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Strategies to Improve Healthcare Transitions:
Patient & Caregiver Engagement and Activation
Sara Butterfield, RN, BSN, CPHQ, CCM
New York State Wide Senior Action Council, Inc.
2011 Annual Convention
October 11, 2011
Centers for Medicare & Medicaid Services (CMS)
 Leads a national healthcare quality improvement program,
implemented locally by an independent network of Quality
Improvement Organizations (QIOs) in each state
IPRO
 The federally funded Medicare Quality Improvement
Organization (QIO) for New York State, under contract with
the Centers for Medicare & Medicaid Services (CMS).
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CMS Goals
National & Statewide Level
Six Priorities
 Making care safer
 Promoting effective coordination of care
 Assuring care is person and family-centered
 Promoting the best possible prevention and treatment of the
leading causes of mortality, starting with cardiovascular
disease
 Helping communities support better health
 Making care more affordable for individuals, families,
employers and governments by reducing the costs of care
through continual improvement
National Perspective
 17.6% of Medicare beneficiaries are re-hospitalized within 30
days of discharge, accounting for $15 billion in spending
 Estimates show that 76% of these readmissions may be
preventable
 Of Medicare beneficiaries re-admitted within 30 days, 64%
receive no post-acute care between discharge and re-admission
Source: MedPAC:June 2007 Report To Congress: Promoting Greater Efficiency in Medicare
New York State Perspective
New York State 30-Day Hospital Readmission Rates
Medicare FFS Beneficiaries Age 65 or Older
CY 2009
CY 2010
All Cause
20.5%
20.9%
Acute Myocardial Infarction
25.2%
23.8%
Heart Failure
28.8%
28.6%
Pneumonia
21.3%
21.1%
Chronic Obstructive Pulmonary Disease
26.2%
26.4%
Diabetes
24.3%
22.3%
End Stage Renal Disease
37.1%
35.4%
Source: CMS ISAT Data
Consumer Perspective
AARP Report: Chronic Care: A Call to Action for
Health Reform
According to the results of the patient survey:

Nearly one in four patients reported experiencing a medical error, and
61 percent of this subgroup said they had experienced a major
problem as a result;

About one in five reported that their health care providers did not
communicate well with each other about the their individual
condition or treatment, which some said compromised their health;

Nearly one in seven said they didn't get a follow-up appointment after
they were discharged or, if they did, it was more than four weeks
later; and

Almost one in five said their transitional care was not well
coordinated.
Contributing Factors
Patients are more chronically ill, more frail, and
have more complex care needs
 Multiple diagnoses
 May see several physicians
 Average 13-16 medications per day
 May be cognitively impaired
 May not have a Primary Care Physician
 Lack of involving a caregiver for safe transition to home
 Access to and/or lack of community services
Other Contributing Factors
Not remembering / understanding physician instructions
 Difficulty communicating with health professionals
Unrealistic expectations
Difficulty arranging for assistance
Finances/affordability
Not enough time for competing demands
Loss of mobility
Language barriers
(Source: Beyond 50.09 Chronic Care: A Call to Action for Health Reform, AARP, March 2009)
Dilemmas

Focus is on discharge versus transition

No ownership of transition

Burden of coordination is placed on patient

Caregiver may not be available / involved at discharge

Absence of common medical record

Absence of cross setting medication reconciliation

Lack of advance directives & screening for palliative care

No reassessment of patient and goals at each transition

Communication gaps exist between disciplines and
health care settings
The Driving Forces….
American Geriatrics Society Health Care
Systems Committee Position
• Clinical professionals must prepare patients/caregivers to
receive care in the next setting & actively involve them in
decisions related to the formulation & execution of the
transitional care plan
• Bi-directional communication between clinical professionals is
essential to ensuring high quality transitional care
• The opportunity to collaborate with a coordinating health
professional functioning across health care settings to reduce
care fragmentation may enhance the care that these
professionals deliver
Source: J Am Geriatric Soc 51:556-557, 2003
Centers for Medicare & Medicaid Services
Care Transitions Initiative
August 2008-July 2011
New York Care Transitions Target Community
 Five county region in Upper Capital Region of New York State with
integrated referral patterns incorporating urban, suburban and rural
communities within 84 zip codes
● Warren, Washington, Saratoga, Rensselaer & Saratoga
 Fifty providers
●
Hospitals (6), Home Health (6), Skilled Nursing Facilities (28), Hospice (5),
Dialysis Centers (5), Multiple Physician Practices
 Impacting 68,206 Medicare Fee for Service (FFS) beneficiaries
Where We Began Our Journey…
The Paradigm Shift:
Discharge Versus Care Transition
Cross-Setting Partnerships
“Our Patient”
“Patient Within Our Community”
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Targeted Opportunities for Improvement
Assessment of patient / caregiver understanding of discharge
medications & instructions using Teach-Back Method
Identification and referral of high-risk readmission patients for
follow-up care
Inclusion of 7-day follow-up physician visit appointment in
discharge instructions with follow-up phone call
Cross setting medication reconciliation & education
Support of patient / caregiver learning for self-management (signs /
symptoms / red flags / action)
Improved cross setting partnerships and communication for care
coordination and management
Streamlined and standardized cross setting information transfer
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Patient Engagement / Activation
The person’s ability to manage their health
and health care
 Self efficacy in managing their behavior
 Readiness to change - motivation
 Knowledge, skill, beliefs, and behaviors
 Linked to the person’s health outcomes
Patient Engagement / Activation
Patients who were not interested or less involved
in care tended to:
 Have more problems with transitioning between care settings
 Reported more problems with care
 Less confident with there ability to manage their chronic
condition
 Worse health status and more chronic conditions
 Required more assistance to arrange for care
(Source: Beyond 50.09 Chronic Care: A Call to Action for Health Reform, AARP, March 2009)
Key Practices Leading to Results
Collaborated with target community providers and stakeholders to identify sites where
seniors gather for social and health activities
•
Senior Centers , Housing Units, Independent & Assisted Living Facilities, Churches, Libraries
Organized one hour beneficiary outreach sessions at each site
•
20 educational sessions completed to date reaching over 315 Medicare beneficiaries in community
•
3 community caregiver outreach exhibits with over 160 attendees
•
2 senior health fairs with over 150 attendees
Developed large font, fifth grade level educational materials to share and reference
during each session:
•
Hospital Discharge Planning “Golden Rules”
•
Medication Management “Golden Rules”
•
Personal Health Record
•
Caregiver Resource Handout
•
United Hospital Fund Next Step In Care Resources
Opened sessions by asking seniors to share their health care experiences and then used
their stories in conjunction with the educational materials to discuss importance of self
empowerment & self-management skills
Shared beneficiary feedback & perceptions with target community providers
Heart Failure Zones
Determine your
zone every day!
Every day:

Weigh yourself in the morning before breakfast, and enter your daily weight in a log.

Take your medicine as directed by your doctor.

Check for swelling in your feet, ankles, legs and stomach.

Eat low-salt food.

Balance activity and rest periods.
Green Zone
Your symptoms are under control. You have:

No shortness of breath.

No weight gain of more than two pounds.

No swelling in your feet, ankles, legs or stomach.

No chest pain.
This zone is your
goal
Yellow
Zone
Caution: This
zone is a warning
Red Zone
Emergency
Call you doctor's office if:

You have a weight gain of two or more pounds in one day or a weight gain of four
pounds or more in one week

You have increased shortness of breath.

You experience more swelling of your feet, ankles, legs or stomach.

You feel more tired and lack energy.

You have a dry or moist hacking cough.

You experience dizziness.

You feel uneasy; you know something is not right.

It is harder for you to breathe when lying down; you need to sleep sitting up in a
chair.

If any of the above symptoms is severe or getting worse, call 911 or go to your
hospital’s emergency room.
Go to the emergency room or call 911 if you have any of the following:

Difficulty breathing; unrelieved shortness of breath while sitting still.

Chest pain.

Confusion or inability to think clearly.
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Next Step In Care Guides and Checklists
http://www.nextstepincare.org
ADMISSION
HIPAA: Questions and Answers for
Family Caregivers
Your Family Member’s Personal Health
Record
Medication Management Form
A Family Caregiver’s Guide to Advance
Directives
PLANNING FOR DISCHARGE
The Next Step in Care: What Do I Need as
a Family Caregiver?
Hospital-to-Home Discharge Guide
DISCHARGE
Family Caregivers’ Guide to
Medication Management
Going Home: What You Need to Know
NEXT STEPS
A Guide to the ER
When the Next Step Is Home Care: A
Family Caregiver’s Guide
When the Next Step Is Rehab: A
Family Caregiver’s Guide
Medicare Beneficiary Feedback Following IPRO
Care Transitions Outreach Sessions
After attending this session I now feel more prepared to….
Source: IPRO Medicare Beneficiary Outreach Program Evaluations
Medicare Beneficiary Feedback on IPRO Care
Transitions Outreach Sessions
I am a retired public health nurse that practiced before the times of Medicare and Medicaid. I think the
guidance you shared here with us today on how to navigate the health care system and take charge of
managing our health information has been very helpful. It is not our way to ask questions of the people who
provide us health care…we often feel we do not have the right and quite often when we do our questions
and concerns go unanswered. Thank you for giving us permission to become empowered!
After participating in this session I am now aware of today’s health care environmental routines/personnel
and the fact that I need to be more aware of the details of my health care.
The information shared will be very helpful to organize my health information. I feel more comfortable
knowing it is okay to ask the health care team questions to enable me to become more involved in my
care.
Before today I never thought about involving my Pharmacist to answer questions and concerns I have
about my medications. Thank you for the suggestion!
I was so anxious in the hospital I did not even think about what I needed to plan for once I got home. This
information and my experience over the past year will help me plan ahead next time.
The information you provided regarding the Hospitalist role was very helpful. I had never heard about that
before and had no idea that my doctor I have gone to for the past 16 years may not even know I was in the
hospital to be involved in my care
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Our Destination……
Ten New Rules to Redesign & Improve Care
1. Care is based on continuous healing relationships
2. Care is customized according to patient needs and values
3. The patient is the source of control
4. Knowledge is shared and information flows freely
5. Decision making is evidence-based
6. Safety is a system property
7. Transparency is evident
8. Needs are anticipated
9. Waste is continuously decreased
10. Cooperation among clinicians is a priority
Source: Adapted from the Institute of Medicine, 2001
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For more information
Sara Butterfield, RN, BSN, CPHQ, CCM
518 426-3300 x104
[email protected]
http:caretransitions.ipro.org
CORPORATE HEADQUARTERS
1979 Marcus Avenue
Lake Success, NY 11042-1002
REGIONAL OFFICE
20 Corporate Woods Boulevard
Albany, NY 12211-2370
www.ipro.org
This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract
with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.
The contents do not necessarily reflect CMS policy. 10SOW-NY-AIM8-11-07