p urpose

1. Caretransition and network activation within home supported discharge service for stroke patients in Portugal Silvina Santana, BertholdLausen, CharikliaTziraki ICIC13, 11– 12 April 2013

2. purpose • to report on the use of a user-centred model and methodology, including the scale CTNAM, to assess the quality of care transition and network activation action, within a randomized control trial on home supported discharge for stroke patients in Portugal

3. context - evidence EVIDENCE we talk a lot about integrated care, integrating care, care coordination, care continuity .... EVIDENCE points of discontinuity, that is, care transitions, have seldom been investigated EVIDENCE care transitions are problematic, dangerous and expensive for the patient, the care provider and the health and social care systems

4. context - in need of a definition • a transition of care refers to a patient movement between care locations, providers or different levels of care within the same location as his/her condition and care needs change: the patient transits • it can be seen as a set of actions designed to ensure coordination and continuity of care (NTOCC, 2008): actions to assure that all goes well when the patient transits • but also as a point in a care process and in space, to which the time dimension is always associated (me, 2013 - I like processes! 

5. context – CT as a point in a care process in processes mapping, we would represent a care transition like this place implies a defined, identifyablestate place a transition e.g., discharge about a CT, we want to know: WHAT, HOW, WHEN, WHO, other resources and WHY, in order to improve and evaluate efficiency and eficacy

6. context – the Portuguese care system • the Portuguese health care system • diversity of entry points • no national EHR • difficult information flow between professionals, services and institutions • inadequate use of scarce and expensive resources • the Portuguese social care network • mostly run by privately owned, non-profit-making institutions (IPSS and Misericórdias), that operate close to the population

7. context – the Portuguese care system • the RNCCI, a kind of 3rd level of care • launched in 2006 by the Portuguese gorvernment, it has been presented as a 3rd level of care, connecting with acute care hospitals and health centres • builds on partnerships among existing institutions in diverse sectors (most of them are IPSS or hospitals belonging to Misericórdias - Charities), integral planning and multidisciplinary practice • country wide, dedicated web-based information system available • home care is supposed to be one important element in this network, but implementation is low so far • integration outside the RNCCI (e.g., between hospitals and primary care) and between the RNCCI and other levels of care is still weak

8. context – the Portuguese care system

9. question • fromthepointoftheviewofthepatients, howisthesystemdoing, regardingtheirtransitionfromonecareprovider to another?

10. methods • we have studied the whole patient’s course, from the admission to the stroke unit to six months after discharge • a methodology has been developed to assess the quality of care transitions and network activation actions • today we present the results from using the CTNAM, the Care Transition and Network Activation Measure

11. methods patient course in the study group discharged directly home Community SU Community 1 month from discharge 6 months homecare team with case manager discharged to an RNCCI inpatient unit Community SU CU Community 1 month from discharge 6 months homecare team with case manager

12. methods 4 main aspects • dealing with the medication at home • dealing with the activities of daily living • finding help in the community • dealing with the moment of discharge itself AT THE DISCHARGE from the SU the RU self-reported patient preparedness informationprovidedbythe hospital orthe RU momentofdischarge TALK ABOUT NETWORK ACTION • A name or/and phone number at the hospital • List of medication, how and when to take • Written care plan, including diagnosis, ... • Discharge letter to be given to family doctor, nurse ... • MEDICATION at home: why, how, sec effects • DAYLY LIFE ACTIVITIES: can and cannot do • ALERT SYMPTOMS • FIND HELP IN THE COMMUNITY • OPTIONS THE PATIENT HAS • INCLUDE THE FAMILY or other informal carer

13. methods Social careentities FHU/Healthcenter (primarycare) Familydoctor as gate keeper Hospital (acutecare) Discharge management team RNCCI stillmostlyinpatient HOME TALK ABOUT CHECK BEHIND help in the community: services, tech aids, economic aid PLAN FORWARD discuss discharge letters care at home and rehab medication and exams: done medication and exams: to do

14. methods Social careentities Hospital (acutecare) Discharge management team HOME RNCCI stillmostlyinpatient Healthcenter (primarycare) Familydoctor PATIENT AND IC • ABLE TO TAKE MEDICATION AT HOME • CHANGE LIFE STYLE/HABITS • DONE CONSULTATION and EXAMS • FOLLOW REHABILITATION PLAN • INFORMAL CARER ABLE TO DEAL WITH NEEDS • ABLE TO FIND SUPPORT IN THE COMMUNITY Perceived quality of care Satisfaction with services

15. results • self-reported patient preparedness (1=not confident at all to 5 = very confident)

16. results • information provided by the unit (1=none, 2=not enough, 3= all I need)

17. results 12 itemsgrouped in 4 dimensions • moment of discharge, talk about (1=completely disagree to 5=fully agree)

18. results • network activation (yes, no)

19. results • primary care (family doctor) action (1=completely disagree to 5=fully agree)

20. results • home care (1=completely disagree to 5=fully agree)

21. conclusions • outside the RNCCI, that still handles a limited percentage of patients in need of rehabilitation after a stroke there is no integrated information system available to the providers involved in the chain of care • tools such as case managers or care plans are not in use • discharging and referring letters are the preferred way of communication between hospitals and family doctors based in health centres of family health units • it is not common practice to provide the patients with an anchor contact point in the discharging unit or helping the patients finding help in the community

22. conclusions • the widely adoption of a standard framework based on a conceptual model for the measurement of care transition quality is strongly recommended • the measure set should include structural, process and outcome measures • process measures should be paired, addressing both the sending and the receiving providers in order to promote shared accountability • the right balance between cost and benefit must be found keeping always in mind the logic of network

23. Caretransition and network activation within home supported discharge service for stroke patients in Portugal thanks ICIC13, 11– 12 April 2013