Transcript Day 2_230-330_Houy P.. - Massachusetts Coalition for the

Patient-Centered Medical
Homes: Managing Patient
Transitions of Care
Marge Houy
Senior Consultant
Bailit Health Purchasing, LLC
1
Objectives
■ Provide background information about
Massachusetts’ PCMH Initiative
■ Provide examples of how practices are
developing the infrastructure to successfully
manage transitions of care
■ Provide an opportunity to share experiences and
learn among themselves
2
Background
■ 49 adult and pediatric practice sites participating
in EOHHS-sponsored PCMH Initiative
■ Undergoing intensive 2-year training to:
 Implement population management approach to
providing evidence-based care
 Create team-based care with each team member
performing “at the top of their license”
 Integrate primary care and behavioral health services
 Partnership with patient in managing health conditions
 Provide patient-centered practice – enhanced access,
cultural sensitivity, etc.
3
Key Measures of
Success
Practices have opportunity to share savings
generated from reduced inpatient days and ED
visits while meeting key quality benchmarks
4
Transitions of Care
Infrastructure/Processes
■ Identify nursing resources to function as practice-based
care manager
■ Key functions
– Work with practice teams to stratify patients and identify high risk
patients: necessarily includes patients with ED or IP admission
– Create high risk patient registry; outreach and engage patients
– Contact discharged patients within 2 days of discharge and bring
in for f/u visit, as appropriate
– Contact patients with chronic condition-related ED visit within 2
days and bring in for f/u visit as appropriate
– Work with patients to promote self-management skills
– Function as member of patient’s care team
5
Example and Discussion
■ Lee Family Practice
6
Key Changes to Achieve an
Ideal Transition from
Hospital (or SNF) to Home
I.
Perform Enhanced Assessment for Post- Hospital
Needs
II.
Provide Effective Teaching and Enhanced Learning
III. Conduct Real-Time Patient and Family-Centered
Handoff Communication
IV. Ensure Post-Hospital Care Follow-Up:
Completing the Transition into Care
Settings within the Community
Office Practices
• Provide timely
access
• Reconcile meds and
plan of care
Home Care
• Reconcile meds
• Reinforce self-care
plan
Skilled Nursing
Facilities
• Assure staff are
capable to care for
patient’s needs
• Reconcile meds and
plan of care
• Communicate as
• Coordinate care
indicated with
with other community primary care provider • Provide timely
clinicians
and specialists
consultation when
patient’s condition
changes
Aligning PCMHI and
STAAR
STAAR Program
PCMHI Initiative
Perform an Enhanced
Assessment of Post Hospital
Needs
Empanelment
■
Involve the patient, family, caregiver(s)
and community providers(s) as full
partners in completing a needs
assessment of the patient’s homegoing needs.
■
Reconcile medications upon admission
■
Identify the patient’s initial risk of
readmission
■
Create a customized plan of care and
discharge plan based on the
assessment
■
Primary care practitioner takes
responsible for knowing his/her panel
of patients and managing care across
the care continuum
Aligning PCMHI and
STAAR
STAAR Program
PCMHI Initiative
Provide Effective Teaching and
Facilitate Enhanced
Learning
Patient-Centered Care
■
■
■
■
Identify and involve all learners on
admission
Customize the patient education process for
patients, family caregivers, and providers in
community settings
Redesign patient education process and
patient teaching print materials
Use Teach Back daily in the hospital and
during follow-up calls to assess the patient’s
and family caregivers’ understanding of
discharge instructions and ability to perform
self-care
■
Make sure the patient understands
and agrees to care
Team-based Care
■
Maximize provider-term
communication
■
Tracking of care transitions
Aligning PCMHI and
STAAR
STAAR Program
PCMHI Initiative
Provide Real-Time Handover
Communications
Care Coordination
■
■
■
■
Give and review with patient and
family members a patient-friendly posthospital care plan which includes a
clear medication list.
Two-way communications with other
providers
■
Tracking of care transitions
■
Transitional care within 48 hours
Provide customized, real-time critical
information to next clinical care
provider(s).,
Enhanced Access
For high-risk patients, a clinician calls
the individual(s) listed as the patient’s
next clinical care provider(s) to discuss
the patient’s status and plan of care.
■
Planned care at every visit
Aligning PCMHI and
STAAR
STAAR Program
PCMHI Initiative
Ensure Post-Hospital Care
Follow-up
Care Coordination
■
Reassess the patient’s medical and
social risk for readmission
■
Prior to discharge, schedule timely
follow-up care and initiate clinical and
social services as indicated from the
assessment of post-hospital needs.
■
Two-way communications with other
providers
■
Tracking of care transitions
How-to Guide:
Completing the Transition to
the Clinical Office Practice
Getting Started
■
Step 1. Form a Team
■
Step 2. The Team Identifies
Opportunities for Improvement
■
Step 3. Develop an Aim Statement
Getting Started
■ Step 1. Form a Team
Consider choosing team members from the
following:
• Patients and family members
• Physicians
• Nurse practitioners
• Nurses
• Office managers
• Schedulers
Getting Started
■ Step 2. The Team Identifies Opportunities for
Improvement
– Diagnostic review of the last 5 patients from
your practice that were rehospitalized within
30 days of discharge
– Review patient satisfaction data regarding
communication and preparations for self care
Getting Started
■ Step 3. Develop an Aim Statement
– Analyze data
– Select target patient population
– Write an aim statement
Clinical Office Practice Key Changes
1. Provide Timely Access to Care Following a
Hospitalization
A. Review on a daily basis information received
from the hospital about admissions and
anticipated discharges.
B. Provide appropriate level and type of followup for high risk, medium risk and low risk
discharged patients
Clinical Office Practice Key Changes
2. Prior to the Visit: Prepare Patient and
Clinical Team
A. Review discharge summary
B. Clarify outstanding questions with sending
physician
C. Make reminder call to patient or family
member
D. Coordinate care with home health care
nurses and case managers if appropriate
Clinical Office Practice Key Changes
3. During the Visit: Assess Patient and
Initiate New Care Plan or Revise
Existing Plan
A.
B.
C.
D.
E.
F.
Ask the patient about his/her goals for visit; what factors
contributed to hospital admission or ED visit; and what
medications he/she is taking and on what schedule
Perform medication reconciliation with attention to the prehospital regimen
Determine need to adjust medications or dosages, follow-up
have on test results, do monitoring or testing; discuss advance
directives; discuss specific future treatments
Instruct patient in self-management; have patient repeat back
Explain warning signs and how to respond; have patient repeat
back
Provide instructions for seeking emergency and non-emergency
after-hours care
Clinical Office Practice Key Changes
4. At the Conclusion of the Visit: Communicate
and Coordinate on-going Care plan
A. Print reconciled, dated, medication list and
provide a copy to the patient, family
caregiver, home health care nurse, and case
manager (if appropriate.)
B. Communicate revisions to the care plan to
patient, family caregiver, home health care
nurse, and case manager (if appropriate.)
C. Ensure that the next appointment is made,
as appropriate
Model for Improvement
Use Model for Improvement to test changes
– Aims
– Measures
– Changes - Plan-Do-Study-Act
Implement
Spread