The Transitions Program breaks the cycle of primary and repeated hospitalizations or institutionalization in the years prior to death.

Provides physicians and other healthcare providers evidence-based prognostic tools to recognize when their patient is at risk for using the hospital for a primary or secondary admission for decompensation care.

Engages patients and caregivers in proactive disease management using disease-specific anticipatory guidance for adults.

Improves patient safety by reducing risks of hospital-acquired disabilities.

Fulfills fiduciary ethics by lowering the cost of care across the healthcare system.

Transitions took the best of the hospice model and integrated those components into work process and structure, through highly coordi-nated, team-based care, focusing on patient values, preferences and cultural background.

PURPOSE

INTERVENTION

Pillar 1

Evidence-based, in-home medical

management

Give patient, family and caregiver knowledge and

skill-set to proactively manage the disease

Match the medical/psychosocial interventions within lifestyle

Improve compliance with medical plan

Avoid healthcare acquired disabilities by keeping people home and out of hospital

Improve end of life care—earlier use of hospice

Pillar 3

Caregiver Support

Identify caregiver needs and support reduce emotion- al and physical strain to care Giver

Improve quality of life in Caregiver

Improve caregiver satisfac-tion

Help caregiver care for their loved one and cope with the often difficult responsibility of doing so

Validate that caregiver can respect patient wishes

Pillar 4

Goals of Care Conversation

Create roadmap for all future care and inter- ventions

Improve communication and establish agreement between patient, family and caregiver on end-of life wishes

Improve surviving family/ caregiver satisfaction

Pillar 2

Evidence-Based Medical

Prognostication

Utilize evidence-based prognostication methods to provide accurate survival and event estimates

Prepare patient, family and caregiver for inevitable disease manifestation process

Allow patient to make informed decisions about their goals of care while family and caregiver are reconciled and patient has capacity

PERSON CENTERED CARE TEAM

Home visits by RN, and MSW from start of care until hospice ready

Pharmacist Consultant for medication review, adjustments, focus on reducing number of medications

24/7 access to RN through hospice Clinical Call Center

IDT meetings every 2 weeks facilitated by CMO Outpatient Palliative Medicine

Patients still see their PCP/Specialist and have access to “disease modifying care”

Partner with Medical Group Population Health teams to coordinate referrals

MD RN MSW SCC Pharm

Pa t i e n t ’ s H o m e

A comprehensive concurrent care model designed to manage patients with late stage illness in their preferred environment of care, using the expertise of skilled healthcare providers through an interdisciplinary team approach.

Identified population: Disease specific, under maximum medical thera-pies, and at risk of using the ED or hospital for symptom management or “decompensation” care.

Congestive Heart Failure

COPD

Dementia

Frailty

Advanced stage cancer

Advanced liver disease

Neuromuscular degenerative diseases

Program Caveat: Engaged champion specialty physicians to introduce program philosophy, help develop disease specific criteria, patient selection and referral process.

Funding: Medicare Advantage plans and ACO’s contracted with Sharp HealthCare medical groups.

TARGET POPULATION IMPACT

TRANSITIONS Community-Based

Palliative Care Program

Daniel R. Hoefer, MD Suzi K. Johnson, MPH, RN