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Effective and Supportive Transitions of Care: The Care Teams Role in Reducing Admissions

Effective and Supportive Transitions of Care: The Care Teams Role in Reducing Admissions. Jim Kinsey, Planetree Presented to Texas Center for Quality and Safety January 2013 . Setting the Stage.

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Effective and Supportive Transitions of Care: The Care Teams Role in Reducing Admissions

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  1. Effective and Supportive Transitions of Care: The Care Teams Role in Reducing Admissions Jim Kinsey, PlanetreePresented to Texas Center for Quality and Safety January 2013

  2. Setting the Stage The term "transitions of care" refers to a patient leaving one care setting and moving to another as their condition or healthcare needs change. The care transition often involves multiple persons including the patient, family or other caregivers... An optimal transition should be well planned with the involvement of the patient and family, and adequately timed. More often, however, the communication between settings and the coordination among caregivers, patients and healthcare professionals fail to provide all the information needed for optimum quality of care

  3. Just the Facts

  4. Just the Facts • Cost $25 billion dollars annually • Most patients are on 6+ medications at time of discharge • Limited access to post-hospitalization follow-up care • Preventable transition errors (mostly medication related) • Penalties: • $280,000,000 in 2012 • Including over 2, 000 hospitals • 1,910 of those hospitals receiving less than • 1% penalty • Penalties increase to 2% in 2013 and 3% 2014 NQF 2010-2012

  5. It is not just about reimbursement…

  6. So where do we begin… Communication Collaboration

  7. Communicate: Patient and Family Activation • Care Partner Programs • Clear concise advance directives • Diagnosing patient preferences

  8. Preference Diagnosis: First Step to Effective Transitions Drawn from Mulley, A.G., Trimble, C. and Elwyn, G. “Stop the silent misdiagnosis: patients’ preferences matter.” BMJ, 2012, 345.

  9. Collaborating for Positive Patient Outcomes

  10. Care Team Activities

  11. Creating a Collaborative • Patients Voice • Tell me about your recent transition of care? • Tell me how we may have done that better? • Provider Voice: Who are the players in your community? • What is working? • What isn't working? • How to we create standard work and processes between our service lines? • How can we standardize treatment philosophies while maintain focus on patient preferences? • Most importantly put down the history and focus on providing exceptional patientexperiences

  12. “…the thought is that we are here to provide service to patients and their families, understanding that patients are not isolated individual units, but they function as part of a social system, so involving family also in access to information, education and care is very important.” Susan Frampton, President Planetree

  13. Jim Kinsey, Planetree 610.733.5140 jkinsey@planetree.org www.planetree.org

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