Transcript CT Patient Discharged

Care Transitions:
A Demonstration Project
Tim Young, LCSW
Piedmont Hospital
Sixty Plus Older Adult Services
The Journey
 2006 - Eric Coleman article
 Summer 2007 – Geriatric Work Session
 Fall 2007 - Awarded an 18 Month CMS/HHS
demonstration grant (July ’08 through December ’09)
 January 2008 - Hosted Transitions training with Eric
Coleman
 July 2008 - Transitions Demonstration Project launched
 Fall 2008 – Project BOOST Pilot Project Launched
Strategic Work Team
 Areas of Opportunity Identified

Discharge Planning

End of Life Issues

Focus on Geriatric Care in ED

Medication Reconciliation

Communication Flow
Eric Coleman’s Model
 4 Pillars

Personal Health Record

Medication Reconciliation

Red Flags

Medical Follow up
Desire to Expand Transitions
Concept
 Challenge

Selling community partners on concept
 Barriers

Overworked staff

Resistance to taking on more work
Transitions Work Team
 Hospitalists Services
 Sixty Plus Older Adult Services
 Patient Care Coordination
 Nursing Services
 Emergency Department
 Pharmacy
 NICHE (Nurses Improving Care for Hospitalized
Elderly)
 Palliative Care
 Cardiovascular Services
 Visiting Nurse Health Systems (VNHS)
Piedmont’s Transitions Model
The Must Haves
 Sustainability
 Communication and Collaboration are key
 Multidisciplinary teams who are accountable, will take
risks and will not accept status quo
 Strong executive staff and physician advocates
 Ability to initially adapt project to support the existing
culture, processes and work flow of your organization
Lessons Learned
 Realistic timelines
 Expectations
 Data and outcomes
 Process improvement and/or research
 Utilize “teachback” technique with patients to
gauge their understanding of discharge plan
Teach Back
 Using simple language
 Ask patient/family to repeat her
understanding of concept
 Identify and correct misunderstandings
 Ask patient/family to demonstrate
understanding again
 Repeat above until convinced of
comprehension or inability to do so
Phase I – Exploring the Process
 Hospital-based transitions coach

Provide Personal Health Record

Begin educational process
 Community-based transitions coach

Review medications

Continue educational process
Phase I - Success
 Discovered barriers
 Home Health Companies
 Difficult to train multiple “teams”
 Patients often not receiving skilled nursing
 Medication Reconciliation

Belief was that medications were “100%
reconciled”

Reviewed internal and external
Partnership with VNHS
Why hospital and home health agency
partnership?
 We are truly in this together!
 No duplication of effort/contact – a natural fit
 On-going contact with patient/family/physician
 Processes in place to “catch” bouncebacks and
clinically determine reason for readmission – swat
team approach
 Improve processes when problem identified
Phase II – Implementation
 Hospital Discharge Planners

Limited to 4 units to reduce staff (2 BOOST)

Limited to Medicare primary patients

3 Counties most served by hospital

Appropriate for home health services
 Home Health Provider - VNHS

Committed 2 SW’ers as coaches
Phase II - Barriers
 Under utilization of home health
 Medication reconciliation

Discrepancies noted by pharmacy
Phase II - Success
 Increased education about home health

“homebound status”

Order for “RN to eval and treat”
 Identified more psychosocial issues affecting
ability to manage post discharge
 Higher visibility of SW’ers for home health
has led to increase in referrals
Criteria
 Medicare as primary coverage
 Age 70 or over
 Inpatient stay on 6 Center, 6 North, 6 South or 5
Center
 Patient is identified for project by IMS Team, Patient
Care Coordinator – physician orders home health
 Meets criteria for home health
 Lives within designated geographic area (3 counties)
 Patient or POA choose to participate and signs
consent
Project Goals
 Reduce 30 day readmission rate
 Reduce ED visits
 Increase patient/family satisfaction
 Develop/implement a sustainable model
 Address process improvement opportunities
 Build broad base of community partners
Align with the Piedmont’s leadership’s strategic plan
(cost reduction, quality, etc.)
For BOOST patients,
IMS indicates CT
appropriate.
PCTC reviews
patient list for nonBOOST CT
appropriate (70 +,
on designated
units, Medicare
primary, lives at
home)
PCC checks
Quest for CT
orders
PCTC
consents
patient to CT
program with
VNHS as HH
provider;
PCTC gives
patient CT
portfolio
PCC Logistics receives HH
referral from physician and
writes orders; VCTL meets
with CT patient to answer
questions, explain HH
program, verify payment
source
CT Patient
HH Non-admit; VNHS to notify
PCTC via email of non-admit;
SOC clinician to notify PCP of
non-admit
Legend
CT Patient under Piedmont Care
CT Patient under VNHS Care
CT Patient
refuses Coach
Visit; Coach
notifies VTM;
VTM to notify
PCTC of coach
refuse by email
CT Patient HH Non-Admit
CT Patient BB High Risk
BOOST - Piedmont's better outcomes for older
adults through safe transitions program
BB - Bounceback
CNS - Clinical Nurse Specialist
If patient did not
CT - Care Transitions
attend MD
CTBS - Care transitions bounceback survey
appointment, notify
CVS - Coach visit survey
HHTM
ED - Emergency Department
GCM - Geriatric Case Manager
HH - Home Health
IMS - Internal Medicine Service
IP - In-Patient
OBV - Observation
PCC - Patient Care Coordinator
PCP - Primary Care Physician
PCTC - Piedmont CT Coordinator
PDFC - Post-discharge follow-up call
CT HH Discharge; VNHS notify
POC - Plan of care
PCTC of any unmet patient needs
SOC - Start of care
VCTL - VNHS CT Liaison
VTM - VNHS Team Manager
BB clinical review by CNS. Huddle
meeting BB case review; identify
as avoidable or unavoidable. If
avoidable, interventions
identified with plan.
CT Patient
Discharged
VNHS Intake Coordinator sends
email to VNHS CT team; HH SOC
visit scheduled within 24 hours
PCTC identifies BB based on
daily report and notifies BB
team via email.
VNHS RN/PT completes
SOC visit within 48 hours
Piedmont BB
(ED/OBV or IP)
within 30 days/90
days
Coach Visit within 48
hours of SOC visit.: 4
pillars; completes CVS;
faxes CVS to PCTC;
refers to Sixty Plus GCM
for complex cases
PDFC within 48 hours.
For BOOST CT patients,
IMS nurse calls.
For non-BOOST CT
patients,
PCTC calls.
CT HH
Resumption
of Care
CT BB VNHS
PDFC
Completes
CTBS
VNHS follow-up call to
confirm patient attended MD
appointment at 14 days postdischarge
Continue POC
HH Clinical Visits 60
day services
CT HH 60-day recert
For BOOST patients,
IMS indicates CT
appropriate.
PCTC reviews patient
list for non-BOOST CT
appropriate (70 +, on
designated units,
Medicare primary,
lives at home)
PCC checks
Quest for
CT orders
PCTC
consents
patient to
CT program
with VNHS
as HH
provider;
PCTC gives
patient CT
portfolio
PCC Logistics receives
HH referral from
physician and writes
orders; VCTL meets
with CT patient to
answer questions,
explain HH program,
verify payment source
CT Patient
Discharged
Care Transitions in Hospital
 Identify as appropriate
 Screen for cognition and depression
 Educate on intervention and obtain signed
consent
 Home health liaison provides additional
education
 Follow up appointments scheduled prior to
discharge
CT Patient
Discharged
VNHS Intake Coordinator sends email
to VNHS CT team; HH SOC visit
scheduled within 24 hours
CT Patient
HH Non-admit; VNHS to notify PCTC
via email of non-admit; SOC clinician
to notify PCP of non-admit
CT Patient
refuses Coach Visit;
Coach notifies VTM;
VTM to notify PCTC of
coach refuse by email
VNHS RN/PT completes SOC
visit within 48 hours
Coach Visit within 48 hours of
SOC visit.: 4 pillars; completes
CVS; faxes CVS to PCTC;
refers to Sixty Plus GCM for
complex cases
PDFC within 48 hours.
For BOOST CT patients,
IMS nurse calls.
For non-BOOST CT patients,
PCTC calls.
If patient did not attend MD
appointment, notify HHTM
VNHS follow-up call to confirm
patient attended MD appointment
at 14 days post-discharge
Continue POC
HH Clinical Visits 60 day
services
CT HH Discharge; VNHS notify PCTC of
any unmet patient needs
CT HH 60-day recert
Care Transitions in Home Health
 Start of care (SOC) within 48 hours
 Hospital notified of non-admissions
 Coach visit made by social worker within 48
hours of SOC
 For on-going psychosocial issues, referral
may be made for GCM
 Confirm that patient kept the follow up
appointment with MD
BB clinical review by CNS. Huddle meeting
BB case review; identify as avoidable or
unavoidable. If avoidable, interventions
identified with plan.
PCTC identifies BB based on daily
report and notifies BB team via email.
Piedmont BB
(ED/OBV or IP)
within 30 days/90 days
CT HH
Resumption of
Care
CT BB VNHS
PDFC
Completes CTBS
Bounceback Protocol
 Receive notice of bounceback within 60 days
 Alert team members of reencounter
 Notify discharge planner of need for
resumption of home health orders
 Meet weekly to discuss these cases
 Implement strategies to address avoidable
reencounters
Case Study - Mrs. H
 88-year-old female
 Admitted with pancreatitis, s/p
cholecystectomy, and a pseudocyst
 History of HTN, DM, afib, upper GI bleed,
pulmonary HTN, CHF, breast cancer, and UTI
 Widowed, lives with daughter
 Ambulatory with cane/walker
 Dependent in ADL’s (bathing, meals,
transportation, meds)
Hospitalizations
 12/22 through 12/24

4th IP stay in 2 months

Seen in ED

Started on TPN at discharge with home health
 2/7 through 2/18

Bounceback discussion

Discharged on home hospice
Care Transitions Group Differences Research Design
Patient Universe – 70 +, Medicare primary insurance, in-patient or observation, any presenting
diagnosis, possible discharge to home (HH orders), SNF or assisted living
Patient Sample – 70 +, Medicare primary insurance,
in-patient or observation, discharged to home
Treatment
Group 1
Demographics – 70 + and Medicare
primary insurance
Non-BOOST in-patient or OBV
Discharged to home
Receives HH via VNHS (coaching visit,
clinical, possible telemonitoring); PCTC
follow-up call
Treatment
Group 2
Demographics – 70 + and Medicare
primary insurance
BOOST in-patient or OBV
Discharged to home
Receives HH via VNHS (coaching visit,
clinical, possible telemonitoring);
BOOST follow-up phone call
Control
Group 3
Demographics – 70 + and Medicare
primary insurance
Either BOOST or non-BOOST inpatient or OBV
Discharged to home
May/may not receive HH; may /may not
receive BOOST follow-up phone call
Non-CT patients
Group Differences Measurable Outcomes
1. Group differences in 30-day In-Patient Readmit Rates
2. Group differences in 30-day ED/obv Rates
3. Group Differences in Avoidable 30-day Piedmont Reencounter (ED, OBV, IP) Rates
4. Group differences in Average Length of Stay during readmit
5. Group differences in Average Number of Days from Discharge
to Readmit
6. Group differences in Average Number of Days from Discharge
to Next ED Visit
7. Group differences in HH admit/HH non-admit patients 30-day
Piedmont Re-encounter Rates (ED, OBV, IP)
Age Ranges of Patients in CT Program
120%
100%
90 +
80%
80 - 89
60%
90 +
80 - 89
70 - 79
40%
20%
0%
70 - 79
CT Average Age = 80 Years
Gender of Patients in CT Program
43%
Male
Female
57%
Total CT Consented Patients by BOOST Status
39%
Non-BOOST
BOOST
61%
CT Diagnosis Categories
Evaluated
 Cardiac and CHF
 Syncope
 COPD
 Clotting (DVT,PE)
 Pneumonia
 Cellulitis
 Renal Failure
 Altered Mental State
 Procedure
 Infection
 Stroke (CVA)
 GI Issues
 Urinary Track Infection
 Other
CT Patients Chief Complaints Upon Admission
Cardiac/CHF
Other
Pneumonia
COPD
Infection
0
5
10
15
20
Medicare 30-Day Readmit Rates
25%
20%
15%
10%
18%
17%
13%
5%
0%
National (65+)
Piedmont (65+)
CT Consented (70+ &
Homebound
Care Transition Patients with Home Health Care
100%
100%
72%
70%
PT with HH
PT without HH
Total
28%
30%
Total Care Transitions PTs
Bounceback PTs
Patient Reasons for Bouncebacks
Self-management Issues
60%
54%
50%
Inadequate
Support System
39%
40%
Medication
Issues
31%
30%
20%
25%
Unaddressed
Co-morbid
Conditions
18%
11%
10%
7%
8%
Procedure
8%
0%
0%
Unavoidable
Avoidable
Transitions in the ED
 Transitions Care Coordinator in ED
 Priority Patients:

Those already enrolled in Transitions

Frequent flyers

Previously seen by Sixty Plus

Identified high risk

Dementia

Limited social support
Transitions in the ED - Process
 Receive notification of repeat encounter
 Screen for cognition and depression
 Ask if patient talked with health care provider
before coming to the ED
 Begin education on Care Transitions pillars
from the ED
 Follow up post discharge
Transitions in the ED - Success
 Developed electronic tool to highlight repeat
encounters
 Increased screening for cognitive issues
and/or depression
 Started education about discharge planning
while in the ED
 Increased referrals to home health services
from the ED