2. Acknowledgments This work was produced, in part, by a grant
from the U.S. Health Resources and ServicesAdministration to the
Huffington Center on Aging at Baylor College of Medicine via a
subcontract toTexas Womans University - Houston. Used with
permission, the principal author for the content was Whitney L.
Mills, PhD.The audio files and voice over were done by Sunrise
Studios, making this Power Point set Sec. 508 Compliant.This
program onTransitions of Care is part of the professional
development initiatives of theTexas Consortium Geriatrics Education
Center at Baylor College of Medicine andTexas Womans University. No
prior permission is needed for educational use. For any commercial
use, however, prior approval must be sought.
3. Purpose To provide a definition and broad overview of
transitions of care, including core elements, current models, and
best practices. To describe the various stakeholders for
transitions of care and the outcomes for each group. To provide
links to additional resources with detailed information about
transitions of care.
4. Transitions of Care Overview
5. Increasing Attention onTransitions Patient Protection
andAffordable Care Act of 2010 Accountable Care Organizations
(ACOs) include doctors, hospitals, long-term care settings, and
other health care providers working as a group Centers for Medicare
and Medicaid Services (CMS) has put a spotlight on transitions of
care Focus is on new programs that incentivize coordination across
sites and help reduce avoidable readmission, while providing
support to individuals and caregivers experiencing a transition of
care
6. What are transitions of care? Transitions of care: the
movement of patients between healthcare locations, providers, or
different levels of care within the same location as conditions and
needs change Transitional care: a set of actions designed to ensure
the coordination and continuity of healthcare as patients transfer
between different locations or different levels of care within the
same location The American Geriatrics Society Health Care Systems
Committee, Coleman, E.A., & Boult, C. (2003). Improving the
quality of transitional care for persons with complex care needs.
Journal of the American Geriatrics Society, 51, 556-557.
7. What are transitions of care? Transitions can occur: Within
settings Between settings Across health states Between providers
Settings may include: Hospitals Subacute/postacute nursing
facilities Patients home Primary/specialty care offices Long-term
care settings
8. Importance ofTransitions of Care Impact of poor transitions
on patients Older adults typically have complex care needs,
resulting in the need to receive care from different providers
across several settings Following hospital discharge, older adults
and their caregivers may be faced with the increased burden of
self-care tasks and complex medication changes May be left feeling
overwhelmed, confused, and uncertain if they are not properly
prepared for the challenges of the extended recovery process
9. Importance ofTransitions of Care Impact of poor transitions
on patients During transitions of care, older adults have increased
risk for adverse events Hospital readmission Emergency room visits
Long-term care placement Medication errors Delays in follow-up care
Mortality
10. Importance ofTransitions of Care Impact on hospitals and
health care systems Increased use of hospital, emergency,
post-acute, and ambulatory services Estimated that 18-20% of all
Medicare patients are readmitted to hospital within 30 days 90% of
these admissions are unplanned Costs: $12-17 billion per year
Medication errors cost at least $3.5 billion per year Coleman EA.
Falling Through the Cracks: Challenges and Opportunities for
Improving Transitional Care for Persons with Continuous Complex
Care Needs. Journal of the American Geriatrics Society.
2003;51(4):549-555.; Institute of Medicine of the National
Academies. Preventing Medication Errors: Quality Chasm Series. The
National Academies Press, 2007
11. Where does it all go wrong? Points of breakdown in
transition process Preparation of the patient and/or caregiver
Communication of the plan of care Medication reconciliation
Transportation of the patient Patient attendance at follow-up
appointments Communication of diagnostic imaging/laboratory testing
results Availability of advance care directives
12. Barriers to ImprovingTransitions Delivery System Level
Healthcare fragmented into independent silos Timely transmission of
vital information Incentives to prescribe or substitute medications
according to its own formulary Insurance coverage often drives
service delivery Understanding and follow-through with care plan
Importance of transitions of care underappreciated Familiarity with
setting to which patients are sent Coleman EA, Berenson RA. Lost in
transition: Challenges and opportunities for improving the quality
of transitional care. Ann Intern Med 2004
13. Barriers to ImprovingTransitions Clinician Level Growing
reliance on institution-based physicians Involvement of multiple
specialists Nursing and SNF staff shortages Poor collaboration and
communication Changing roles of social workers and care
managers
14. Barriers to ImprovingTransitions Patient Level Little
advocacy for improved transitions of care Older patients and their
caregivers are often not adequately informed about their situation
Lack of empowerment Documents received at discharge may be
confusing Communication
15. Improving quality of transitions of care 1. Foster greater
engagement of patients and family caregivers 2. Elevate status of
family caregivers as essential members of the care team 3.
Implement performance measurement 4. Define accountability during
transitions 5. Build professional competency in care coordination
6. Explore technological solutions to improve cross- setting
communication 7. Align financial incentives to promote cross
setting collaboration
http://www.caretransitions.org/What_will_it_take.asp
16. National Models and Best Practices
17. CareTransitions Intervention Goal: to improve care
transitions by providing patients with tools and support that
promote knowledge and self-management of their condition as they
move from hospital to home Population: General medicine patients
with complex care needs Key Provider: Transitions Coach
18. CareTransitions Intervention Key Elements Personal Health
Record Discharge Preparation Checklist Session withTransitions
Coach while admitted to hospital Follow-up visits and phone calls
fromTransitions Coach
19. CareTransitions Intervention Key Elements The Four Pillars
Medication Self- Management Patient is knowledgeable about
medications Patient has a medication management system Dynamic
Patient- Centered Record Patient understand and utilizes the
personal health record (PHR) to facilitation communication and
ensure continuity of care plan across providers and settings
Patient or informal caregiver manages the PHR Follow-up Patient
schedules and completes follow-up visit with the PCP or specialist
Patient is empowered to be an active participant in these
interactions Red Flags Patient is knowledgeable about indications
that their condition is worsening and how to respond
20. CareTransitions Intervention Outcome: Readmission rates
observed within 180 days of hospital discharge 8.30% 16.70% 25.60%
11.90% 22.50% 30.70% 30-day Rehospitalization 90-day
Rehospitalization 180-day Rehospitalization Intervention Group
(n=379) Control Group (n=371)
21. Transitional Care Model Goal: to develop a streamlined plan
of care to prevent hospital readmissions and prepare patient and
caregiver to implement plan with active engagement of
patients/caregivers and in collaboration with patients physicians
and other health care team members Population: General medicine
patients, focused on older adults with two or more risk factors Key
Provider: Transitional Care Nurse
22. Transitional Care Model Key Elements Transitional Care
Nurse (TCN) In-hospital assessment, preparation, and development of
evidence-based plan of care Regular home visits and ongoing
telephone support TCN accompanies patients to initial follow-up
appointments
23. Transitional Care Model Outcome: Readmission rates observed
during 52- week follow up after index hospital admission 10% 28%
48% 23% 56% 61% Readmitted within 6 weeks Readmitted within 26
weeks Readmitted within 52 weeks TCM Group Control Group
24. Transitional Care Model Outcome: Total health care costs
observed during 52- week follow- up after index hospital admission
$3,630 $7,636 $6,661 $12,481 26 weeks after discharge 52 weeks
after discharge TCM Group Control Group
25. Project RED Project Re-Engineered Discharge Goal: to
enhance the care of patients transition from hospital to home
through use of a quality improvement toolkit to reduce readmission
rates, improve patient and family preparation for discharge, and
enhance patient satisfaction Population: General medicine patients
Key Provider: Patient Discharge Advocate, Pharmacist
26. Project RED Key Elements Checklist Medication
reconciliation Reconcile discharge plan with national guidelines
Follow-up appointments Outstanding tests Post-discharge services
Written discharge plan What to do if a problem arises Patient
education Assess patient understanding Discharge summary to primary
care physician Telephone reinforcement with physician
27. Project RED Outcomes: Number of patients utilizing health
services within 30 days of index hospital admission 166 90 76 116
61 55 Hospital Utilizations Emergency Dept Visits Readmissions
Usual Care Group (n=368) Intervention Group (n=370)
28. Project RED Outcomes: Outcomes obtained during 30-day
follow-up phone call presented by number of patients 217 275 135
163 242 292 190 197 Able to ID discharge diagnosis Able to ID PCP
name Visited PCP Felt "prepared" or "very prepared" to leave
hospital Usual Care Group (n=308) Intervention Group (n=307)
29. Project BOOST Better Outcomes for Older adults through
SafeTransitions Goal: to improve the care of patients as they
transition from the hospital to home Population: general medicine
patients, focused older adults Key Provider: hospitalist nurse
30. Project BOOST Key Elements Assessment at hospital admission
Provide education and preparation to patient throughout admission
Patient education and medication reconciliation at discharge using
teach-back method Schedule follow-up appointment Follow-up phone
call within 72 hours for high-risk patients
31. Project BOOST Key Elements -Toolkit Broad assessment of
admitted patients Risk-specific patient/caregiver discharge
preparation Teach-back method Follow-up calls to patients within 72
hours of discharge on how to care for themselves
33. Project BOOST Outcome: Cost analysis $21,389 $412,544
$11,285 $268,942 Emergency Dept Visits Hospital Visits Usual Care
Group (n=376) Intervention Group (n=373)
34. INTERACT II Interventions to Reduce Acute CareTransfers
Goal: To improve care of nursing home (NH) residents by identifying
situations that commonly result in transfers to the hospital and
working together to manage them effectively and safely in the NH
without transfer whenever possible Population: NH residents Key
Providers: NH staff members of all disciplines and levels
35. INTERACT II Key Elements ClinicalTools A set of
communication tools, care paths, advance care planning designed to:
Indentify changes in resident condition Evaluate these changes
Manage some conditions in NH Document changes and how they were
assessed/managed Communicate effectively with staff in NH and staff
at local hospital
36. INTERACT II Outcome: Mean hospitalization rate per 1000
resident days 3.99 4.01 3.96 2.69 3.32 3.13 3.71 2.61 All
Intervention Facilities (n=25) "Engaged" Intervention Facilities
(n=17) "Not Engaged" Intervention Facilities (n=8) Control
Facilities (n=11) Pre-Intervention During Intervention
37. Common Ground
38. Common Ground - Interventions Medication reconciliation and
management Plan for how follow-up tests and appointments will be
completed Red flags indicating condition is worsening and
appropriate response for each Summary of care provided by discharge
setting and a common plan of care across sites Contact information
for PCP and emergency care Foll0w-up call or visit from designated
individual
39. Common Ground - Outcomes Health care system Reduced
hospitalization/readmission rates Reduced costs Improved quality of
care Improved communication with patient and other health care
providers Patients Increased satisfaction Better prepared at
discharge (e.g., able to identify index diagnosis, able to name
PCP, etc.) Greater attendance at follow-up appointments Improved
communication with health care team
40. Common Ground - Coaches Get involved while the patient is
still in the hospital Provide education and preparation for
discharge throughout the hospital stay Ensure follow-up appointment
has been scheduled Ensure information regarding care plan has been
transmitted to next care site and/or to patient Follow-up phone
call and/or visit to ensure patient is following care plan and has
no new questions
43. ProjectWebsites CareTransitions Intervention
http://www.caretransitions.org TransitionalCare Model
http://www.transitionalcare.info ProjectRED
https://www.bu.edu/fammed/projectred ProjectBOOST
www.hospitalmedicine.org/BOOST Interact II
http://interact2.net
44. More Information NationalTransitions of Care Coalition
www.ntocc.org AHRQ bibliography on transitions of care
http://healthit.ahrq.gov/portal/server.pt/community/health_it_
tools_and_resources/919/care_transitions
45. Acknowledgments This work was produced, in part, by a grant
from the U.S. Health Resources and ServicesAdministration to the
Huffington Center on Aging at Baylor College of Medicine via a
subcontract toTexas Womans University - Houston. Used with
permission, the principal author for the content was Whitney L.
Mills, PhD.The audio files and voice over were done by Sunrise
Studios, making this Power Point set Sec. 508 Compliant.This
program onTransitions of Care is part of the professional
development initiatives of theTexas Consortium Geriatrics Education
Center at Baylor College of Medicine andTexas Womans University. No
prior permission is needed for educational use. For any commercial
use, however, prior approval must be sought.