A U G U S T 1 5 , 2 0 1 3
MANITOWOC COUNTYCARE TRANSITION PROGRAM
Judy Rank – DirectorCathy Ley – Supervisor Care Transitions Coach
MANITOWOC COUNTY CARE TRANSITION PROGRAM
Julie Place, Director of [email protected]
Marcia Donlon, Director of Home Health & Hospice Services [email protected]
Judy Culligan, Social Worker/Discharge [email protected]
BUILDING THE PARTNERSHIPS
• Acute Care for the
Elderly (A.C.E.)
• Began with a grant
from The Aurora
Foundation
• Included Both Hospitals
and 6 Nursing Homes
A.C.E. TEAM
• Acute Care for the Elderly
• Team Consists of :
Hospital Staff
Nursing Home Staff
Physicians
ADRC
Home Care Agencies
Other Long-Term Coalition Members
A.C.E. TEAM
• Purpose is to coordinate cares for the elderly
to assure quality and continuity
• A.C.E. Team evolution to present
Education related to needs of patients and staff
Assisting different providers to work together
Development of pathways
Avoidable re-admissions and current issues
GETTING STARTED WITH CARE TRANSITIONS –RESOURCES OFFERED BY THE AGING & DISABILITY
RESOURCE CENTER (ADRC)
• Home-Delivered Meals
• Subsidized Transportation
• Assistance in accessing public benefits i.e.: Medicaid, Family Care & Foodshare
• Caregiver Support Programs
• Prevention Programs
• Information & Assistance
PARTNERSHIPS ALREADY BUILT
• Hospitals and Rehab Centers providing space for
Prevention Programs
• Staff from facilities are co-facilitating Prevention
Programs
• Long-Term Care Coalition
• Social Worker/Discharge Planner Network
APPROACHING THE MEDICAL COMMUNITY
• Talked with Discharge Planners
• Talked with Management Staff
• Wanted opportunity to prove the program
CARE TRANSITION INTERVENTIONTHE ERIC COLEMAN MODEL
Why Was This Model Chosen?
• Community-Based Model
• Low-Cost Intervention
• Eau Claire County was using this model and it was
successful
• One of our Community Hospitals had worked with
Dr. Coleman on a prior project
• This model would work in our community and with
our partners
THE ERIC COLEMAN MODEL
Model Consists of:
A Transition Coach who makes:
• One Hospital Visit
• One Home Visit
• 3 Follow-Up Phone Calls
The Four Pillars of the Model:
1. Medication Self-Management
2. Personal Health Record
3. Follow-Up Visit with Physician
4. Red Flags or Warning Signs of the Condition
THE ERIC COLEMAN MODEL
Transition Coach Role
“The Transition Coach’s role is based on teaching the skills,
knowledge, and attitude necessary to empower patients to
manage their own care.”
The goal is to teach people to fish, rather than just giving
them the fish.
THE ERIC COLEMAN MODEL
Transition Coach Role
• Coaching is not a replacement of any other current
provider
• It does not attempt to replace discharge planners
or home health nurses
• Coaching is intended to supplement any other
service that a consumer receives and enhance
their effectiveness in utilizing these services
• Coaching requires flexibility and letting go of rigid
agendas
THE FOUR PILLARS
1. Medication Self-Management
• The goal is that the consumer is knowledgeable
about his/her medications and has a management
system
• The management system has to be realistic and
individual to the person
• Coach is non judgmental and realistic
THE FOUR PILLARS
2. Personal Health Record (PHR)
• List of medications (dose, frequency, reason) how
they actually take it, not necessarily as prescribed
• Space for the consumer’s self-identified goal
• Space for patient’s concerns &questions for follow-
up visit with their physician
• Space for information about Red Flags/Warning
Signs
THE FOUR PILLARS
3. Follow-Up Visit With Physician
Coach will assist consumer in getting ready for their
follow-up visit with physician
o Is appointment scheduled? If not coach can work with
consumer to build skills to effectively get a quick
appointment
o Are there any barriers in getting to this appointment and if
so, what can consumer do to remove the barriers?
o Are there any questions you have for your doctor?
THE FOUR PILLARS
4. Red Flags / Warning Signs
• Consumers will identify and write down the
indications that their condition is worsening – i.e.,
“How were you feeling before you went to the
hospital? What was happening?”
• What is the consumer’s plan when they experience
these red flags/warning signs?
TRAINING PROCESS
• We participated in the Care Transition Program’s
Regional Training
• Prior to training, we needed to complete a
Readiness Assessment Tool, which is designed to
help you think through the elements of the Care
Transitions Intervention. This document covers
goals, commitment, role changes, implementation,
documentation, and ongoing support.
• Training lasted one day and occurred in Aurora,
Colorado
• Staff was trained in October 2012
PLANNING – MOVING FORWARD
• Set up meetings with our 2 hospital partners Aurora Medical Center and Holy Family Memorial to plan for implementation
• The hospitals worked together to develop a screening tool which would work for the program and both hospitals
• As a group we determined which medical diagnoses would be included
• The hospitals identified which of their staff members would complete the forms and make the referrals to us and how the referrals would get to the ADRC
• Hospital staff did a “test run” of screening tool prior to start of program, to make sure form worked smoothly
IMPLEMENTATION
Began the program in November 2012
• Did the roll-out with both hospitals simultaneously
• Made the first hospital visit on November 6, 2012
• Met with our partners more frequently in the
beginning to address any issues or questions that
came up
• Steady growth in the program since the start
STARTED WITH A.C.E. TEAM –(ACUTE CARE FOR THE ELDERLY)
• Community focus versus “competition”
• 2011 Team selected for Chamber of Commerce Award for the work done together to improve the community
• ACE Team was known and respected within hospitals
ADRC INITIATED ACTION WITH HOSPITALS
• Introduced Care
Transitions Initiative
and Plan
• Important to identify
right leads from the
start
• Included Hospitals
as Key Stakeholders
from the start to
develop the model
ATTENDED TRAINING SESSIONS IN DENVER TO LEARN ERIC COLEMAN MODEL – 4 ATTENDEES
• Information & Assistance Workers from the ADRC
who would become the actual coaches for
Manitowoc County
• Representative from Felician Village – Senior Care
Complex
• Representative from Holy Family Memorial – Why
was this important???
NEXT STEPS:
• Team meetings at both hospitals to educate physicians and staff on Care Transitions – I organized and facilitated
• Develop referral tool to share at meetings and get staff familiar with and use
• Communicate, communicate, communicate information
• Ask staff often how things are going with referrals
• Invite coaches to numerous meetings & events to build relationships
• Reassure that coaches will NOT impede referrals to home care or hospice service
SHARING INFORMATION
• It is important to share information back with
physicians and staff regarding the number of
referrals and outcomes – they love to hear the
stories
• Also conveys that the coaches are improving care,
and this is a partnership
• Late adapters…..- keep moving on the journey and
reinforcing positives
• Pharmacy connection
CARE TRANSITIONS PROCESS
• We identify
potential clients for
the Care Transitions
Program upon
admission and
throughout the
patient’s stay
• The tool for
Assessing
Readmission Risk &
Eligibility for the
Care Transitions
Program is used to
identify these clients
CARE TRANSITIONS PROCESS
• Once a patient is identified through the screening
process, a Care Transitions Coach at the ADRC is notified
• If we feel a particular patient would benefit from the
Care Transition Program and does not meet the criteria
on the screening tool, we will discuss the case with a
Transitions Coach to see if they can take them on
• Response time for a Care Transitions Coach to make a
hospital visit is usually on the same day the referral is
made
CARE TRANSITIONS PROCESS
• Along with the program screening tool, Coaches
are given the patient’s History & Physical, Face
Sheet with Demographics and Discharge Summary
if applicable
• The patient information is placed in a folder in a
designated area on each unit. Coaches will collect
the information from the folder so that the Social
Worker or Case Manager doesn’t have to be
present for the Coach to see the patient
CARE TRANSITION PROGRAM RESULTS NOVEMBER 3, 2012 – JUNE 30, 2013
• 138 Total Referrals from Hospitals (2 main referral sources) and a few from Nursing Homes
• 23 of the 138 declined intervention. These people were discharge prior to a Care Transition Coach hospital visit
• 102 total of the 138 received or are still receiving intervention
• 49 of the 138 declined to continue the program after a hospital visit from the Coach or receiving their personal health record
CARE TRANSITION PROGRAM RESULTS NOVEMBER 3, 2012 – JUNE 30, 2013
• 4 of out 138 were hospitalized while in the program;
all in the first month of the program – 2 of the 4 were
re-hospitalized before ever being seen at home
• 29 of the 138 fully completed the program
• 0 Re-hospitalizations within 30 days for those who
have completed the program
THE FUTURE OF CARE TRANSITION
• Current Funding
o 100% Time Reporting
o ADRC Budget Item
• Future Funding
o 100% Time Reporting
o Provider Participation
WHAT’S NEXT?
• Future Partnerships
• Future Expansion of Prevention Programs
• Marketing to Community