Transcript Slide 1

Transitions of Care
www.ntocc.org
What is “Transition of Care”
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The movement of patients from one health care
practitioner or setting to another as their condition
and care needs change
Occurs at multiple levels
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Within Settings
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Between Settings
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Primary care  Specialty care
ICU  Ward
Hospital  Sub-acute facility
Ambulatory clinic  Senior center
Hospital  Home
Across health states
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Curative care  Palliative care/Hospice
Personal residence  Assisted living
(c) Eric A. Coleman, MD, MPH
What is “Transitional Care?”
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A set of actions designed to ensure the coordination and
continuity of health care as patients transfer between
different locations or different levels of care within the same
location
Based on a comprehensive care plan and availability of welltrained practitioners that have current information about the
patient's goals, preferences, and clinical status.
Includes:
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Logistical arrangements
Education of the patient and family
Coordination among the health professionals involved in the transition
Coleman EA, Boult C, The American Geriatrics Society Health Care Systems Committee. J Am
Geriatr Soc 2003;51:556-7.
Ineffective Transitions
Lead to Poor Outcomes
Wrong treatment
 Delay in diagnosis
 Severe adverse events
 Patient complaints
 Increased healthcare costs
 Increased length of stay
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Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature Review
Report. March 2005. Available www.safetyandquality.org/internet/safety/publishing.nsf/Content/
AA1369AD4AC5FC2ACA2571BF0081CD95/$File/clinhovrlitrev.pdf
Problems That Illustrate
Inadequacies of Care Transitions
Medication errors
 Increased health care utilization
 Inefficient/duplicative care
 Inadequate patient/caregiver preparation
 Inadequate follow-up care
 Dissatisfaction
 Litigation/Bad publicity
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(c) Eric A. Coleman, MD, MPH
Barriers to Improving
Transitions of Care
Barriers to Care Coordination
System level barriers
 Practitioner level barriers
 Patient level barriers
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(c) Eric A. Coleman, MD, MPH
System Level Barriers
(c) Eric A. Coleman, MD, MPH
Practitioner Level Barriers
Practitioners often have not practiced in
settings where they transfer patients
 Sending practitioners may not
communicate critical information to
receiving practitioners
 Practitioners may not know the patient
and his or her preferences for care
 Practitioners have no accountability
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(c) Eric A. Coleman, MD, MPH
Patient Level Barriers
Patients assume that someone is in
charge of coordinating care
 Patients (and caregivers) are often the
only common thread weaving between
care sites
 Yet they navigate the system with few
tools or training to manage in this role
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(c) Eric A. Coleman, MD, MPH
AGS Position Statement
Position 1:
Clinical professionals must prepare patients
and their caregivers to receive care in the
next setting and actively involve them in
decisions related to the formulation and
execution of the transitional care plan
Coleman EA, Boult C, The American Geriatrics Society Health Care Systems Committee. J Am
Geriatr Soc 2003;51:556-7.
(c) Eric A. Coleman, MD, MPH
AGS Position Statement
Position 2:
Bidirectional communication between
clinical professionals is essential to
ensuring high quality transition care
Position 3:
Develop policies that promote high quality
transitional care
Coleman EA, Boult C, The American Geriatrics Society Health Care Systems Committee. J Am
Geriatr Soc 2003;51:556-7.
(c) Eric A. Coleman, MD, MPH
AGS Position Statement
Position 4:
Education in transitional care should be
provided to all health professionals involved
in the transfer of patients across settings
Position 5:
Research should be conducted to improve the
process of transitional care
Coleman EA, Boult C, The American Geriatrics Society Health Care Systems Committee. J Am
Geriatr Soc 2003;51:556-7.
(c) Eric A. Coleman, MD, MPH
Expectations for Both
Sending and Receiving Teams
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Shift from the concept of “discharge” to “transfer
with continuous management”
Begin transfer planning upon or before
admission
Incorporate patient/caregivers’ preferences into
plan
Identify a patient’s social support and function
(how will this patient care for herself after
transfer?)
Collaborate with practitioners across settings to
formulate and execute a common care plan.
(c) Eric A. Coleman, MD, MPH
Expectations for the
Sending Team
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The patient is stable for transfer
The patient and caregiver understand the
purpose of the transfer
The patient and family understand their
coverage
The receiving institution is capable and
prepared
The care plan, orders, and a clinical summary
precede the patient’s arrival
The patient has a timely follow-up appointment
(c) Eric A. Coleman, MD, MPH
Expectations for the
Receiving Team
Review the transfer forms, clinical
summary, and orders prior to or upon the
patient’s arrival.
 Incorporate the patient/caregiver’s goals
and preferences into the care plan.
 Clarify discrepancies regarding the care
plan, the patient’s status, or the patient’s
medications
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(c) Eric A. Coleman, MD, MPH
What is the National Transitions of
Care Coalition?
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The National Transitions of Care Coalition
was formed to bring together stakeholders
from various care settings to address
improving care coordination and
communication when patients, especially
older adults, leave one health care setting
and move to another.
Goals
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Identify issues and barriers to transitions across the
continuum of care
Evaluate appropriate referral criteria between levels of
care
Assess available technology, evidence based guidelines,
medication reconciliation, and adherence gaps
Establish disease state priorities for coalition focus, e.g.,
venous thromboembolism, diabetes/glycemic control,
acute coronary syndrome, and stroke
Develop tools, guidelines, and pathways for
communication between patients, providers, and payers
Develop awareness and resource implementation plans
for coalition members to disseminate
Advisory Task Force
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Academy of Managed Care Pharmacy
American Association of Homes and
Services for the Aging
American College of Healthcare
Executives
American Geriatrics Society
American Medical Directors Association
American Medical Group Association
American Society of Consultant
Pharmacists
American Society of Health-System
Pharmacists
American Society on Aging
AXA Assistance, USA
Case Management Society of America
Consumers Advancing Patient Safety
Health Services Advisory Group
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Institute of Healthcare Improvement
Joint Commission Intl Center for Patient
Safety
The Joint Commission
Liptiz Center for Integrated Health Care
Mid-America Coalition on Health Care
National Association of Directors of Nursing
Administration – Long Term Care
National Association of Social Workers
National Business Coalition on Health
National Quality Forum
National Case Management Network
Predictive Health, LLC
Society of Hospital Medicine
The Joint Commission Disease-specific
Care Certification
URAC
Raise NTOCC Awareness
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Information and tools available by stakeholder
Consumer
Professional
Policy Maker
Media
Working Groups
Education &
Awareness
Tools &
Resources
NTOCC
Metrics &
Outcomes
Policy &
Advocacy
Education & Awareness
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Working to address awareness and general
knowledge about the problems associated
with transitions of care and provide the
necessary information to various
stakeholders – patients, caregivers, health
care professionals, and government officials.
Policy & Advocacy
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Assessing ways to improve care through
enhanced communication tools,
collaborative partnership and evaluating the
possibility of enhanced reimbursement for
transitional care support and technical
medical information shared between care
settings.
Tools & Resources
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Identifying practical tools and resources
that can be used by health care
professionals, care givers and patients to
improve communication in a consistent
manner between care settings and reduce
risk associated with care transitions.
Metrics & Outcomes
To develop and adopt a framework for
measuring transitional care.
 To recommend metrics or standards to
demonstrate the impact of interventions
on reducing risk associated with
transitional care
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Case Studies for
Discussion
Case 1
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During a patient’s monthly follow-up
appointment with the cardiologist, he informed
the doctor that he was having trouble with one
of his medications. The doctor asked which one.
The patient said “The patch, the nurse told me
to put on a new one every day and now I’m
running out of places to put it!” The physician
had him undress and discovered that the man
had over a two dozen patches on his body.
Case 2
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An older man with atrial fibrillation who takes
warfarin for stroke prophylaxis was hospitalized
for pneumonia. His dose of warfarin was
adjusted during the hospital stay and was not
reduced to his usual dose prior to discharge.
The new dose turned out to be double his usual
dose and within two days he was rehospitalized
with uncontrollable bleeding.