Care Coordination

Damien DoyleMD/CMD/FAAFP

Medical DirectorOptum HealthCare of MidAtantic

Staff PhysicianCharles E. Smith Life Communities

Damien_J_Doyle@Optum.com

“The single biggest problem with communication is the illusion that it has taken place”

George Bernard Shaw

System vs. Patient – An inherent Conflict

• Care delivered by specialized practitioners with narrow focus

• Organizations deliver care along product lines and specialties and are site specific

• Patients are increasingly complex with a greater variety of co-morbidities managed in a growing variety of settings

Too many cooks….

• Typical Medicare beneficiary sees an average of 2 PCPs and 5 specialists annually

• Who coordinates this care?

Care Coordination Definition

• Many definitions exist and this is part of the confusion

• “The term ‘care coordination’ has no well-established definition. Rather, it is generally understood to mean a process of improving communication among the various medical professionals with whom patients come in contact and between these professionals and the patients themselves (and their families).” Brown 2004

Care Coordination Definition

• From the National Library of Medicine, Closing the Quality Gap Vol. 7 “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services.”

Care Coordination Goals

• (1) identify the full range of medical, functional, social, and emotional problems that increase patients' risk of adverse health events

• (2) address those needs through education in self-care, optimization of medical treatment, and integration of care fragmented by setting or provider

• (3) monitor patients for progress and early signs of problems

• Such programs hold the promise of raising the quality of health care, improving health outcomes, and reducing the need for costly hospitalizations and medical care.”

• Chen 2000

Transition of Care Definition

• Movement of patients between health care locations, providers or different levels as their care needs change– Within settings

• PCP to specialist• ICU -> ward

– Between settings• Hospital -> Subacute or Home

– Across health states• Curative -> Palliative

AMDA Transitions of Care Practice Guideline 2010

Care Transitions: Definition• “Care Transitions” refers to the

movement patients make between health care practitioners and settings as their conditions and care needs change during the course of a chronic or acute illness

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Care Coordination and

Transition of Care are critically and

inherently linked

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Charles E. Smith Life Communities

OUR SPECTRUM OF SERVICES

Most Acute

Most Restrictive

Medical Model

Least Acute

Least Restrictive

Social Model

Subacute

Home Living Support

Independent Living

CA

RE M

AN

AG

EM

EN

T

Hebrew Home70 Bed Unit

Hirsh Health Center 1991

Ring 1989 (250 Apts.)Revitz 1978 (250 Apts.)

Hebrew Home 451 BedsWasserman 1969Smith-Kogod 1981

Landow House 200560 UnitsOutpatient

Diagnostic & Treatment

Assisted Living

Nursing Home

Subacute

Home Care Solutions, LLC Joint Ownership Augustine Home Health2000

37 Total Acres

Is This Really a Problem?

• ~ 10% of all NH residents had an ED visit in past 90 days (Caffrey, US Dept HHS 2004)

• Of these, 40% have a potentially preventable cause

• Of Patients who are hospitalized,– 19% re-hospitalized within 30 days– 42% re-hospitalized within 24 months

• Hard to define what is the appropriate/expected number

What illustrates bad Care Coordination

• Medication Errors• Increased Health Care Utilization• Inefficient/Duplicative Care• Inadequate patient/caregiver preparation• Inadequate follow-up care• Dissatisfaction• Litigation/Bad publicity

• Eric Coleman, MD/MPH• University of Colorado, Denver

High Risk for Transition Problems• Multiple Medical Problems• Dementia• Depression or other Mental Health issues• Isolated – lack of caregivers• Poverty• Non-English speaking• Minorities• Recent immigrants and refugees • IE, most of our patients!

What are the Common Factors?• Most transitions are unplanned and

due to acute illness• Patients are vulnerable – functional

loss, delirium, pain and anxiety are all common

• Only true common factor is the patient themselves

What Can We Do?

• Move?• Give up?

Safer Coordination

• Communication• Medication Reconciliation• Patient Centered Care • End of Life Care – Patient driven plan

of care

Safer Coordination - Communication

• Discharge Instructions – Expectations– Shift the concept of “discharge” to

“transfer with continuous management”– Begin transfer planning upon admission– Incorporate patient/caregiver

preferences– Identify social support and function– Collaborate with practitioners across the

spectrum

Safer Coordination – Communication

• Expectations for the Transferring Team– Patient is Stable– Patient and caregiver understand the purpose

of the transfer– Patient and caregiver understand their

coverage– Receiving institution is capable and prepared– Care plan, orders, and clinical summary

precede the patient’s arrival– Timely follow-up is arranged

Safer Coordination – Communication

• Expectations for the Receiving Team– Review the transfer forms, clinical

summary and orders– Incorporate the patient/caregiver goals

and preferences– Clarify any discrepancies regarding the

care plan, patient’s status or medications

Care Coordination Models

• Key national models– Care Transitions Program– Transitional Care Model– Transforming the Care at the

Bedside– Project RED (Re-Engineer

Discharge)

– Project Better Outcomes for Older adults through Safe Transitions (BOOST)

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Celtic Healthcare

Care Transitions: Four PillarsColeman, Univ. of Colorado

www.caretransitions.org

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Celtic Healthcare

Transitional Care ModelNaylor, Univ. of Pennsylvania

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Celtic Healthcare

Transforming The Care at the Bedside Model

Institute of Healthcare Improvement

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Celtic Healthcare

Project REDBoston University

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Celtic Healthcare

• Transition Coach” (Nurse or MSW)– Prepares patient for what to expect and to

speak up– Educated on use of a Personal Health

Record– Educates the care team in home of patient’s

needs

• Follows patient to the home– Reconcile pre- and post-hospital

medications– Practice or “role-play” next encounter or

visit

• Phone calls after discharge– Single point of contact; reinforce, ensure

follow up

• Does not replace hospital discharge planning!

Home Healthcare Role

Specialized Care Models

• ISNP (Institutional Special Needs Population) – Medicare Advantage Programs

• Home Care Management Programs• NORC (Naturally Occurring

Retirement Communities) http://www.aoa.gov/AoARoot/AoA_Programs/OAA/oaa_full.asp#_Toc153957728

Resources and References• Home Health Quality

Improvement Campaign– Original Campaign Transitional Care Coordination

Best Practice Package and resources• www.homehealthquality.org/hh/ed_resources/

interventionpackages/tcc.aspx

– Current Campaign • www.homehealthquality.org

– Care Transitions Program• www.caretransitions.org

• Coleman, E., et. Al. (2006). ARCH INTERN MED., Vol. 166.

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Care Transition Tools and Resources (cont.)

• Medication Management Tools – Collaboration for Homecare Advances in

Management and Practice (CHAMP) Program

– www.champ-program.org • Barriers to Medication Adherence, Medication

Management Evidence Brief, Reducing Adverse Drug Events

• Beers Criteria, ARMOR Polypharmacy Tool, How to Write a Pill Card, Medication Reconciliation Process, Risk Assessment for Non-adherence, Script for Adherence Counseling, Speak Up Brochure – Help Avoid Mistakes with Your Medicines, Tips for Preventing Problems When Taking Multiple Medications, Your Medications – What to ask

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• “There was an important job to be done and Everybody was sure that Somebody would do it. Anybody could have done it, but Nobody did it… Everybody blamed Somebody when Nobody did what Anybody could have done” – Anonymous