Transcript ICD-10 Implementation in a 5010 Environment

CMS National Conference
on Care Transitions
December 3, 2010
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Reducing Re-hospitalization:
Coaching Empowers Patients to be the
Solution and Improves Health Outcomes
Laurie Robinson, RN, CPE, CPUR
Director of Quality
eQHealth Solutions
(225) 248-7035
[email protected]
Objectives
• To be able to identify barriers to
smooth transitions.
• To understand the role of the coach and
the role of the patient in the coaching
relationship.
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Our Experiences
• CMS project: Baton Rouge Community
– Collaboration with hospitals.
– Process re-design
– Partnering with patients and caregivers
– Patient tools
– Tracking success
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Drivers of Re-hospitalization
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Fragmentation of patient information.
Inappropriate end of life care.
Medication issues.
At-risk patients not properly identified at
discharge.
Lack of post-discharge follow-up.
Lack of disease-specific protocols.
Patient adherence to the plan of care.
Patient knowledge deficit.
Lack of community awareness.
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Coaching Intervention: Strategies
to Address Drivers
• Fragmentation of patient information.
– Portable Health Record.
• Medication issues.
– Medication reconciliation.
• Lack of post-discharge follow-up.
– Post discharge follow up appointment.
• Patient adherence with the plan of care.
– Written plan of care.
• Patient knowledge deficit.
– Patient education tools.
What is Transition
Coaching?
• Empowering and encouraging the patient on self care.
• The Patient and/or the Care Givers are the “Doers”.
• The coach reinforces the discharge plan of care as
determined by the treatment team.
• A series of hospital visits and post discharge
telephonic follow ups that focus on the discharge plan of
care.
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The eQHealth Coaching Model
• Hospital medicine or case manager refers the
patient to the program.
• The coach visits the patient in the hospital
• The coach completes post discharge telephonic
follow ups.
• Each interaction with the patient focuses on the
post discharge plan of care, medications,
post discharge follow up, warning signals,
Portable Health Record and a patient
centered goal.
• Patient tools are used to reinforce teaching.
Who is Eligible for the Program?
• Medicare fee for service beneficiaries.
• Beneficiaries that reside in the designated zip
codes.
• One of the following diagnosis
– AMI
– COPD
– CHF
– Pneumonia
• Be able to engage in or have a caregiver that
assists with self management.
The Coaching Process
• Coaching interactions occur with the patients at
scheduled intervals:
– Hospital visits (begin day 2)
– Telephonic post discharge
• Day 2
• Day 7
• Day 14
• Day 21
• Day 30
Coaching Process cont.
• At each interaction the coach focuses on
the following:
– Post discharge plan of care.
– Medications.
– Post discharge follow up.
– Warning signals.
– Portable Health Record.
– Patient centered goal.
Results
March 2009 – October 31, 2010
Community baseline readmission rate 19.6
Hospital
Referrals
Coached
Readmission
30 day readmission
rate
Hospital A
739
107
8
7%
Hospital B
345
81
5
7%
Hospital C
187
47
9
19%
Hospital D
52
10
4
40%
Hospital E
45
5
2
40%
Total
1368
250
28
11.2
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