Transitional Care: Patient-Centered Collaboration Across the Continuum

1. Transitional Care: Patient-Centered Collaboration Across the Continuum Judy Scott, BSN, RN, CCM September 26, 2012

2. Objectives • Upon completion of this session, the participant will be able to: • Describe how to create a business plan that supports Transitional Care • Explain Relational Coordination’s role in Transitional Care • Describe two outcome measures for Transitional Care • Discuss three lessons learned through Transitional Care

3. Background and Introduction • Across the country, 20% of Medicare beneficiaries are readmitted to the hospital within 30 days of discharge (Healthcare Advisory Board, 2010) • Unplanned readmissions cost Medicare $17.4 billion in 2004 (Healthcare Advisory Board, 2010) • Avoidable readmissions accounted for $12 billion in costs to Medicare in 2005 (Healthcare Advisory Board, 2010) • Causes of avoidable readmissions include hospital-acquired infections and other complications; premature discharge; failure to coordinate and reconcile medications; inadequate communication among healthcare personnel, and poor planning for safe transitions of care. (Berenson, Paulus, & Kalman, 2012)

4. Background and Introduction • At IUH North Hospital, 16.5% of Medicare beneficiaries are readmitted within 30 days • Of patients we discharged to a Skilled Nursing Facility (SNF) in 2011, 13.06% were readmitted to our hospital within 30 days; this rate goes up to 22% depending on the SNF • 30-day SNF readmissions cost our hospital an estimated $268,540 in 2011 • According to the Healthcare Advisory Board (2010), Payments will soon be bundled for episodes of care. This means we will receive one payment to share between the physician, the hospital, and the post-acute care provider. • An episode of care is defined as 3 days prior to admissions to 30 days post-discharge • Readmissions that occur within 30 days of hospital discharge will not be reimbursed • This change forces hospitals and post-acute providers to work more collaboratively together to improve patient care quality and reduce readmissions

5. The Big Question • Could we improve patient outcomes and reduce our 30-day readmission rates if we utilized the Transitional Care Model for patients who discharge from our hospital to a skilled nursing facility (SNF)?

6. What is Transitional Care? • Mary D. Naylor, PhD, RN, is the Marian S. Ware Professor in Gerontology and Director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing. She has conducted research in care transitions since 1989. • “The Transitional Care Model provides comprehensive in-hospital planning and home follow-up for chronically ill older adults hospitalized for common medical and surgical conditions. The heart of the model is a Transitional Care Nurse (TCN), who follows patients from the hospital and into their homes and provides services designed to streamline plans of care, interrupt patterns of frequent acute hospital and emergency department use, and prevent health status decline.” Retrieved August 7, 2012 from http://www.transitionalcare.info/

7. Evidence ReviewKeywords: Skilled nursing facility, hospital readmissions, case management, transitional care, relational coordination • Level II – Randomized Control Trial (RCT) • Coleman, E.A., Parry, C., Chalmers, S., & Sung-Joon, M. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine.166, 1822-1828. This study showed that tools and guidance from a transition coach reduced hospital readmissions for patients discharged home. • Level III – Control trial without randomization • Williams, G., Akroyd, K., & Burke, L. (2010). Evaluation of the transitional care model in chronic heart failure. British Journal of Nursing 19 (22), 1402-1407. • Wong, F.KY., Chan, M.F., Chow, S., Chang, K., Chung, L., Wai-man, L. & Lee, Rance (2010). What accounts for hospital readmissions? Journal of Clinical Nursing 19, 3334-3346. These studies showed that utilizing a transitional care model or community health nurses to follow-up with patients reduced hospital readmissions.

8. Evidence ReviewData Bases Searched:Medline, EBSCO, PubMed • Level IV - Well-designed case-control and cohort studies • Naylor, M.D., Bowles, K.H., & Brooten, D. (2000). Patient problems and advanced practice nurse interventions during transitional care. Public Health Nursing, 17(2), 94-102. • Naylor, M.D. & McCauley, K.M. (1999). The effects of discharge planning and home follow-up intervention on elders hospitalized with common medical and surgical cardiac conditions. Journal of Cardiovascular Nursing, 14(1), 44-54. • Watkins, L., Hall, C., & Kring, D. (2012). Hospital to home: A transition program for frail older adults. Professional Case Management, 17(3), 117-123. The Naylor, et. al. studies supported the use of APNs to follow-up with patients post-discharge and were successful in reducing readmissions. In the Watkins and Kring study, they proved that a hospital to home program of patient follow-up reduced readmissions by 67% • Level VI - Evidence from a single descriptive or qualities study • Havens, D.S, Vasey, J., Gittell, J.H., & Wei-Ting, L. (2010). Relational coordination among nurses and other providers: Impact on the quality of patient care. Journal of Nursing Management. 18, 926-937. • Smith, S.B. & Alexander, J.W. (2012). Nursing perception of patient transitions from hospitals to home with home health. Professional Case Management, 17(4), 175-185. The Havens, et. al. study showed that using Relational Coordination improved patient care quality. The study by Smith, S.B. & Alexander, J.W. showed that nurses perceive the transition of patients from hospital to home with home care needs improvement.

9. What are we trying to accomplish? • Improve safety and clinical outcomes for patients transitioning from our hospital to skilled nursing facilities (SNF) and then on to home.

10. How will we know that a change is an improvement? • 30-day SNF readmissions will be reduced • We will experience Medicare cost avoidance by reducing readmissions • Patients will report satisfaction with the program and improved confidence in their self-care abilities

11. What changes can we make that will result in an improvement? • Implement Transitional Care (TC); a patient-centered approach to guide the patient and caregiver through the care continuum. • By adding a Transitional Case Manager (TCM), we allow the inpatient case managers to align their focus with that of the system to reduce length of stay, and we allow the TCM to focus on chronic case management.

12. Building the Case for Transitional Care: Revenue Potential • 2011: 55 SNF readmissions within 30 days of hospital discharge • The literature shows that 76% of Medicare readmissions are avoidable. For us, that meant that 42 readmissions could have been avoided in 2011 • Based on Medicare payment rates, this represents $359,436 inunreimbursed care under the new ACO model

13. Revenue Potential • Those 42 preventable readmissions account for 265 patient days (average LOS for SNF discharges was 6.3d) • Given our overall average LOS of 3.9d, we could have admitted an additional 68 patients during this time period, representing over $581,944 in lost revenue potential (based on Medicare reimbursement) • Median Medicare Cost/Case = $4,630 • Multiplied by 68 = $314,840 • Revenue potential minus cost/case = $267,104 net revenue potential

14. Potential Return on Investment • Net revenue potential: 267,104 • Potential lost revenue: + 359,436 $626,540 • Program costs: - 120,000 • Potential ROI: $506,540

15. The Right Thing to Do • It’s not all about the money... • It’s about bridging communication gaps • It’s about ensuring the safe transition of our patients and coordinating care from one setting to the next • It’s about taking the best possible care of our patients to improve clinical outcomes and enhance patient/family satisfaction...even if that means moving beyond the hospital walls to do it.

16. Executive Team Support • IUH is evolving into an Accountable Care Organization • Executive Team encourages innovation and creativity • It is the right thing to do for our patients • Culture and Maxims • Take Ownership • Do More • Show Kindness • Create Joy • Connect Fully

17. Building the Program • Case Manager candidate selection: • Highly motivated • Critical thinker • Problem solver • Strong clinical background • Collaborative

18. Building Relationships • Patient/Caregiver • Advanced Healthcare Associates • Four local Skilled Nursing Facilities; selected based on our referral patterns • Home Care Agencies

19. Relational Coordination • “Coordinating work across functional and organizational boundaries through relationships of shared goals, shared knowledge and mutual respect, supported by frequent, timely, accurate, problem-solving communication.” Retrieved August 7, 2012 from: http://rcrc.brandeis.edu/rc/

20. Relational Coordination • Shared Goals: Improve patient outcomes • Shared Knowledge: Bridge communication gaps; patient report, clinical education, patient education materials • Mutual Respect: Understand the specialized care delivered across the continuum

21. Relational Coordination • Another way to look at it: • “While coordination is the management of interdependencies between tasks, relational coordination is the management of interdependencies between the people who perform those tasks” (Gittell, 2009, p.15) • Relational Coordination can improve communication among colleagues who work in different areas of expertise. It results in fewer chances for errors to occur and will drive quality performance in a positive direction. (Gittell, 2009)

22. Post-Acute Facility Collaboration • Began in 2010 • Learn from each other; developing mutual respect • Provide free clinical education for post-acute care providers • Identified opportunity to improve communication at time of transition to the SNF • Developed standard Patient Report Tool • Transitional Care Program developed in 2011; implemented February, 2012 • Collaboration continues today

23. Innovative Partnership • In addition to clinical case management, our Transitional Care program includes an innovative partnership with a transitional care physician • This former IU Health hospitalist works closely with our case manager to meet the clinical needs of our patients throughout their stay in the SNF • The transitional care physician acts as the patient’s primary care physician until discharge from the SNF at which time, the patient’s primary care physician resumes care of the patient

24. Physician Collaboration • Transitional Care Physician is employed by Advanced Healthcare Associates • TCM partners with the Transitional Care Physician to coordinate the patient’s care throughout their SNF stay • TCM proactively monitors the patient for any clinical changes and engages the TCP as needed • Early recognition of subtle changes in the patient’s clinical condition has allowed treatment to occur in the SNF and has prevented hospital readmissions

25. Nuts and Bolts of the Program • Training • HIPAA Compliance • Informed Choice • Patient Enrollment • Patient Visits • Essential Functions • Documentation • Discharge Packet • Home Care Plan • Communication and Handoffs

26. Training • Johns Hopkins Nursing Institute • Scholarships • Guided Care Certification • Major focus on motivational interviewing • Patient engagement • Medical Home Model but principles apply to Transitional Care

27. HIPAA Compliance • Consent to participate • Includes release of information consent so we can access patient information in the SNF and beyond • Program intent and consent form were reviewed and approved by IUH Legal Department

28. Referral and Choice Process • Introduction letter is given to the patient • Explanation of the program offered during the Informed Choice Process • Patient selects post-acute facility • Transitional case manager and physician are notified of the referral and are given basic patient information: name, MRN, room number, discharge location, anticipated discharge date

29. Patient Enrollment • The TCM meets the patient in the hospital prior to discharge • The patient consents to participate in the program and agrees to release their health information • The patient’s discharge summary is reviewed by the TCM prior to discharge for medication reconciliation and to clarify any information for the SNF provider

30. Patient Visits • Multiple 1:1 patient visits in the SNF weekly • Early identification of subtle clinical changes • Prompt intervention • Care coordination • Patient education • Ongoing medication reconciliation

31. TCM Essential Functions • Develop and nurture a collaborative partnership with the patient/caregiver and post-acute facilities (Relational Coordination) • Create a seamless path for the patient/caregiver; one consistent resource to answer questions or concerns, provide ongoing education, and navigate the patient through the care continuum • Act as the patient’s link to all physicians (the hospitalist, transitionalist, specialist(s), and primary care physician) as well as other healthcare providers involved in their care • Empower patients to be active participants in their care and decisions regarding their care through education and action plans • Connect the patient to community resources, home health agencies, and health plan case managers as needed  • Conduct medication reconciliation at discharge to assure safety and continuity • Bridge the communication gaps that can exist when patients transition from one care setting to another

32. Documentation • Morrisey Concurrent Care Manager (MCCM) • Continuum Module • Documentation occurs at the patient level rather than the encounter level; spans the continuum • Can view continuum notes from the acute side if patient is readmitted

33. MCCM Continuum

34. Continuum Notes

35. SNF Discharge Packet • Comprehensive packet is faxed to the PCP and any specialists involved in the patient’s care at the time of SNF discharge. Packet includes: • Hospital discharge summary • Summary of events during SNF stay • Transitional Care physician notes • Therapy notes • Lab and test results; resulting treatments • Vital signs • Diet • Discharge medications • Any special concerns to be followed-up by the PCP • Post-discharge follow-up tests and appointments

36. Transitional Care Home Plan • Medications • Patient-friendly language • Schedule • Reason • Wound care as needed • Diet • Activity • Follow-up appointments • Post-SNF care as needed (HHA) • Additional information as needed

37. Sample Home Care Plan – Page 1

38. Sample Home Care Plan – Page 2

39. Outcomes through May 2012

40. Outcomes through May 2012 • 45% Reduction in overall 30-Day SNF readmissions since our Transitional Care Program was implemented Feb 24, 2012!

41. Cost Avoidance through May 2012 • Median Medicare Cost/Case = $4,630 • Cost of SNF Readmissions Jan11 thru Jan12 = $300,950 • 45% cost reduction, minus program costs = $108,326 in cost avoidance thru the first 4 months • Annualized cost avoidance = $324,978 • Estimate does not include revenue potential from additional admissions

42. Patient Satisfaction • Tool has been developed • Currently under review by IUH Marketing Dept. before implementation

43. Lessons Learned • Patient hand-off from hospital to SNF needs improvement • Medication reconciliation is a high risk area; needs improvement • Need mechanism to notify the ED of transitional care patients, even if they’ve been discharged home from the SNF • SNF patient education needs improvement; patients are unprepared to care for themselves at home • SNF discharge process is somewhat fragmented; needs improvement • Need mechanism to collaborate with other programs within IUH system to coordinate patient care (i.e., GRACE, Chronic Disease Management, etc.) • It is challenging to coordinate care for patients who have primary care physicians outside the IUH system • Once the patients return home from the SNF, they need continued monitoring to assure appropriate follow-up and prevent further readmissions (Some of our patients readmitted to the hospital from home outside the 30-day window)

44. Home Care Pilot • Goals: • Reduce hospital readmissions beyond 30 days post-discharge • Improve the patient’s self-care abilities and outcomes • Skilled nursing visit within 48hrs of SNF discharge; then once weekly x 4 weeks • Medication adherence • Follow-up appointments • Therapies as needed • Continued patient education

45. Thank you!

46. References • Berenson, R.A., Paulus, R.A., & Kalman, N.S. (2012). Medicare’s readmissions-reduction program: A positive alternative. The New England Journal of Medicine, 366(15), 1364-1366. • Gittell, J.H. (2009). High performance healthcare: Using the power of relationships to achieve quality, efficiency and resilience. New York, NY: McGraw Hill. • Havens, D.S, Vasey, J., Gittell, J.H., & Wei-Ting, L. (2010). Relational coordination among nurses and other providers: Impact on the quality of patient care. Journal of Nursing Management. 18, 926-937. • Healthcare Advisory Board (2010). Succeeding under bundled payments. Retrieved May 10, 2011 from www.advisory.com. • Naylor, M.D., Bowles, K.H., & Brooten, D. (2000). Patient problems and advanced practice nurse interventions during transitional care. Public Health Nursing 17(2), 94-102. • Naylor, M.D. & McCauley, K.M. (1999). The effects of discharge planning and home follow-up intervention on elders hospitalized with common medical and surgical cardiac conditions. Journal of Cardiovascular Nursing, 14(1), 44-54. • Smith, S.B. & Alexander, J.W. (2012). Nursing perception of patient transitions from hospitals to home with home health. Professional Case Management, 17(4), 175-185. • Watkins, L., Hall, C., & Kring, D. (2012). Hospital to home: A transition program for frail older adults. Professional Case Management, 17(3), 117-123. • Williams, G., Akroyd, K., & Burke, L. (2010). Evaluation of the transitional care model in chronic heart failure. British Journal of Nursing 19 (22), 1402-1407. • Wong, F.K.Y., Chan, M.F., Chow, S., Chang, K., Chung, L., Wai-man, L. & Lee, Rance (2010). What accounts for hospital readmissions? Journal of Clinical Nursing 19, 3334-3346.