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Implementing Care Transition Strategies to
Improve Medication Management and
R d A t C H it li tiReduce Acute Care Hospitalizations
New England Home Care Conference and Trade ShowMay 31 & June 1, 2012
PresentersPresenters• Colleen Bayard PT, MPADirector of Regulatory and Clinical Affairs,Home Care Alliance of Massachusetts
• Jeanne Ryan, OTR, MA, CHCE, COS-CExecutive Director, VNA & Hospice of
Cooley Dickinson/Cross-Continuum Services
Board of Directors, Home Care Alliance of Massachusetts
VNA & Hospice of Cooley VNA & Hospice of Cooley DickinsonDickinson
• STAAR Initiative: STate Action on Avoidable Re-hospitalizations
• Hampshire County Cross ContinuumHampshire County Cross Continuum Team
• 3026 Application
• Coaching Networking Breakfast
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Home Care Alliance of Home Care Alliance of MassachusettsMassachusetts
• STAAR Initiative: STate Action on Avoidable Re-hospitalizations
• Opt-In Response team
• ASAP Coordinating Group
• Technical Assistance 3026
ObjectivesAt the end of this program the learner will:• 1. Identify 3-4 partners in transition process from one care
setting to the next.
• 2. Identify 2-3critical pieces of patient information necessary to insure seamless transitions between care settings.
• 3) State 2 – 3 of the challenges agencies face when promoting home care.
• 4)Identify 3 – 4 components of the standards that address transitions to and from home care.
International Perspective
• U.S. ranks last of 8 countries for access, coordination & safety in health care
• 54% of chronically ill did not get54% of chronically ill did not get recommended care, fill prescriptions or see a doctor
• 1/3 of U.S. patients experience poorly coordinated care
2008 Commonwealth Fund International Health Policy survey
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National Perspective
• 17.6% of Medicare beneficiaries are re-hospitalized within 30 days of discharge, accounting for $15 billion in spending
Estimates sho that 76% of these readmissions ma be• Estimates show that 76% of these readmissions may be preventable
• Of Medicare beneficiaries re-admitted within 30 days, 64% receive no post acute care between discharge and readmission
MedPAC: June 2007 Report to Congress: Promoting Greater Efficiency in Medicare
National Perspective-Home Health
• Nationally, 28% of home care patients are hospitalized unexpectedly
• Nearly 58% of acute care hospitalizations occur within the first three weeks of a home health admissionfirst three weeks of a home health admission
• 25% of ACH occur within seven days of home health admission
• 68% of ACH patients had been hospitalized within the two weeks prior to a home health admission
• 40% of hospitalizations are avoidable
State PerspectiveMassachusetts Readmission Rates
• “Massachusetts is not doing the best job in care transitions. We are 41st out of 50, in hospital readmissions and being 50 is being last. If we merely met the standards of Vermont which is number one in the country thatof Vermont, which is number one in the country, that would be 6000 fewer hospital readmissions yearly and would save $73 million per year just with Medicare alone. We need to spend more attention on Care Transitions; what gets attention gets done.”
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Contributing Factors to High Readmission Rate
Patients are more chronically ill, more frail, and have more complex care needs:
• Multiple diagnoses/chronic co-morbidities• May see several physicians (average 4-6)• Average 13-16 medications per day• May be cognitively impaired• May not have a Primary Care Physician• Access to and/or lack of community services• May lack a caregiver for safe transition to home
Care Transition
• “The movement of a patient between health care practitioners and/or settings as their condition and care needs change during the g gcourse of a chronic or acute illness”
Transition Points
• During transitions, patients with complex medical needs, primarily older patients, are at risk for poorer outcomes due to pmedication errors and other errors of communication among the involved healthcare providers and between providers and patients/family caregivers
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Discharge
Historically, movement of patient between practitioners or settings has been viewed as a discharge which has implied an:g p
• “Unloading” of the patient• “Out of sight, out of mind” mentality• “They’re your problem now”
Coordinating Care Across the Coordinating Care Across the ContinuumContinuum
• Patient-centered care is built upon processes which support the “best interest of the patient and their families”
• Patients want their care to be coordinated in a way that keeps them home and prevents them from being readmitted to the hospital
Coordinating Care Across the Coordinating Care Across the ContinuumContinuum
• Therefore, hospital readmissions are viewed as:
• Non-patient centered careNon patient centered care
• A failure of service providers to coordinate a patient’s care across the continuum
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STAAR InitiativeSTate Action on Avoidable Rehospitalizations
• • Commonwealth Fund-supported initiative to reduce• avoidable re-hospitalizations, taking states as unit of• intervention• – May 1, 2009 launch• – Anticipated 4-year initiative• • State-based Initiatives• – Public, non-governmental, and/or private sector leadership• focused specifically on re-hospitalizations• – 3 states selected to receive Commonwealth Fund-IHI supported• technical assistance (Massachusetts, Michigan, Washington
STAAR InitiativeSTate Action on Avoidable Rehospitalizations
• High-leverage opportunities for action• 1. Improve Transitions for All Patients• a) Transitions “out” of the hospital• b) Reception “in” to home (home health, office practice)• c) Reception “in” to skilled nursing (post-acute rehab, NH)• 2. Proactively Address the Needs of “High Risk” Patients• a) Enhanced services for high risk patients• 3. Engage Patients/Caregivers• a) Proactive role, navigating/advocacy skills• b) Shared care plans• c) Proactive advanced care planning
STAAR InitiativeSTate Action on Avoidable Rehospitalizations
• May 2009 to Fall 2010• • Front-line process improvement technical assistance• – May 2009: identify 15-20 hospitals in MA to improve transitions out• – June-August 2009: hospitals and cross-continuum partners complete
prework*• – September 2009: Transitions Out collaborative launch in MA• – October 2009-Dec 2010: process improvements active phase• – Fall 2010 : Reception In collaborative launch in MA• – Fall 2010 : Second wave of Transitions Out collaborative
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STAAR InitiativeSTate Action on Avoidable Rehospitalizations
• Cross Continuum Team made up of staff from Cooley Dickinson Hospital, VNA & Hospice of Cooley Dickinson and local p yNursing facilities launch Transitions Out collaborative in Fall of 2009
AIMAIM•To decrease the 30 day readmission rate at Cooley Dickinson Hospital (CDH) from-11.3% (baseline Jan-Dec 08) by 25% to 8.5% by June 30, 2010.
•Decrease ACH Rate by 10% by 12/31/10
•Improve Management of Oral Medication by 25% 12/31/11
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System Approach System Approach “It takes a community to reduce readmissions”“It takes a community to reduce readmissions”
HomeAmherst
Advocacy Group
PCP Offices E.D.
Tele-metry Unit
Case Manage-
ment
Med/Surg Unit
PCP Offices
SNFVNACardiac Rehab Home
Community Hospital Community
Patient Journey Through the Microsystems
Goal = Improve communication at the handover transitions of care
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Readmit Interview &
Complex CM Planning
Hand-off communicatio
nAdmission
Nurse
Med Recon-ciliation
IDR Work-sheet
Pneum
Zone Tool
Teach B k
PCP appts made
prior to D/C
Teaching in first visitComplete Adm at 2nd visit
Tests of Change
CHF Zone Tool Teach
Back &Nurse
Training
Patient Unit
"Status Board"
DPH Universal Transfer
Form
PCP appointments in 72 h
LOS Rounds
Interact Transfer
Form
Palliative Screening
and Referral
CHF Zone Tool
Teach Back
AssessmentAssessment
• 40% patients readmitted within 7 days of discharge
• Frequent complaints from post acute providers regarding discharge planning processes and hand off communication.
DiagnosisDiagnosis
• Lack of standardized systems for discharge planning processes.
• No feedback/communication process to assure post acute providers receive information needed to provide patient care post discharge.
• Medications errors, omissions, duplication when patient moves across settings
• Each settings gives patient and family different disease management
• Information
p g
• Lack of adequate medication reconciliation at each transition
• Lack of standardized education material given to patients and families regarding disease management
Team MembersTeam MembersName Title FacilityVickie Bishop Ast Director Nursing Calvin Coolidge Nursing & Rehab
Lisa Mercier Director of Nursing Calvin Coolidge Nursing & RehabDaniel Barrieau Director Respiratory Therapy Cooley Dickinson Hospital
Linda Chastain RN, Pulmonary Clinic Cooley Dickinson Hospital
Tammy Cole-Poklewski Director, Quality, Patient Safet Cooley Dickinson Hospital
Sally Crowthers Clinical Director, Med / Surg NCooley Dickinson Hospital
Shannon Dillard QI Coach Cooley Dickinson Hospital
Peter Elsea MD, Hospitalist Cooley Dickinson Hospital
Warren Fisher MD, Medical Director Cooley Dickinson Hospital
Geri Molaghan CHF Coordinator Cooley Dickinson Hospital
Jay Pasternack Behavioral Health Cooley Dickinson Hospital
Christine Plantier Complex Case Manager Cooley Dickinson Hospital
Carol Smith Exec VP/COO Cooley Dickinson Hospital
Nancy Sunflower Charge Case Manager Cooley Dickinson Hospital
Diane Walker Clinical Dietician Cooley Dickinson Hospital
Ann Careau Director Marketing Cooley Dickinson VNA & Hospice
Kelli Barrieau Director, Quality VNA Cooley Dickinson VNA & Hospice
Jeanne Ryan Exec Director VNA/Hospice Cooley Dickinson VNA & Hospice
Sally Dunn Client Represenative Curaspan (eDischarge software)
Mark Bird Social Worker Hampshire Care Nursing Home (Ov
Robert Gallant Exec Director Highland Valley Elder Service
Nancy Maynard Highland Valley Elder Service
Michelle Wuest Administrator Linda Manor Extended Care Facility
James Lomastro Administrator Northampton Rehab & Nursing
Cheryl Pascucci Vice President NP Care (independent NP group co
Jeffrey Zesiger MD, Medical Director Private Physician
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Team MembersTeam MembersName Title FacilityVickie Bishop Ast Director Nursing Calvin Coolidge Nursing & Rehab
Lisa Mercier Director of Nursing Calvin Coolidge Nursing & RehabDaniel Barrieau Director Respiratory Therapy Cooley Dickinson Hospital
Linda Chastain RN, Pulmonary Clinic Cooley Dickinson Hospital
Tammy Cole-Poklewski Director, Quality, Patient Safet Cooley Dickinson Hospital
Sally Crowthers Clinical Director, Med / Surg NCooley Dickinson Hospital
Shannon Dillard QI Coach Cooley Dickinson Hospital
Peter Elsea MD, Hospitalist Cooley Dickinson Hospital
Warren Fisher MD, Medical Director Cooley Dickinson Hospital
Geri Molaghan CHF Coordinator Cooley Dickinson Hospital
Jay Pasternack Behavioral Health Cooley Dickinson Hospital
Christine Plantier Complex Case Manager Cooley Dickinson Hospital
Carol Smith Exec VP/COO Cooley Dickinson Hospital
Nancy Sunflower Charge Case Manager Cooley Dickinson Hospital
Diane Walker Clinical Dietician Cooley Dickinson Hospital
Ann Careau Director Marketing Cooley Dickinson VNA & Hospice
Kelli Barrieau Director, Quality VNA Cooley Dickinson VNA & Hospice
Jeanne Ryan Exec Director VNA/Hospice Cooley Dickinson VNA & Hospice
Sally Dunn Client Represenative Curaspan (eDischarge software)
Mark Bird Social Worker Hampshire Care Nursing Home (Ov
Robert Gallant Exec Director Highland Valley Elder Service
Nancy Maynard Highland Valley Elder Service
Michelle Wuest Administrator Linda Manor Extended Care Facility
James Lomastro Administrator Northampton Rehab & Nursing
Cheryl Pascucci Vice President NP Care (independent NP group co
Jeffrey Zesiger MD, Medical Director Private Physician
#1#1Lack of Standardized Transition ProcessLack of Standardized Transition Process
• Create standardized transition process from start to finish
• Cross Continuum service providersCross Continuum service providers collaborate to create the process
What information do we each need as the patient moves from one setting to the next? Let’s create the transition process together.
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eDischarge Case Management eDischarge Case Management CURRENT PROCESSCURRENT PROCESS
Patient needs post acute provider
Case Mgr. open eDischarge file for patient & load with patient information from;
-medical record (prog notes)-transfer orders (1, 2, 3 pgs)
Case Mgr. asks patient for their choice of facility or
Post acute gets back to hospital -accept-decline
Pending additional information needed
Additional Patientyother provider
Case Mgr. "make referral"-put in criteria -SNF -Hosp Match selection -Acute Rehab to patient -IV/DME specific request
Case Mgr. eDischarge-implementation page,
write narrative notes/may send additional
information as requested
Case Mgr. send to postacute provider & wait
for response
information needed from post acute
Patient discharge to post acute
Post acute notifies Case Mgr.
of need for additional
information
Patient needs post acute care
eDischage loaed with patients information
(goal: 1 page/day for patient with all required info.)
eDischarge Case Management FUTURE PROCESS
eDischarge "match" & information sent
Post acute accepts
Patient discharged to post acute & all
information needed is received
#2:No Feedback loop from Post Acute Providers#2:No Feedback loop from Post Acute Providers
Create feedback loop via: • “Post Discharge Communication Survey” to
insure all service providers are receivinginsure all service providers are receiving necessary information at transition point.
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Post Discharge SurveyPost Discharge SurveyPost Discharge HAND OFF COMMUNICATION Survey
In an effort to improve our discharge planning process the Cooley Dickinson Hospital Readmission Team and the Case Management Department are requesting your feedback about the information provided to your facility at the time of this patients discharge. Please take the time to respond to the questions below.
The completed survey can be faxed to 582-2264. Thank you in advance for your time.
Tammy Cole-Poklewski, RN MS Director Care Management & Standards Compliance Readmission Team Leader
Date of Discharge from Cooley Dickinson Hospital: ___________________________ Name of your agency: _________________________________ Name of contact person at your facility:____________________Telephone #: ________________ Patient Name:_____________________________ Date of Birth:___________________ Yes No Comment 1 Did you receive the discharge summary when
the patient arrived at your facility?
2 Did you receive the discharge paperwork and page 3 referral?
3 If the patient was discharged and needed supplies for care were the supplies sent by CDH to your facility? (i.e., colostomy supplies or other special order supplies that usually take a couple days to obtain)
4 Has the family or patient presented any concerns regarding their stay at Cooley Dickinson Hospital?
5 Did you receive a phone call from anyone at CDH regarding the patient? If yes, please state who called – staff nurse, ED case manager, case manager, etc.
Note: NO responses to questions 1-3 will be immediately directed the Tammy Cole-Poklewski or Nancy Sunflower for follow up by the Case Manager. Additional Comments:
#3: Lack of Medication Reconciliation at each transition point#3: Lack of Medication Reconciliation at each transition point
• Include updated/up to the minute medication list on discharge summary paperworkp p
• Complete medication reconciliation at time of hospital transition
Universal Transfer Form – CDH Test of ChangeCDH Current Discharge Paperwork 4 pages– cut & paste pieces are missing
pieces on CDH form that are part of the DPH Universal form
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Mass DPH Proposed Universal Transfer Form – STAAR Team tested this form, identifying gaps. Need for updated medication list at time of discharge identified and included in new form.
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#4:Lack of standardized patient education material across #4:Lack of standardized patient education material across settingssettings
• Cross continuum team created standardized education/teaching tool to be initiated at the hospitalp
• Education/teaching tool utilized across all settings
Name:_____________________
Date: _____________________
CONGESTIVE HEART FAILURE SIGNS AND SYMPTOMS
♥ Your weight is stable♥ You have no trouble breathing♥ You can do your usual activities♥ Your symptoms are under control
NORMAL WEIGHT ● You are doing well - Continue to: ● Take your medications as ordered ● Write down your weight each morning ● Follow a Heart Healthy Low Sodium diet ● Plan activities and get enough rest ● Keep all doctor appointments
Green Zone Means:
YELLOW ZONE: CALL FOR INSTRUCTIONS WHEN: Yellow Zone Means:
CALL FOR INSTRUCTIONS
HOW YOU FEEL WHAT YOU DO
What is Congestive Heart Failure?Congestive Heart Failure (CHF) means that your heart can't pump blood as well as it should.
GREEN ZONE: YOU ARE DOING WELL WHEN:
1 Teaching
3636Revised 8/09
♥ Your weight goes up ____ pounds in _____ days♥ You have new swelling in your feet, ankles, hands or abdomen♥ You feel winded or have increased shortness of breath♥ You have a problem breathing when you're laying down♥ You feel more tired or have less energy than usual♥ You have a dry, harsh cough that does not go away
● CALL FOR INSTRUCTIONS: Home Doctor ___________________________ Phone ___________________________ VNA office
RED ZONE: MEDICAL ALERT WHEN: ♥ You have severe shortness of breath ♥ You feel palpitations or a "racing heart" ♥ You have chest pain that does not go away ♥ You have increased restlessness or nervousness ♥ You feel like fainting or passing out Call 911 immediately
Red Zone Means:
●You need to be evaluated ♥ Call 911 Immediately
gTool
used for all Hampshire
County
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Acute Care Hospitilization
28%
24%
20%
25%
30%
2009 2010
0%
5%
10%
15%
45%
57%
40%
50%
60%
Oral Meds2009 2010
0%
10%
20%
30%
40%
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Readmission RateReadmission Rate
UCL 12.211
10.135
11.135
12.135
13.135
Rat
e
CDH % Inpatient Readmit to Acute Care within 30 Days (CDB919) Care Transition Coach
initiated
CL 9.180
LCL 6.148
5.135
6.135
7.135
8.135
9.135
Jan
2009
Feb
2009
Mar
200
9
Apr
200
9
May
200
9
Jun
2009
Jul 2
009
Aug
200
9
Sep
2009
Oct
200
9
Nov
200
9
Dec
200
9
Jan
2010
Feb
2010
Mar
201
0
Apr
201
0
May
201
0
Jun
2010
Jul 2
010
Aug
201
0
Sep
2010
Oct
201
0
Nov
201
0
Dec
201
0
Jan
2011
Feb
2011
Mar
201
1
Apr
201
1
May
201
1
Rea
dmit
R
Coaching Networking BreakfastCoaching Networking Breakfast
Lessons LearnedLessons Learned
• Improve communication with referral sources
• Develop a relationship with dischargeDevelop a relationship with discharge planners
• Cross-continuum teams• Medication reconciliation• Teaching materials
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History of the ProjectHistory of the Project
• Home Care Alliance of Massachusetts
• Elevation of Transitions to a Priority Issue with Policy Makers , Payers and Providers
Transitions as a Priority IssueTransitions as a Priority Issue
• “Massachusetts Strategic Plan for Care Transitions”
• STARR Project• STARR Project
• PPACA and hospital non payment for readmissions
• Nursing Home INTERACT
Home Care is the Answer ? Home Care is the Answer ? Home healthcare is the component of the
healthcare industry best positioned to bridge gaps in care between hospitals and homegaps in care between hospitals and home,
especially for high risk groups such as older adults coping with multiple health
problems.”(Naylor, 2006)
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“Home health is likely the (only) truly scalable infrastructure for improving quality and access for the low-
mobility, high risk Medicare beneficiaries who drive the majority of program expenditures and suffer the most---1st
step in impacting quality for this group may be
Home Care is the Answer ?Home Care is the Answer ?
step in impacting quality for this group may be conceptualizing home health as THE central architecture/ platform to deliver transitional, post-acute, and primary care/ chronic care management for these individuals.”
Dr Steve Landers, Cleveland Clinic, 2009 CMS Briefing on HHQI
Premise Behind Alliance Premise Behind Alliance OPTOPT--In Project In Project
Home health agencies need to do a better and more aggressive job of:• making care transitions policy conversations about
helping hospitals (and especially the new breed of h it li t) i i l i t hhospitalist) in screening people into home care
• helping referral sources to understand what they can expect from a home care referral in terms of skilled and supportive care, medication reconciliation and management and patient teaching etc .
Alliance’s Transitions of Care GroupAlliance’s Transitions of Care Group
How do we…• get “home health care” to the discussion table?• prove we are the experts in home health care?• prove we are the experts in home health care?• illustrate are importance in the continuum of
care?• Acknowledge that…
• Home Care is the Answer
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OPTOPT--InIn
OPTimum Performance StandardsOPTimum Performance StandardsOPTimum Performance Standards OPTimum Performance Standards for Patient Centered Transitions to for Patient Centered Transitions to
and from Home Health Careand from Home Health Care
What is OPTWhat is OPT--IN IN
• A set of standards for the home care industry and its partners across all health care sectors• Promote seamless care transitions• Advance positive outcomes • Reduce risks found to cause patient
re-hospitalizations.
Seven OPTSeven OPT--In StandardsIn Standards
• Development from Home Health Care regulatory frameworkregulatory framework• COPs• OASIS-C
• Based on industry quality practices
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Standard I Standard I ReferralReferral
HHA collaborate with referral sources to achieve smooth transition
• Timely admission to home health care• MD specified admission--• Same day/ 24 Hrs• No later than 48 Hrs
Standard II Standard II Initial Home AssessmentInitial Home Assessment
Each patient receives patient specific, comprehensive assessment that accuratelycomprehensive assessment that accurately reflects the patient’s current health status includes information to establish the POC
Initial Home AssessmentInitial Home Assessment
Assess clinical, functional, service needs, home environment
Multi factor Falls riskMulti-factor Falls risk
Hospitalization risk
Depression screening (PHQ-2) Pfizer
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Initial Home AssessmentInitial Home Assessment--ContinuedContinued
Reconcile meds- follow up with MD in 1 calendar dayAbility to manage self-careAbility to manage self careAssess for HHA, other disciplinesAssess social supports, psycho-social needsPatient specific goals
Standard IIIStandard IIICollaborate with Patient and Collaborate with Patient and
Physician to Establish the POCPhysician to Establish the POC• Following discussion of pt’s condition
with MD, clinician incorporates specific Best Practices into POC• Based on OASIS-C process measures
(M2250-M2400)• Face to Face Encounter
Standard IVStandard IVPlan of Care/CoordinationPlan of Care/Coordination
• POC provides an inter-disciplinary approach for providing SN, PT, OT, ST, HHA, MSW, as needed, ,
• Evidenced-based practice• Case conferencing & ongoing care coordination
(MD/specialists)• Close coordination amongst therapy disciplines• Referral to disciplines/resources as needed
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Standard VStandard VHealth Coaching, Teaching and Health Coaching, Teaching and
Enhanced LearningEnhanced Learning
• Personalized teaching –for patients to better manage their chronic illness
PersonalizedPersonalized teachingteaching• Customize education- (Cultural and health
literacy considerations)• Red Flags …“Call Me First”• Medication Management• Self- Management tools… “Teach Back”• Goal setting…identify obstacle to reach goal
Standard VIStandard VIReRe--AssessmentAssessment
• Ongoing re-assessment of each patientpatient
But no less than 60 days/or as often as condition requiredTherapy Regulations: Minimum of every 30 days, 13th and 19th therapy visits
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ReRe--AssessmentAssessment
Continue need for home health care
Meet pt’s medical, nursing, rehab, and psycho/social needs
Discharge planning for smooth transition for patient self-care
Standard VIIStandard VII
Discharge Planning/Transition toDischarge Planning/Transition toDischarge Planning/Transition to Discharge Planning/Transition to Another FacilityAnother Facility
Standard VIIStandard VII (continued) (continued)
Discharge PlanningDischarge Planning
Transitional coaching completed/DC initiatedinitiatedo Personal Health Record/Med Listo Physician/Specialists follow-upo Who/when to call …Self-management
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Standard VIIStandard VII (continued) (continued)
Transition to Another FacilityTransition to Another Facility
Deteriorating medical condition/family unable to provide care/planned follow-up d i iadmissiono “Hand over” to another facility
Terminal illnesso Palliative Care/Bridgeo Hospice
Home Care IS the Answer…Home Care IS the Answer…
Expert PanelExpert Panel• The following individuals contributed to the content of OPT-In document:
• Kathleen Aubert, RN • Colleen Bayard PT, MPA • Keren Diamond, RN • Meg Doherty MSN ANP BC MBA• Meg Doherty, MSN, ANP-BC, MBA• Merrily Evdokimoff, RN MSN,• Cheryl Pacella DNP(c), HHCNS-BC, COS-C, CPHQ • Patricia O’Brien, RN, MBA• Helen, Siegel, RN, MSN• Jeanne M. Ryan, MA, OTR, CHCE, COS-C• Laurie Rubin• Jean Zalenski, PT, DPT, MEd.•
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Contact InformationContact Information
• cbayard@thinkhomecare.org• jeanne_ryan@cooley-dickinson.org
ReferencesReferences• www.caretransitions.org• www.ihi.org• Massachusetts Health Care Quality and Cost Council• Massachusetts Coalition for the Prevention of Medical Errors• National Transitions of Care Coalition, • www.qualityforum.org
QuestionsQuestions