Post on 06-Jan-2016
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Preparing Patients and Caregivers to Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: Participate in Care Delivered Across Settings:
The Care Transitions Intervention The Care Transitions Intervention
Monique Parrish, Dr.PH, MPH, LCSW
Background: Coleman Care Transitions Background: Coleman Care Transitions ModelModel
Qualitative Studies– Inadequately prepared for next setting– Conflicting advice for illness management– Inability to reach the right practitioner– Repeatedly completing tasks left undone
The “Silent” Care CoordinatorsThe “Silent” Care Coordinators
By default, older patients and family caregivers function as their own care coordinators
First line of defense for transition related errorsModel explicitly recognizes their role as
integral members of the interdisciplinary team
Randomized Controlled TrialRandomized Controlled Trial
Variable Intervention Control P-Value
Age (years) 76.0 76.4 0.52
Female (%) 48.2 52.3 0.26
Married (%) 58.2 53.8 0.23
Lives alone (%) 30.9 30.8 0.99
Sad or Blue (%) 30.3 26.4 0.24
CHF (%) 16.5 12.9 0.17
COPD (%) 17.0 18.5 0.61
Arrhythmia (%) 12.8 19.0 0.02
CAD (%) 14.1 13.5 0.81
Chronic Disease Score
6.8 7.1 0.31
Variable Intervention Control P-Value
Prior Hosp (%)
1+ past 6 mo
29.3 26.1 0.36
Prior ED (%)
1+ past 6 mo
40.3 38.9 0.69
D/C Destin.
Home (%)
Homecare (%)
SNF (%)
Other (%)
50.8
24.7
21.0
3.5
52.9
25.9
19.3
1.9
0.71
Friday D/C (%) 14.6 16.5 0.48
Variable Intervention Control
Adjusted
P-value
Re-hospitalized
w/in 30 days 8 % 12 % 0.048
Re-hospitalized
w/in 90 days17 % 23 % 0.04
Re-hospitalized
w/in 180 days26 % 31 % 0.28
Variable Intervention Control
Adjusted
P-value
Readmit for Same Dx w/in 30 days
3 % 5 % 0.18
Readmit for Same Dx w/in 90 days
5 % 10 % 0.04
Readmit for Same Dx w/in 180 days
9 % 14 % 0.046
Care TransitionsCare Transitions
“Care Transitions” refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.
The Care Transitions Intervention:The Care Transitions Intervention:
Designed to encourage older patients and their caregivers to assert a more active role during care transitions
The Four PillarsThe Four Pillars
Four PillarsFour Pillars
Medication Self-Management Patient Centered Health Record (PHR)
Primary Care Provider/Specialist Follow-Up
Knowledge of Red Flags
Pillar #1:Pillar #1: Medication Self-ManagementMedication Self-Management
Focus: reinforcing the importance of knowing each medication – when, why, and how to take what is prescribed, and developing an effective medication management system
Pillar #2:Pillar #2: Personal Health Record (PHR)Personal Health Record (PHR)
Focus: providing a health care management guide for patients; the PHR is introduced during the hospital visit and used throughout the program
Key Elements of the Personal Health Key Elements of the Personal Health RecordRecord
Record of patient’s medical historyRed flags, or warning signsMedication list and allergies Advance DirectivesStructured Checklist of critical activities
(instructions, f/u appointments)Space for patient questions and concerns
My Medications are:Medication Dose______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________Allergies: _____________________
Reason Side Effects______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
____________________________________________________________Remember to take this Record with youto all of your doctor visits
PersonalPersonalHealthHealthRecordRecord
The Personal Health Record of:
Josephine Patient
Personal Information:
Address:
Home Phone#:
Birth Date:
Patient ID#
PCP Name:
Advanced Directives?:
Hospitalization Information:
Admitted: _/_/_ Discharged: _/_/_
Reason for Hospitalization:
___________________________________________
Caregiver Information:
Name:
Phone #:
Relation to Patient:
Personal History
Please check any illnesses or health
problems listed below that you have
ever experienced.
Arthritis
Abnormal Heart Rhythm
Cancer
Diabetes
Hardening of the Arteries
Heart Disease
Heart Failure
High Blood Pressure
Hip Fracture
Lung Disease
Medical/Surgical Back conditions
Pneumonia
Stroke
Other: ____________________
After I leave the hospital…
1. I will write down questions I have about my condition.
2. I will take all bottles of medicine I am using to each doctor visit.
3. I will call _________________
immediately at (XXX) XXX-XXX if I experience any of the following:
• Temperature above 101° F
• Uncontrollable pain
• Increased confusion
• Increased redness or d
drainage around wound
• Questions about which
medications to take
Before I leave the hospital…. I have the instructions I need to
keep my health condition from becoming worse.
I know what symptoms to watch out for.
I know the name and phone number of who to call if I see any of these symptoms.
My family or someone close to me knows what I will need once I leave the hospital.
I know what medications to take, how to take them, and possible side effects.
I will schedule a follow up appointment with my primary care doctor.
I will have a clear and complete copy of my discharge instructions.
Goal AttainmentGoal Attainment
“What is one personal goal that is important for you to achieve one month
after you get home?”
Response CategoriesResponse Categories
1. I have not worked on it
2. I have not met that goal, but am working on it
3. I have met the goal as well as I expected
4. I have met the goal better than I expected
FindingsFindings
Patients who worked with the Transition Coach were more likely to achieve their goals around symptom control and functional status
Pillar #3:Pillar #3: Primary Care Primary Care
Provider/Specialist Follow-UpProvider/Specialist Follow-Up
Focus: enlist patient’s involvement in scheduling appointment(s) with the primary care provider or specialist as soon as possible after discharge
Pillar #4:Pillar #4: Knowledge of Red FlagsKnowledge of Red Flags
Focus: patient is knowledgeable about indicators that suggest that his or her condition is worsening and how to respond
Key Elements of InterventionKey Elements of Intervention
“Transition Coach” (Nurse or Nurse Practitioner)– Prepares patient for what to expect and to speak up– Provides tools (Personal Health Record)
Follows patient to nursing facility or to the home– Reconciles pre- and post-hospital medications– Practices or “role-plays” next encounter or visit
Phone calls 2, 7 and 14 days after discharge– Single point of contact; reinforce, ensure follow up
Intervention ActivitiesIntervention Activities
– Hospital Visit*– Home Visit– 2-Day Follow-Up Call– 7-Day Follow-Up Call– 14-Day Follow-up Call
First Interaction (Hospital or First Interaction (Hospital or Home Visit)Home Visit)
Introduce the Program– Structure of the intervention: visits and calls– Role and purpose of the coach– Accessibility of the coach
Introduce and complete the Personal Health Record
Assure Coverage of Intervention Activities Checklist (Four Pillars)
2, 7 and 14-Day Phone Calls2, 7 and 14-Day Phone Calls
Follow-up on issues discussed during hospital/home visit.
Review the Four Pillars as they apply to each patient at the appropriate stage in the transition (see Intervention Activities Checklist)
Anticipated Cost SavingsAnticipated Cost Savings
For 350 chronically ill older adults with an initial hospitalization, anticipated net costs savings over 12 months:
US$ 295,594US$ 295,594
CoachingCoaching
What is coaching?How does coaching differ from what
nurses, social workers, and community workers do to help patients?
Key Attributes for the Key Attributes for the Transition CoachTransition Coach
Ability to shift from a “doing” role to a coaching role
Skill and knowledge to manage and reconcile medications
A strong enough sense of empowerment to empower a patient and/or caregiver
Ability to engage in critical thinking within the framework of a care plan
Took Kit for CoachesTook Kit for Coaches
Medication Discrepancy Tool (promoting Medication Safety)
Intervention Activities ChecklistPHR
Introducing the Medication Introducing the Medication DiscrepancyDiscrepancy Tool (MDT) Tool (MDT)
Patient-centeredApplicable across a variety of health settingsIdentify patient- and system-level factorsItems need to be actionable at point of care
Non-Intentional Non-ComplianceNon-Intentional Non-Compliance
Prior to hospitalization, a patient was prescribed Digoxin 0.25 mg daily
The patient’s discharge instructions read, “Digoxin 0.125 mg daily”
The patient had only the pre-hospitalization 0.25 mg Digoxin pills and had been taking these since discharge
Intentional Non-ComplianceIntentional Non-Compliance
A patient was admitted to the hospital for COPD exacerbation
Following discharge, he was not using his maintenance steroid inhaler because he believed that “that medication makes my breathing worse”
D/C Instructions D/C Instructions Incomplete or IllegibleIncomplete or Illegible
The patient’s hospital discharge instructions were written as follows:
“KCl 10 mEq BID”
14 Percent Experienced 14 Percent Experienced 1+ Med Discrepancies1+ Med Discrepancies
62 percent experienced one25 percent experienced two 8 percent experienced three 5 percent experienced four or more
Patient-Level Contributing FactorsPatient-Level Contributing Factors
Non-intentional non-adherence 34%
Money/financial barriers 6%
Intentional non-adherence 5%
Didn’t fill prescription 5%
Other 1%
Subtotal 51%
System-Level Contributing FactorsSystem-Level Contributing Factors
D/C instructions incomplete/illegible 16%
Conflicting info from different sources 15%
Duplicative prescribing 8%
Incorrect label 4%
Other 7%
Subtotal 49%
30-Day Hospital Re-Admit Rate30-Day Hospital Re-Admit Rate
Patients with identified med discrepancies 14.3%
Patients with no identified med discrepancies 6.1%
P=0.041
The lack of quality measures for The lack of quality measures for care transitions remains a care transitions remains a
significant barrier to quality significant barrier to quality improvementimprovement
Brief History of the Brief History of the Care Transitions Measure (CTM)Care Transitions Measure (CTM)
Qualitative studies shaped itemsTransition-specific items => Common set of itemsItems discriminate among facilitiesCTM endorsed by NQF in May 2006
Supported by The National Institute on Aging and The Commonwealth Fund
CTM ItemsCTM Items
The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital
When I left the hospital, I had a good understanding of the things I was responsible for in managing my health
When I left the hospital, I clearly understood the purpose for taking each of my medications
Demand for the CTMDemand for the CTM
Over 1400 requests for permission to use from 15 Countries
Adopted by WHO multi-national (Europe) hospital quality collaborative
Highmark Blue Cross Blue Shield P4PMaine to vote on statewide public reporting
Qualitative EvaluationQualitative Evaluation
To evaluate the efficacy of the intervention
To augment the quantitative findings
Conclusion: Qualitative DataConclusion: Qualitative Data
Patients appreciated the follow-up, expertise, support and accessibility of the Transition Coach.
Reception of the PHR was mixed, with ½ using it, and ½ not at 30+ days post-intervention.
Barriers to successful implementation of intervention
Transition CoachTransition Coach
Competence– “She was always able to answer my questions”
Accessibility– “There was somebody I could go to if I needed, if I had
any questions, I knew I had somebody I could call.” Security
– “I was pretty skeptical about it. But it turned out to be a real beneficial thing…the program gives you a real inner comfort—when you’ve confirmed that you’re doing it right and you know what to expect.”