Transcript Transitions of Care - PCMH e

Transitions of Care
Fort Collins Family Medicine
Residency
Fort Collins, CO
Andrea Hooley, RN
Aaron Jarrett, MD, PGY-2
Jenn Nolte, RN
Bonnie Walser, BS RT(R)
Context
 6-6-6 Community-based Program
 Medicine service census 5-20/day
 24/7 coverage
 Dedicated patient population from Family Medicine
Center and Salud
Pilot project to find our readmission
rate:
• FMC 30 day re-admissions
– 4 weeks (06/10,
09/10, 12/10, 03/11)
•
•
•
•
16%
24%
26%
15%
(5/31)
(7/29)
(6/23)
(5/33)
Comp of Adm
Med
F/u labs
Worsening of
Dx
Initial Data
Brainstorming Ideas from 2012
 Discharge Planners **
 Medication reconciliation processes **
 Enhanced patient education at discharge
 Discharge Checklists
 Telephone follow-up **
 Transition Coaches
 Home Case Management program **
 Home visit programs**
 Everyone has an F/U appointment before they discharge
**= hospital doing at some level
Main goals of TOC program
1. Reduce readmission rate of FMC service line
2. Improve patient satisfaction, especially in
regards to communication
3. Streamline access to follow-up/primary care
4. Improve outcomes by addressing context of
health outcomes
Who they are and what they doTransitional Care Nurse Case
Managers
 Talk to each patient for risk assessment
 Participate in rounds
 Educate patients
 Educate providers
 Schedule follow up appointments
 Follow up phone calls
Transition nurses don’t…
 arrange nursing home placement or home
health care
 review d/c paperwork with the patient
 go on home visits
FMC TRANSITIONAL CARE RISK
ASSESSMENT TOOL
Socioeconomic Challenges
Interventions:
- Provide information about community resources for additional patient
support (food stamps, LEAP, housing, transportation, medication
assistance)
- Coordinate with Discharge Planning for transportation or prescription
financial assistance.
Inadequate Patient Support
(absence of caregiver to assist
with discharge and home care)
Interventions:
- Follow-up phone call at 72 hours to assess condition, adherence and
complications
- Follow-up appointment with aftercare medical provider within 7 days
- Involvement of home care providers of services with clear
communications of discharge plan to those providers
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FMC TRANSITIONAL CARE RISK
ASSESSMENT TOOL
Problem Medications
(anticoagulants, insulin, oral hypoglycemic agents, aspirin &
clopidogrel dual
therapy, digoxin, narcotics, diuretics)
Interventions:
- Medication specific education provided to patient/caregiver
- Monitoring plan communicated to patient and aftercare
providers, where relevant (e.g. warfarin, digoxin and insulin)
- Review potential adverse effects (red flags) and action steps with
patient/caregiver
Improving Access
 Transition RNs directly schedule hospital
follow-ups
 Ideally with hospital provider
 Follow-up appointment attendance has
improved
Readmission Data
Readmission Data
Inpatient Satisfaction Scores
Case: A difficult situation
32 year old Mexican undocumented immigrant, previously
healthy…
10/13 – Anasarca, focal segmental glomerulosclerosis
11/13 - Strongyloides superinfection, respiratory failure
1/14 – Anasarca, HTN
2/14 – DVT and PE
3/14 - Pneumonia, septic shock
4/14 – Anasarca, pain
5/14 – Pneumonia
6/14 – Anasarca, pain
Provider perspectives
From an intern:
“Not only do the patients get more access to posthospital resources (because somebody has the time to
really figure out what those resources can do for the
patient), I have more freedom to BE A DOCTOR because I
have more time to focus on medicine!”
From an upper level
“I don’t understand how we did this without them
before—seriously, we’re still swamped with stuff, and they
have more than a full time job each…”
Staff perspectives
 “It is so helpful for Behavioral health to have their
communication come directly to our department.”
SW Staff
 Front Desk
 Lab
Next Steps
 Our patient satisfaction scores are increasing.
 We will continue to monitor readmission rates.
 We hope that patient safety is improved.
 Expansion to Peds/OB services?
 Publication on Transitions of Care
Questions?
Aaron Jarrett, MD
[email protected]
Andrea Hooley, RN, BSN
[email protected]
Jennifer Nolte, RN, BSN
[email protected]