Transcript Collaboration of Care Journey

Care Transitions in COPD
and beyond
Laura Cole RN, MSN,CPHQ
Objectives
• Why readmissions and care coordination are
important
• Overview of care transitions
• Strategies to reduce readmissions in the COPD
populations
• Discussion of current practices in the community
• Identify opportunities to continue to drive changes
Readmission Rates by Diagnosis
Collaboration for Care Journey
Causes of readmissions
Low Literacy
Causes of readmissions
Low Literacy
No family support
Causes of readmissions
Low literacy
Access to Primary Care
No family support
Causes of readmissions
Low literacy
Access to Primary Care
No family support
Social Determinants
Causes of readmissions
Low literacy
Access to Primary Care
Provider Communication
No family support
Social Determinants
Causes of readmissions
Low literacy
Access to Primary Care
Provider Communication
No family support
Social Determinants
Fragmentation
Causes of readmissions
Low literacy
Access to Primary Care
Provider Communication
Provider/ Patient Bias
No family support
Social Determinants
Fragmentation
Causes of readmissions
Low literacy
Access to Primary Care
Provider Communication
Provider/ Patient Bias
No family support
Social Determinants
Fragmentation
Lack of standardization
Developing a plan for your
care transitions efforts
1. Do you have every one at the table?
2. What is our data telling us?
3. What are quick wins versus long term projects?
Resource:
AHRQ's Hospital Guide to Reducing
Medicaid Readmissions
Design interventions
AHRQ guide for Medicaid Readmissions
Data Drives Change
Where are the bright spots in
your health system
What is important to your organization?
What unit is doing well? What are they doing
differently?
What programs can you build off? Access Health,
CHF, Primary Care, Home Health
How are you connecting with other providers?
Understand the patients needs
The continuum of engagement framework
County Health Rankings
Connect with the community
What is a Community?
What is a Community?
Pain clinics
Complimentary
Medicine
providers
Patient support
groups/
Foundations
Housing Advocates/
homeless services
Urgent cares
Business
coalitions
AARP
Faith based
organizations
United Way
Office on Aging
Community
Health Workers
SC Thrive
Food banks
Home Care
EMS
FamilyCaregivers
Rehab
Hospitals
Emergency
Rooms
Hospice
Outpatient
Rehab
Pharmacy
Public Health
nurse
Agencies on
Aging
Medicaid
Agency
Skilled nursing
Correction
system
Specialist
Home Health
Aging and
disability
resource
centers
Community
Resources
DME
Trade Associations
Hospital
Free clinics
HOP contact
GED/ literacy
programs
Primary Care
Transportation
FQHC
Legal Aid
Electronic Medical
Records
Senior Centers
WellVista
Health Plans
Mental Health
DSS
Substance Abuse
Adult Daycare
Assisted Living
facilities/
Retirement Villages
PACE programs
Community
based social
workers
Universities/Technical
Schools
Low volume
Health Plans
Specific Strategies to reduce
readmissions in COPD
Cost of COPD
• 49 billion in direct and indirect cost
• Cost of a COPD patient is $6,000 higher than nonCOPD patient
• Average cost of ER visit: $647
• Average cost of Admission: $7242; $20,757;
$44,909
• Readmission:
• 13-14% of COPD patients had a 30 day readmission
• 41-49% were readmitted in 60 days
Managing your population
• Utilization
• Co-morbidities
• Physical activity reduces risk of readmission
• Social determinants
• Psychosocial
• Medications
• End of life
• Pulmonary rehabilitation/
Baker,Zou, Su (2013) Risk assessment of readmissions following initial COPD- related hospitalization
Project BOOST
Puhan,M, Scharplatz M, Troosters T,Steurer, J
Changing the way we think
Discussion
• How does understanding the whole person inform
your care?
• How do you actively collaborate with cross-setting
partners?
• How do you deliver proactive, persistent post
hospital care?
How SCHA can help
Building relationships
• Identifying internal gaps and silos
• Facilitating discussions with external partners
Data interpretation and process improvement
• Provide trended and benchmarked data
• Create actionable strategies and accountability
Education
• Provide tools and resources with best practices
• Provide educational events
Summary
• Changing from fee for service to integrated payment
system
• no outcome, no income
• Sustainability of successes
• Patient and family centered care
• Addressing disparities
• Navigation of the health system
• We, not me
• Navigate, advocate and support
• Don’t over medicalize
• View through a social/ behavioral lens