Marge Houy

Senior Consultant

Bailit Health Purchasing, LLC

Patient-Centered Medical Homes: Managing Patient Transitions of Care

1

Objectives

■ Provide background information about Massachusetts’ PCMH Initiative

■ Provide examples of how practices are developing the infrastructure to successfully manage transitions of care

■ Provide an opportunity to share experiences and learn among themselves

2

Background

■ 49 adult and pediatric practice sites participating in EOHHS-sponsored PCMH Initiative

■ Undergoing intensive 2-year training to: Implement population management approach to

providing evidence-based care Create team-based care with each team member

performing “at the top of their license” Integrate primary care and behavioral health services Partnership with patient in managing health conditions Provide patient-centered practice – enhanced access,

cultural sensitivity, etc.

3

Key Measures of Success

Practices have opportunity to share savings generated from reduced inpatient days and ED visits while meeting key quality benchmarks

4

Transitions of Care Infrastructure/Processes■ Identify nursing resources to function as practice-based

care manager

■ Key functions– Work with practice teams to stratify patients and identify high risk

patients: necessarily includes patients with ED or IP admission

– Create high risk patient registry; outreach and engage patients

– Contact discharged patients within 2 days of discharge and bring in for f/u visit, as appropriate

– Contact patients with chronic condition-related ED visit within 2 days and bring in for f/u visit as appropriate

– Work with patients to promote self-management skills

– Function as member of patient’s care team

5

Example and Discussion

■ Lee Family Practice

6

Key Changes to Achieve an Ideal Transition from Hospital (or SNF) to Home

I. Perform Enhanced Assessment for Post- Hospital

Needs

II. Provide Effective Teaching and Enhanced Learning

III. Conduct Real-Time Patient and Family-Centered

Handoff Communication

IV. Ensure Post-Hospital Care Follow-Up:

Completing the Transition into Care Settings within the Community

Office Practices Home CareSkilled Nursing

Facilities

• Provide timely

access

• Reconcile meds and

plan of care

• Coordinate care

with other community

clinicians

• Reconcile meds

• Reinforce self-care

plan

• Communicate as

indicated with

primary care provider

and specialists

• Assure staff are

capable to care for

patient’s needs

• Reconcile meds and

plan of care

• Provide timely

consultation when

patient’s condition

changes

Aligning PCMHI and STAAR

STAAR ProgramPerform an Enhanced

Assessment of Post Hospital Needs

■ Involve the patient, family, caregiver(s) and community providers(s) as full partners in completing a needs assessment of the patient’s home-going needs.

■ Reconcile medications upon admission

■ Identify the patient’s initial risk of readmission

■ Create a customized plan of care and discharge plan based on the assessment

PCMHI InitiativeEmpanelment

■ Primary care practitioner takes responsible for knowing his/her panel of patients and managing care across the care continuum

Aligning PCMHI and STAAR

STAAR ProgramProvide Effective Teaching and

Facilitate Enhanced Learning

■ Identify and involve all learners on admission

■ Customize the patient education process for patients, family caregivers, and providers in community settings

■ Redesign patient education process and patient teaching print materials

■ Use Teach Back daily in the hospital and during follow-up calls to assess the patient’s and family caregivers’ understanding of discharge instructions and ability to perform self-care

PCMHI InitiativePatient-Centered Care■ Make sure the patient understands

and agrees to care

Team-based Care■ Maximize provider-term

communication

■ Tracking of care transitions

Aligning PCMHI and STAAR

STAAR ProgramProvide Real-Time Handover

Communications■ Give and review with patient and

family members a patient-friendly post-hospital care plan which includes a clear medication list.

■ Provide customized, real-time critical information to next clinical care provider(s).,

■ For high-risk patients, a clinician calls the individual(s) listed as the patient’s next clinical care provider(s) to discuss the patient’s status and plan of care.

PCMHI InitiativeCare Coordination■ Two-way communications with other

providers

■ Tracking of care transitions

■ Transitional care within 48 hours

Enhanced Access■ Planned care at every visit

Aligning PCMHI and STAAR

STAAR ProgramEnsure Post-Hospital Care

Follow-up■ Reassess the patient’s medical and

social risk for readmission

■ Prior to discharge, schedule timely follow-up care and initiate clinical and social services as indicated from the assessment of post-hospital needs.

PCMHI InitiativeCare Coordination

■ Two-way communications with other providers

■ Tracking of care transitions

How-to Guide:Completing the Transition to the Clinical Office Practice

Getting Started

■ Step 1. Form a Team

■ Step 2. The Team Identifies

Opportunities for Improvement

■ Step 3. Develop an Aim Statement

Getting Started

■ Step 1. Form a Team

Consider choosing team members from the following:

• Patients and family members

• Physicians

• Nurse practitioners

• Nurses

• Office managers

• Schedulers

Getting Started

■ Step 2. The Team Identifies Opportunities for Improvement

– Diagnostic review of the last 5 patients from your practice that were rehospitalized within 30 days of discharge

– Review patient satisfaction data regarding communication and preparations for self care

Getting Started

■ Step 3. Develop an Aim Statement

– Analyze data

– Select target patient population

– Write an aim statement

Clinical Office Practice Key Changes

1. Provide Timely Access to Care Following a Hospitalization

A. Review on a daily basis information received from the hospital about admissions and anticipated discharges.

B. Provide appropriate level and type of follow-up for high risk, medium risk and low risk discharged patients

Clinical Office Practice Key Changes

2. Prior to the Visit: Prepare Patient and Clinical Team

A. Review discharge summary

B. Clarify outstanding questions with sending physician

C. Make reminder call to patient or family member

D. Coordinate care with home health care nurses and case managers if appropriate

Clinical Office Practice Key Changes3. During the Visit: Assess Patient and Initiate New Care Plan or Revise Existing Plan

A. Ask the patient about his/her goals for visit; what factors contributed to hospital admission or ED visit; and what medications he/she is taking and on what schedule

B. Perform medication reconciliation with attention to the pre-hospital regimen

C. Determine need to adjust medications or dosages, follow-up have on test results, do monitoring or testing; discuss advance directives; discuss specific future treatments

D. Instruct patient in self-management; have patient repeat backE. Explain warning signs and how to respond; have patient repeat

backF. Provide instructions for seeking emergency and non-emergency

after-hours care

Clinical Office Practice Key Changes

4. At the Conclusion of the Visit: Communicate and Coordinate on-going Care plan

A. Print reconciled, dated, medication list and provide a copy to the patient, family caregiver, home health care nurse, and case manager (if appropriate.)

B. Communicate revisions to the care plan to patient, family caregiver, home health care nurse, and case manager (if appropriate.)

C. Ensure that the next appointment is made, as appropriate

Model for Improvement

Use Model for Improvement to test changes

– Aims

– Measures

– Changes - Plan-Do-Study-Act

Implement

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