or refused?
⃞ Yes
⃞ No
Comments
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Questions and Answers
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Transition of Care Tools
• Fax Sheet for Provider Communication
• Transition of Care Toolkit
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Transition of Care Toolkit
• Summary of health plan projects that focus
on improving transitions
• Importance of transitions and a list of
research-based hospital discharge
programs
• Risk Assessments and intervention links:
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RARE Campaign
(Reducing Avoidable Readmissions
Effectively)
Many regional hospitals are participating in
the statewide RARE Campaign and working
internally on ways to reduce Readmissions
during hospitalization, and best practices to
reduce avoidable readmissions with
partnering agencies.
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RARE Campaign
(Reducing Avoidable Readmissions
Effectively)
Lead Partners:
• Institute for Clinical Systems
Improvement (ICSI),
• Minnesota Hospital Association (MHA),
• Stratis Health
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Transition of Care Toolkit
Risk assessments/intervention resources:
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Health Literacy
Depression
Substance abuse
Falls
Cognitive impairment
Pain
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Risk Factors for Readmission
• Limited Health Literacy
 Teach-back method
• Depression
 Patient Health Questionnaire-9
• Substance abuse
 AUDIT-C (At-risk Drinking)
 CAGE or CAGE-AID
(Alcohol and Drug Disorders)
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Other Important Risks
• Falls
• Cognitive impairment
• Pain
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Questions and Answers
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Annual Audits:
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Monitor and provide feedback to care
coordinators on TOC communication
process
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Monitor and meet CMS requirements for
providing effective transition support
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Opportunities:
Hospital
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Connect with health plan care coordinator
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Notify care coordinator of discharge
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Opportunities:
Desired Outcomes:
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Optimize services
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Decrease confusion
•
Reduce readmissions
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Improving TOC: Summary
• Care coordinator’s management of
transitions and member/patient/family
education is key to preventing readmissions
• The Four Pillars of Optimal Transition are
evidenced-based
• The TOC Log is a dual purpose document:
 prompts for care coordinator
 an auditable tool
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Questions and Answers
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