VOLUME 21
ISSUE 2
WINTER 2011
Published by the National Association of Professional Geriatric Care of Managers 3275 West Ina Road Suite 130 Tucson, Arizona Geriatric Care Management 85741 520.881.8008 / phone 520.325.7925 / fax www.caremanager.org
Rehospitalization: How Care Managers Help Decrease Hospital Visits
Guest Editor’s Message ...... 2 By Cathy Jo Cress, MSW
Bridging the Gap: The Role of Geriatric Care Managers in Reducing Avoidable Hospital Readmissions...... 3 by Marisa Scala-Foley, MGS, Michelle M. Washko, PhD, Caroline Ryan, MA, Abigail Morgan, MSS, MLSP
Do Geriatric Care Management Interventions Make a Difference? Prove It...... 10 by Deborah Newquist, PhD, MSW, CMC
Transitioning Care to the Home: Reducing Rehospitalization Among Frail Elders...... 13 By Rona Bartlestone, LCSW, BCD, CMC, C-ASWCM
Evidence-Based Transitional Care for Chronically Ill Older Adults and Their Caregivers...20 By M. Brian Bixby, MSN, CRNP
Helping Reduce Hospital Readmissions Using Seven Key Elements...... 25 By Cathy Jo Cress, MSW
Reducing Hospital Readmissions— One Hospital’s Journey to Implement Safer Transitions in Care...... 29 By Robin Jones, RN of Geriatric Care Management Winter 2011
Guest Editor’s Message By Cathy Jo Cress, MSW
An estimated 90% of hospital tion. The hunt for ways to improve and hospitals by becoming a part of the readmissions take place within 30 health care for older persons with LTC and transition in care system and days of discharge and are unintended. chronic illnesses put the spotlight the hospital-to-home team. They can do These readmissions, often avertable, on areas where care is deficient and this providing the necessary coaching cost Medicare $17.4 billion in 2004. costly. Transitions of care (TOC) are and support to patients and their fami- The financial toll of avoidable read- one such segment of the health care lies so that older clients are not readmit- missions is only one harmful effect experience. ted, and stay in the community, thereby on the U.S. health care system, now For years GCMs have provided reducing health care system expenses. in the process of a major reinvention. services to their clients during transi- This issue of the Winter Geriatric The human cost of repeated disease tions of care. Routinely moving Care Management Journal contains can be equally damaging in terms of clients from home to hospital to re- articles that show recent studies and re- the corrosion in function, reduced habilitation and back home, or to al- search on transitions in care and demon- symptom-free days, and loss of faith ternative living arrangements, GCMs strates how geriatric care managers can in a health care system previously have advocated for their clients. By be part of that home team and actually trusted to preserve or improve health. transmitting and reconciling medica- prevent hospital admission while doing Health care errors and adverse events tions and other information from one their regular job. That job is using the often associated with transitions in provider to another; counseling and continuum of care to keep older clients care only swell national discontent and educating clients and their families at the safest level of care. growing very public distrust in our about health conditions; navigating I want to thank the following poorly performing system. warped systems and coordinating authors for creating a new dimension Health care reform, exemplified services to meet changing client need, to the dialogue and call for action for by the Affordable Care Act of 2010 GCMs are experts in spotting the GCMs: Robin Jones, Marisa Scala- (ACA), propels the topic of chronic gaps and filling them. Foley, Michelle Washko, Caroline Ryan, care into the forefront and speaks for Geriatric care managers can help Abigail Morgan, M. Brian Bixby, Debo- the need to mandate care coordina- the long-term care system, doctors, rah Newquist, and Rona Bartlestone.
Editorial Board Rona Bartelstone, LCSW Fort Lauderdale, FL Cathy Cress, MSW Santa Cruz, CA Lenard W. Kaye, PhD Orono, ME of Leonie Nowitz, MSW, LICSW New York, NY Journal Emily Saltz, MSW, LICSW Newton, MA Geriatric Care Management Monika White, PhD Santa Monica, CA Published by the: National Association of Professional Geriatric Care Managers Editor-In-Chief 3275 West Ina Road, Suite 130, Tucson, Arizona 85741 • www.caremanager.org Karen Knutson MSN, MBA, RN © Copyright 2011 Charlotte, NC The Journal of Geriatric Care Management is published two times per year as a membership benefit to Graphic members of the National Association of Professional Geratric Care Managers. Non-members may subscribe Design to Journal of Geriatric Care Management for $95.00 per year. Send a check for your one-year subscription to: HagerDesigns Subscription Department, NAPGCM, 3275 West Ina Road, Suite 130, Tucson, Arizona 85741. Dallas, Texas
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Bridging the Gap: The Role of Geriatric Care Managers in Reducing Avoidable Hospital Readmissions By Marisa Scala-Foley, MGS, Michelle M. Washko, PhD, Caroline Ryan, MA, Abigail Morgan, MSS, MLSP
Summary establishes the Community- based Care Transition Avoidable hospital Nearly one in five Medicare Program, which provides readmissions have received scrutiny due to their link beneficiaries discharged from the funding to community-based organizations and hospitals with poor quality health hospital are readmitted within 30 outcomes and high care that “furnish improved care costs. Two provisions days, and about one-third within transition services to high- of the Patient Protection 90 days, and up to 76 percent risk Medicare beneficiaries” and Affordable Care Act (H.R. 3590, 2010). The specifically target avoidable of these readmissions may be Community-based Care hospital readmissions, one preventable (MedPAC, 2007). Transition Program is of which focuses on care part of a companion effort transitions -- the movement undertaken by the U.S. of patients between health Department of Health and care practitioners and settings as 90 days, and up to 76 percent of these Human Services called the Partnership their condition and care needs change readmissions may be preventable for Patients. One of the two major during an illness. Proper planning (MedPAC, 2007). Such unwanted goals of the Partnership is to “help offers a proven way to prevent hospital readmissions have high patients heal without complication,” rehospitalizations and improve costs – both financially, for health aiming for a 20 percent reduction in outcomes for patients. This article care payment systems, as well as hospital readmissions by the end of discusses the role of geriatric care physically and emotionally for people 2013 (U.S. Department of Health & managers within care transition with Medicare and their families. In Human Services, 2011). teams and strategies implemented by 2004, Medicare spent $17.4 billion care transitions programs to reduce in hospital payments on unplanned Readmissions and Care avoidable hospital readmissions. readmissions (Jencks, 2009). Transitions The 2010 Patient Protection Care transitions are defined Introduction and Affordable Care Act (ACA) as “the movement patients make Viewed as an indicator of poor has a three-part aim of better between health care practitioners and quality and high cost, the problem of care for individuals, improved settings as their condition and care avoidable hospital readmissions has population health, and lower costs. needs change during the course of a received increasing scrutiny in recent While numerous provisions of the chronic or acute illness” (University years, with policymakers, payers, ACA seek to foster improved care of Colorado Denver, 2011). Such health systems, health and long-term coordination for Medicare and transitions might include going from supports and services providers, Medicaid beneficiaries, two provisions a hospital or skilled nursing facility and community-based organizations specifically target avoidable hospital to home, from a hospital to a skilled alike working toward reducing readmissions, albeit in different nursing facility, from one level of rehospitalizations (MedPAC, 2007; ways. Section 3025 authorizes the care to another (e.g., from a surgical MedPAC, 2008). Nearly one in five Secretary of Health and Human unit to an intensive care unit within Medicare beneficiaries discharged Services to reduce Medicare payments a hospital), or even from one form of from the hospital are readmitted within to hospitals with higher-than-expected 30 days, and about one-third within readmission rates, and Section 3026 continued on page 4
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Bridging the Gap: The Role Care Transitions— Care Transitions and the of Geriatric Care Managers Addressing the Problem Aging Network in Reducing Avoidable Hospital Readmissions Transitional Care – defined by In 1965, Congress enacted the the American Geriatrics Society as Older Americans Act (OAA) to continued from page 3 “a set of actions designed to ensure provide a broad range of coordinated payment to another (e.g., from private the coordination and continuity services to older Americans which pay to a Medicaid waiver). of health care as patients transfer would enable them to maintain between different locations or Poor care transitions can result in maximum independence as they different levels of care within the same increase in age. These services include medication errors, gaps in follow-up location” – is designed to prevent nutrition programs, health promotion care, miscommunication, unnecessary unnecessary rehospitalizations and activities, ombudsman services in rehospitalizations, and nursing home improve outcomes for older people Long-Term Care settings, home- admissions (Jencks et al, 2009; (American Geriatrics Society Health and community-based services, and American Geriatrics Society Health Care Systems Committee, 2007). caregiver support, to name a few. This Care Systems Committee, 2007). A Evidence-based care transition models legislation also created the AoA and 2009 AARP survey of persons with -- including the Care Transitions the “Aging Network”—a national chronic conditions found that 21 Intervention (University of Colorado system with entities at the federal, percent of those surveyed felt that Denver, 2011), the Transitional Care state and territorial, tribal, and local their health care providers did not Model (University of Pennsylvania levels. It includes 56 State Units on communicate well with each other – School of Nursing, 2011), Better Aging, 629 Area Agencies on Aging with 20 percent believing that this had Outcomes for Older Adults through (AAAs), 246 tribal organizations, had a negative impact on their health. Safe Transitions, or BOOST (Society some 20,000 local community service Nearly 20 percent also cited a lack of of Hospital Medicine, 2011) , Guided organizations, hundreds of thousands coordination in their care transitions Care (Johns Hopkins University, of volunteers, and a wide variety of (AARP, 2009). 2011), Geriatric Resources for national organizations, all of which In addition to the medical factors Assessment and Care of Elders, or work together to provide social GRACE (Counsell et al, 2006), the associated with poor transitions, services to older adults. State Units on Bridge Program (Illinois Transitional unmet needs in the community can Aging, which are state and territorial Care Consortium, 2011), Project impact the success of care transitions. government agencies, administer, Re-Engineered Discharge, or Some studies have found that between manage, design, and advocate for RED (Boston University Medical 40 and 50 percent of readmissions benefits, programs, and services. Center, 2011), Interventions to may be due to social factors and a Reduce Acute Care Transfers, More locally, Area Agencies on lack of access to community resources or INTERACT (Florida Atlantic Aging provide a range of services (Proctor et al, 2000). In a recent study University, 2011), and more -- have that help individuals remain in their evaluating the home food environment been developed to provide support homes and communities for as long as of hospital-discharged older adults, to individuals and caregivers during possible. The Aging Network serves one-third of participants reported and after the transition across large numbers of older people and individuals with disabilities, including being unable to both shop and prepare hospital, skilled nursing facility, and diverse populations and those with meals after discharge (Anyanqu et community settings. al., 2011). Medicaid waiver program low incomes. Through this network, research also demonstrates that greater While the models may differ AoA reaches approximately 11 million volume of attendant care, homemaking in terms of staffing, duration, and individuals each year. The Aging services, and home-delivered meals target setting, in most care transitions Network receives not only the majority are associated with lower risk of programs, individuals and caregivers of AoA’s federal appropriation, but at risk for poor transitions and hospital admissions (Xu et al, 2009). also funding from a variety of other hospital readmissions are identified sources (including the Centers for Supporting care transitions needs and connected with designated care Medicare & Medicaid Services, or to be a collaborative, community- transition staff prior to discharge. CMS, and the Department of Veterans based process that brings together Interdisciplinary communication Affairs, or VA) to deliver long-term professionals from all health-care and coordination as well as patient services and supports. AoA is the only related fields – including geriatric care activation ensures that individuals federal-level agency solely devoted management – to facilitate smooth and their caregivers understand post- to serving the social service needs of transitions and prevent readmissions discharge instructions regarding their Americans aged 60 and over by means (Ventura et al, 2010). This article medications and self-care, connect of programmatic activity. The Aging will discuss the role of geriatric care with outpatient physicians and other Network specifically targets services to managers within care transition teams community services and supports post- the most vulnerable and frail elderly, and common strategies implemented discharge, and recognize and know and participants in Older Americans by care transitions programs to reduce how to respond to symptoms that may Act (OAA) services are more likely avoidable hospital readmissions. indicate potential complications. to be in poor health, need support
page 4 of Winter 2011 Geriatric Care Management for multiple Activities of Daily beyond the short-term care transition introduction to warning signs and Living (ADLs) and more likely to be program period which may also have symptoms, and development of a managing multiple chronic conditions the potential to impact frequency of post-discharge follow up plan (Parry (Kleinman and Foster, 2011; Altshuler readmissions (Proctor, 2000). et al, 2003). Finally, successful and Schimmel, 2010). It is this target transitions across care settings depend population that is most likely to be at Care Transitions and upon effective communication, risk for multiple hospital readmissions the Current Role of incorporating multi-disciplinary team and can benefit from support during Professional Geriatric perspectives with sharing important transitions across settings. Care Managers client information and building a sense Supporting transitions across care Professional Geriatric Care of shared accountability as individuals settings has been an Aging Network Managers are important partners transition from one setting to another activity for many years, and AoA and within local Aging Network (Parry et al, 2003). CMS have funded several initiatives initiatives and these community In terms of the current roles of related to improving the coordination partnerships play a critical role within GCMs, NAGCM standards of practice of care transitions. Since AoA and interdisciplinary care transitions relate well to the common elements CMS first began supporting the teams. As members of care transition of successful care transitions. Of development of Aging and Disability teams, it is helpful for professional particular note are the standards Resource Centers (ADRC) in 2003, Geriatric Care Managers (GCM) to relating to the client relationship ADRCs have been working to assist understand effective care transitions and professionalism of practice: (1) individuals in “critical pathways,” strategies and how these strategies fit identifying the client, (2) promoting defined as the times or places when within their current professional roles self-determination, (3) right to people make important decisions and responsibilities. privacy, (4) definition of the role to about long-term supports other professionals, and (5) and services . This work development of care plans included several innovative (National Association of community interventions Many care transition programs Professional Geriatric Care to facilitate the hospital Managers, 2011). discharge process and help within the Aging Network are able nursing facility residents to capitalize on existing infrastructure • Identifying the client. return to the community. In to implement evidence-based care GCMs serve as client 2009, AoA and CMS named transition strategies and provide advocates and liaisons “person-centered hospital between various members of increased access to critical discharge planning” as a key the client’s system, including operational component of long-term services and supports family members, in-home an ADRC and in 2010, 16 post-discharge. aides, physicians and others states were awarded funding (Kelsey & Laditka, 2007). to significantly strengthen This standard reinforces the the role of ADRCs in concept of patient activation, implementing evidence-based care Often the first transition that where self-management of health transition programs (Administration individuals experience within the and health decisions must include on Aging, 2011). health care system is the transition both the patient and family as Many care transition programs from the community to the hospital, part of the core health care team within the Aging Network are able to and can provide important information (Bodenheimer et al., 2002). This capitalize on existing infrastructure to the hospital about the resources standard also relates to the theme to implement evidence-based care and supports that the individual of shared accountability and transition strategies and provide and caregiver accessed prior to collaboration between providers in increased access to critical long-term hospitalization. Community transition order to support a care transition. services and supports post-discharge. partners, including GCMs, have the A GCM has the ability to examine For example, community care unique ability to move across settings the client system across care transition staff from an ADRC or AAA with the individual and caregiver, settings and collaborate with not only provide options and access and the community is also frequently community partners to provide to transportation and remove barriers the last “receiver” post- discharge important insight to health care for attending physician appointments, from healthcare settings. GCMs and professionals whose perspective but also empower and educate community-based care transitions and influence may be limited to a individuals on how to make the most staff, such as AAA/ADRC staff, particular setting. serve an important role in preparing of the appointment. Connection to • Promoting self-determination. the individual and caregiver for the community-based programs and Core to this standard is the GCM services are especially important next care setting through medication for individuals who need support reconciliation, patient activation, an continued on page 6
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Bridging the Gap: The Role information about this role be care transition, this standard of Geriatric Care Managers conveyed to other members of closely relates to supporting in Reducing Avoidable the care transitions team, such as follow-up care and medication Hospital Readmissions hospital, rehabilitation, or nursing management post-discharge, continued from page 5 facility staff. as well as developing care o Whether GCM will need business plans that support patient/client identifying and articulating clients’ affiliate agreements with hospitals activation. After a discharge from values and preferences in their care under HIPAA -- or will hospital a hospital, care plans often require plans, regardless of the physical, case management department adjustments. GCMs are well suited mental or emotional capacity of consider a GCM a member of the to inform the discharge process of the client (National Association core care team, therefore bypassing clients’ existing care plans as well of Professional Geriatric Care HIPAA requirements (Yang & as community resources available Managers, 2011). This standard Kombaracaran, 2006). to address new supportive service can be most closely tied with the needs. GCMs also frequently • Definition of the role to other care transition theme of patient accompany clients to physician professionals. GCMs should activation. Patient activation appointments and help their clients clearly define their role and scope describes an individual’s ability make sure that important questions in terms of a client’s wishes to self-manage their own health, are addressed. GCMs can help and the GCM’s professional and personally engage in option identify poly-pharmacy issues, capacity (National Association development and decision- activate clients to address their of Professional Geriatric Care making processes (Hibbard et al, medication questions with their Managers, 2011). This standard 2004). Rather than responding follow-up primary care physicians, most closely aligns with the to presented care options, clients or make referrals to pharmacists for critical theme of supporting and family members should be medication therapy management. multidisciplinary communication full collaborators and developers However, specialized training and and shared accountability during of their own health goals to the collaboration with other healthcare a transition across the continuum maximum extent possible. professionals is needed to fully of care. GCMs can serve as the address important medication • Right to privacy. The right to bridge between actively engaged reconciliation processes post- privacy needs to be maintained patient and family members discharge (Rust and Davis, 2011). to the maximum extent possible, and the professional health care while fully disclosing the limits team. In addition to providing Discussion to confidentiality upfront to the perspective of clients across the Transitioning from one care client. Previous qualitative studies continuum of care, GCMs bring setting to another can be potentially indicate that GCMs continue an underrepresented expertise harmful for individuals with serious frequent contact with clients across through their geriatric perspective or complex illnesses, in part because various hospital, nursing home and training to multidisciplinary the care transition process is prone and home settings, and often act as teams in settings where trained to errors resulting from poor patient advocates (Dobrish, 1987, gerontologists may be in short Kelsey & Laditka, 2007). As such, supply (Counsell et al, 2007). communication and coordination, GCMs can be integral members Yet involvement in a truly inadequate care management or of an interdisciplinary care collaborative and interdisciplinary follow-up care, etc. In addition, transitions team. Such a role may team process remains a difficult poor care transitions are costly. require additional considerations concept to incorporate into Almost one in five Medicare patients for disclosing patient or client everyday practice (Netting & (approximately 2.6 million older information. Client populations Williams, 1996). Geriatric adults) are readmitted to the hospital that are at high risk of multiple care managers’ commitment within 30 days of their original readmissions will require upfront to identifying the client and discharge. This extrapolates to a cost discussions and preparation of total client system provides an of over $26 billion per year (U.S. appropriate agreements (informed advantage in being able to view Department of Health & Human consent, release of information, the sum of all parts at play, but Services, 2011). Successful and etc.) for the GCM should they can also put GCMs at odds with cost-effective care transitions require be hospitalized. Considerations a sense of shared accountability better connections between medical can include: as GCMs may see themselves as providers and community services o How will a GCM be notified of a more accountable to clients than to providers. While there are roles for hospitalization a team of loosely connected health many different professionals to play in care professionals. o What role does the client wish this process, geriatric care managers the GCM to play during the • Development of plans of care. In can clearly be part of a community- hospitalization, and how will terms of supporting a successful based solution.
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Investing in geriatric appropriate skills training to help References care managers for them meet the demands that will be AARP. Chronic Care: A Call to Action care transitions. asked of them. For example, geriatric for Health Reform. Rep. Washington, care managers should consider DC: AARP, 2009. Chronic Care: A Call Given the new emphasis on how care transition strategies align to Action for Health Reform. AARP. care transitions in the Affordable with their existing professional Web.
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Bridging the Gap: The Role “Improving Care Transitions | Making “Partnership for Patients | HealthCare.gov.” of Geriatric Care Managers Care Safer | Partnership for Patients | Home | HealthCare.gov. U.S. Department in Reducing Avoidable Healthcare.gov | HealthCare.gov.” Home of Health & Human Services, 2011. Web. Hospital Readmissions | HealthCare.gov. U.S. Department of 11 Oct. 2011.
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Yang, Julia A., and Francis A. Kombarakaran. “A Practitioner’s Response Dr. Michelle Washko is a Caroline Ryan is an Aging to the New Health Privacy Regulations.” gerontologist with expertise in Services Program Specialist Health & Social Work 31.2 (2006): 129- the area of productive aging, in the Office of Program 136. Print. specifically around the issues Innovation and Demonstration of older workers, the eldercare at the Administration on Aging. workforce, and prevention. She Caroline was previously employed Marisa Scala-Foley serves as came to the Administration on by Aging Care Connections in a Social Science Analyst under Aging from the U.S. Department La Grange, Illinois, where she the Office of Policy, Analysis of Labor, where she helped to implemented and evaluated a and Development at the U.S. administer Title V of the Older community-based service model Administration on Aging (AoA), Americans Act, along with that supported older adults and where she focuses on technical developing demonstration grant their families as they transitioned assistance and partnership programs for older workers, and home from a community hospital building related to the Affordable conducting analyses regarding and four skilled nursing facilities. Care Act. Prior to joining AoA, the aging workforce. Previously, In 2009, Caroline was selected she served as Director of the she served as a Senior Research as a Practice Change Fellow AoA-funded National Center for Associate at the Institute for and designed a community-based Benefits Outreach and Enrollment the Future of Aging Services, program to support the transition at the National Council on Aging, conducting applied research on home from the hospital for older and has worked her entire career the long term care workforce and adult observation patients and in the field of aging on issues service coordination in affordable their families. Caroline received related to developing accessible senior housing. She was also her undergraduate degree educational materials and an adjunct professor in the from Washington University infrastructure for health-care and Department of Psychology and in St. Louis and her Master’s long-term care education (for an instructor to older learners degree and Certificate in Health consumers and professionals), in the Gerontology Institute at Administration and Policy from consumer navigation of the U.S. the University of Massachusetts The University of Chicago School health-care and long-term care Boston. Dr. Washko holds a of Social Service Administration. systems, and consumer direction PhD and a Masters degree in in long-term care for older Gerontology from the University adults. Marisa holds a Masters of Massachusetts, and a Masters in Gerontological Studies from degree in Individual & Family Abigail Morgan is a Social Miami University (Ohio), and a Studies from the University of Science Analyst with the U.S. Bachelor’s degree in Sociology/ Delaware. Along with her work, Administration on Aging (AoA). Gerontology from the College of Dr. Washko actively publishes Within the Office of Policy, the Holy Cross in Worcester, MA. and is engaged in various Analysis and Development, she professional organizations. focuses on resource development Since 2000, she has held several and providing technical appointed and elected positions assistance to organizations within in the Gerontological Society the Aging Network related to of America (GSA), and was Medicare and Medicaid program one of the founding members policies. Prior to working of the International Council at AoA, Abigail worked as a of Gerontological Student Program Manager at the National Organizations (ICGSO) in the Association of Area Agencies International Association of on Aging where she focused on Gerontology and Geriatrics Medicare outreach and education, (IAGG). as well as capacity building, business practices and training for Area Agencies on Aging. She has a Masters in Social Service and a Masters in Law and Social Policy from Bryn Mawr College.
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Do Geriatric Care Management Interventions Make a Difference? Prove It. By Deborah Newquist, PhD, MSW, CMC
The environment within which services, for decades. The GCM studies to document the who, what, geriatric care managers (GCMs) Model is person-centered, face-to- how, and so what of GCM services. provide their services is undergoing face, and uses the same qualified care a sea of change. Health care reform, manager throughout the spectrum Models of Research on embodied in the Affordable Care Act of care. It is assessment driven Care Coordination of 2010 (ACA), has catapulted the and includes a comprehensive care Numerous types of studies, topic of chronic care into the forefront. plan and ongoing evaluation. It articles, and reports have been Along with the cresting wave comes also includes education, advocacy produced in recent years examining recognition of the need for and and patient empowerment where care coordination in general, and importance of care coordination. appropriate. Strikingly, it is these including transitions of care in Explicit mention of care coordination very features of the GCM Model particular, in an attempt to identify services is found throughout the that are now being recognized (but program models that produce ACA (U.S. Department of Health and sadly not credited to GCMs) and improved patient quality of care and Human Services, 2011). The search promoted by case managers, disease cost-effective outcomes. A wide range for ways to improve health care for management specialists, transition of of research types can be found and older persons with chronic illnesses care specialists, patient advocates, and are instructive for GCMs to consider. has shed light on many areas where others in the medical arena, many of These include collections of case care is deficient and unnecessarily whom heretofore focused primarily studies describing particular programs costly. Transitions of care (TOC) is on managing diseases or health care or models around the country (Cooley, one such segment of the health care utilization alone (Brown, 2009; Parry, Feeney, & Krakauer, 2010; Kanaan, experience. Coleman, Smith, et al, 2003; Social 2009). A variation on that approach Work Leadership Institute, 2008; For years GCMs have provided would be case studies of “hot spot” The Transitional Care Model, 2011). patients (those heavy users of services) TOC services to their clients as part Another important feature of the tracing their experiences to identify of their care management approach. GCM Model is also that it can adapt factors and methods for bringing GCMs have been involved in its approach to encompass persons order to medical chaos (Gawande, shepherding clients from home to whose self-management requires 2011). Population studies of particular hospital to rehabilitation and back tailored supports, such as for early groups of clients or patients, such as home, or to alternative living as dementia patients who live alone. reports of patients from particular circumstances demanded. They have settings or with particular diagnoses, advocated for clients in the different Now is a critical time for GCMs have also been done (Naylor, 2005- care levels; transmitted and reconciled to showcase their model to the larger society, and particularly to those 2008; Windham, Bennett, & Gottlieb, medications and other information 2003). Convenience samples have from one provider to another; shaping the future of health care delivery. GCMs need to demonstrate also been used, for example utilizing counseled and educated clients and their worth and expertise in managing only members of a particular HMO. their families about health conditions; the chronic care of older persons in Studies which have aggregated data navigated twisted systems with mind order to help shape future trends, and from multiple sources are another bending options; coordinated services to preserve their ongoing practice approach, such as a study of all to meet changing client needs; and opportunities. GCMs are experts in Medicare patients’ readmission rates in they have seen to it that gaps were maximizing the health, functioning, all hospitals within a specified hospital identified and filled. In fact, GCMs independence, and quality of life of service delivery area (Robinson & have bridged the medical and social older persons with chronic illnesses Stansbury, 2010). Qualitative studies arenas regularly with a holistic focus and disabilities. Demonstration and of patient experiences have been on each client’s needs and goals. dissemination of the methods and conducted to aid in the development GCMs have practiced the GCM outcomes of GCM services are needed and refinement of program models Model of Care, which includes TOC now more than ever before. We need (Parry, Kramer, & Coleman, 2006).
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Meta-analyses of multiple studies to a controlled trial. Although some (Cress, 2012). So too is the step-wise have also been conducted to distill believe that nothing short of a random- process of assessment, care planning, key models (Boult, et al, 2009; ized controlled trial is worthwhile, then care coordination. Brown, 2009). the literature shows that information Other issues involve data storage, “Evidence-based outcomes” gained through various research ef- retrievability, and availability. How is the new vogue of research and forts, both qualitative and quantita- are GCMs storing their client data, practice. To determine whether tive, adds to our understanding. Also, and are those data easily retrievable an intervention makes a difference starting small and moving toward a for research purposes? Client in effecting an outcome, studies more sophisticated methodology has confidentiality and releases are also of attempt to compare outcomes to value over not doing anything at all paramount importance. Additionally, a specified standard and measure if a program cannot do a clinical trial would GCMs be willing to collaborate comparative differences. So, for initially. and share information about their example, if the national average for Groundwork for programs, or would proprietary hospital readmissions for a particular Research on the GCM concerns preclude that? patient group is X, a study of one Model hospital’s population might deploy Conclusion Some issues that GCMs TOC services to that patient group We are moving into a new era can confront in undertaking or and then compare their outcome to where managing chronic diseases and participating in research on the the national average or benchmark preventing or forestalling disabilities GCM Model involve the need for (Cooley, Feeney & Krakauer, 2010). associated with age are in the standardized clinical approaches. Or they might use a pre and post-test forefront. Improving transitions of GCM processes are not uniformly model, comparing readmission rates care is one aspect of this effort. after the TOC services were provided standardized within practices and Where do geriatric care with readmission rates from before across practices. Thus, the kinds of managers fit into this new paradigm? (Robinson & Stansbury, 2010). data collected may vary. GCMs need to balance standardization against the Traditionally, this is our domain. The gold standard, according to priority of client-centeredness. In Many new players are moving into many, is the randomized, controlled other words, do you force a client to this space however. If we cannot trial. An example of this approach answer all the questions on a particular document our approaches and would be to randomly separate form, even if some of them are not demonstrate their effectiveness, all Medicare patients discharged relevant to his or her circumstance, we run the risk that our clients of from a given hospital into two like just so your data are uniform and the future will be cared for in other groups (matched for age or number your processes strictly standardized? spheres. ACOs, transition coaches, of diseases, or admission diagnosis, Another issue is: how do you measure patient advocates, medical homes, etc.—controlling the intervening GCM clinical skills and judgments; do and others will siphon off clients and variables), with one group to receive they fit into a reductionistic research GCMs will suffer. the TOC service intervention and the model that attempts to quantify all GCMs and the national other control group to not receive the variables? association need to embark on a TOC services, and then to measure research program. Information and compare the readmission rates The GCM Model follows a step- about who we are, what we do, and of the two groups to see if the TOC wise process of care coordination why it matters will aid in our public services made a difference ( Coleman, guided by a plan of care which relations efforts and in our public et al, 2006; Naylor, et al, 2004). is based on a multi-dimensional assessment and ongoing monitoring policy activities. Sole practitioners Studies are always assessed by and evaluation. This is a standardized and larger practices will be better able the research community as to their clinical approach with flexibility to to assess how they are doing if they reliability, validity, generalizability, customize when and where appropriate have industry standards to compare and limitations. In addition, policy- from the model, similar to the one themselves against. The national makers looking for solutions also described by Naylor. She refers to profile of the organization and its seek to know if proposed models it as “individualized care guided members will rise as reports and are cost-effective. They also want by evidence-based protocols” (The publications emerge. to know if a model is scalable, Transitional Care Model, 2011). I call on GCMs to: meaning can the model serve While the assessment instruments and • Participate in research studies larger numbers of persons and still data management systems used by about GCMs when asked. maintain its operational integrity and GCMs vary, basic information about effectiveness. each client’s physical and mental As an example NAPGCM has Research on a particular program health, and functional, social, spiritual, established a new research might commence with a case study, legal, financial, and environmental development committee. The first followed later by a more in-depth status, and each client’s goals, are meeting will soon create strategies population study, leading still later central to a standard GCM assessment continued on page 12
page 11 of Geriatric Care Management Winter 2011
Do Geriatric Care References Journal of the American Geriatrics Society Management Interventions 52:675-684. Boult, C., Green, A.F., Boult, L.B., Make a Difference? Prove It. Pacala, J.T., Snyder, C., & Leff, Parry C., Coleman, E.A., Smith, J.D., continued from page 11 B. (2009). Successful Models of Frank, J.C., Kramer, A.M. (2003) The Comprehensive Care for Older Adults Care Transitions Intervention: A Patient- for GCM research, including with Chronic Conditions: Evidence for Centered Approach to Facilitating how GCMs can prevent hospital the Institute of Medicine’s “Retooling Effective Transfers Between Sites of readmission. So, if you are asked for an Aging America” Report. Journal Geriatric Care. Home Health Services to participate in a NAPGCM of the American Geriatrics Society, Quarterly. 22(3):1-18. research study, this would be your 57(12):2328-2337. opportunity to help the association Parry C., Kramer, H., Coleman, E.A. Bartelstone, R. 2011;Bartelstone (2006). A Qualitative Exploration of a prove that statistically GCMs can (2011). Transitioning Care to the Home: avert hospital readmission. Patient-Centered Coaching Intervention to Reducing Rehospitalization Among Improve Care Transitions in Chronically • Conduct your own research in- Frail Elders. GCM Journal Fall, 2011, Ill Older Adults. Home Health Care house. Volume 21, Issue 2 Services Quarterly: 25(3-4):39-53. Brown, R. (2009). “The Promise of Care As an example, SeniorBridge, a Robinson, L. & Stansbury, L. (2010). Coordination, Models that Decrease national geriatric care management CMS-Funded Care Transitions Health Hospitalizations and Improve Outcomes agency collects their own data see Care Quality Improvement Project Cuts for Medicare Beneficiaries with Chronic (Bartelstone, 2011; Bartelstone, Hospital Readmission Rate in Coached Illnesses”. Executive Summary. The GCM Journal Fall, 2011, Volume Population. The Remington Report. July/ National Coalition on Care Coordination August: 10-13. 21, Issue 2, “Transitioning (N3C). Care to the Home: Reducing Rehospitalization Among Frail Coleman, E.A., Parry, C., Chalmers, Social Work Leadership Institute (2008). “Toward the Development of Care Elders”). S., & Min, S.J. (2006). The Care Transitions Intervention: Results of a Coordination Standards.” New York • Collect and store data in a manner Randomized Controlled Trial. Archives Academy of Medicine. that makes it available for retrieval of Internal Medicine, 166:1822-1828. and analysis. The Transitional Care Model (TCM), Cooley, M., Feeney, D., & Krakauer, (2011). Retrieved on 06/28/11 from www. As an example, SeniorBridge is R. (2010). “Reducing Readmissions: transitionalcare.info/Abou-1783.html able to retrieve and analyze their Interventions, Incentives and own data to show that geriatric Infrastructure.” Manasquan, NJ: The U.S Department of Health and Human care management can prevent Healthcare Intelligence Network. Services, (2011). www.healthcare.gov/ hospital readmission (Bartelstone, law/about/TheFullLaw,bySection 2011;Bartelstone, GCM Journal Cress, C. (2012). Care Planning and Windham, B.G., Bennett, R.G., Gottlieb, Fall, 2011, Volume 21, Issue 2, Geriatric Assessment. In C. J. Cress (Ed.). Handbook of Geriatric Care S. (2003) Care management interventions Transitioning Care to the Home: Management, Third Edition. (pp. 73- for older persons with congestive heart Reducing Rehospitalization Among 99). Sudbury, MA: Jones and Bartlett failure. American Journal of Managed Frail Elders”). Learning. Care. 9:447-459. • Be willing to share data. Gawande, Atul (2011). The Hot As an example, if the new Spotters: Can we lower medical costs by Deborah Newquist is Assistant NAPGCM research committee giving neediest patients better care? The Clinical Professor of Gerontology asks you to share data, please New Yorker. January 24, 2011. at the University of Southern consider doing so, to help the Kanaan, S. B. (2009). “Homeward California (USC) and the entire association. Bound: Nine Patient-Centered Programs Principal of Deborah Newquist • Support the development of Cut Readmissions.” Report prepared for Associates, an aging services standardized protocols. the California HealthCare Foundation. consulting firm. She received her The new NAPGCM research Naylor, M.D. (2005-2008) Principal PhD from UCLA; MSW and MPA committee will be developing these Investigator, “Transitional Care from USC; and is a certified care standardized protocols, so your of Hospitalized Nursing Home manager and past President of support of the committee and its Residents.” Rand-Hartford Center for NAPGCM. eventual findings will be of benefit Interdisciplinary Geriatric Health Care to the entire association and its Research, University of Pennsylvania School of Nursing. members. Naylor, M.D., Brooten, D.A., Campell, The national association is R.L., Maislin, G., McCauley, K.M., & currently exploring how to move Schwartz, J.S. (2004). Transitional care forward on a research initiative. It of older adults hospitalized with heart will require all of us working together. failure: a randomized, controlled trial.
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Transitioning Care to the Home: Reducing Rehospitalization Among Frail Elders Rona S. Bartelstone, LCSW, BCD, CMC, C-ASWCM
There have been Act (PPACA) to positively numerous studies in recent impact this challenge. There years that document the Emergency room visits and hospital is also recognition that the relatively high risk of admissions are failures of the baby boom generations rehospitalization among healthcare system to provide timely, will exponentially impact recently discharged, complex effective care. The problem stems the cost of long-term care care Medicare beneficiaries. from our healthcare system’s focus with increasing longevity and incidents of complex According to the 2009 on disease management and a lack of attention to the reality that activity chronic care needs. It is Jencks article in the New now recognized that when limitation is an independent risk England Journal of Medicine, patients with complicated one in five seniors are factor for increased healthcare costs. medical, functional, and rehospitalized within 30 days cognitive conditions receive of being discharged from a care coordination in the hospital, fueling the reality seniors with multiple chronic home by specially trained geriatric that Medicare beneficiaries account conditions who received help with care managers, hospitalizations for 15 percent of the US population instrumental activities of daily living and emergency room admissions but more than two-thirds (37 percent) (IADL) and activities of daily living are substantially reduced. In fact, of hospitalizations and almost half (ADL) were seven times more likely SeniorBridge’s data show 90 percent (47 percent) of total hospital costs. to be among the top five percent of fewer emergency room admissions, 80 Furthermore, more than 56 percent patients most expensive to treat -- percent fewer hospitalizations, and 70 are rehospitalized within a year. more than twice the rate of those with percent fewer rehospitalizations within Alarmingly, only half of discharged multiple chronic conditions alone. 30 days in older adults receiving care beneficiaries recall receiving self- Chan et al. reported in the management in the home. care instruction or seeing a doctor Archives of Physical Medicine and This article discusses a care after discharge, suggesting that a Rehabilitation in 2002 that these management model of service delivery substantial number of hospitalizations increases in cost are attributed to an that reduces hospitalizations, 30- could be prevented. Finally Peikes increase in the frequency of all events day hospital readmissions, and ER reported in 2009 that patients with (e.g., hospital admissions, outpatient visits by focusing on the functional multiple complex chronic illnesses are visits) rather than an increase in the challenges of care recipients in the likely to be hospitalized 1.3 times per intensity or cost of those events. community, in addition to health care year. These startling facts make it diagnoses. The integrated approach of Emergency room visits and imperative to seriously consider addressing the medical, psychosocial, hospital admissions are failures of the alternative methods of providing long- and environmental challenges of frail healthcare system to provide timely, term care to Medicare beneficiaries seniors in the community enables the effective care. The problem stems and especially to those with multiple focus of care to shift from the acute from our healthcare system’s focus complicating diagnoses that make care care setting to the home care setting. on disease management and a lack of in the community most challenging. As healthcare companies innovate attention to the reality that activity While this phenomenon is not new, to create sustainable solutions to this limitation is an independent risk factor it is being newly examined due to growing challenge, SeniorBridge has for increased healthcare costs. concerns about the growing cost created a model that facilitates good In fact, according to a of health care and the emerging social policy without investment of LewinGroup analysis of Medical provisions under the Patient Expenditures published in 2010, Protection and Affordable Care continued on page 14
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Transitioning Care to company’s interdisciplinary approach providers to assure that the services the Home: Reducing utilizes an integrated care management in the home are consistent with the Rehospitalization Among team of nurses and social workers to physician-driven plan of care. In this Frail Elders address functional, environmental, manner, the care manager becomes continued from page 13 behavioral, and medical needs. This the physician extender into the home person-centered approach facilitates setting, while assuring maximum use public funds and is therefore poised to the creation of partnerships that build of primary care to forestall preventable inform social policy and create models on the strengths of care recipients in use of emergency room visits and for replication and continuity. As the a manner tailored to their needs and hospitalizations. largest care management company in preferences. the country, SeniorBridge provides The Problem: SeniorBridge’s proprietary a role model for how other care Addressing Function web-based electronic health record management practices can also begin Among Vulnerable allows for documentation of health to impact positive health outcomes for Populations: information from multiple physicians Medicare beneficiaries throughout the The Robert Wood Johnson and care manager assessments country. Foundation analysis of the 2006 including information about the Medical Expenditures Panel Survey SeniorBridge’s integrated living environment, the social support shows that three-fourths of people approach addresses the reality that system, the behavioral health issues, 65 years of age and older have two disease management is only part of the and legal and financial status in or more chronic conditions. And problem -- and that until we address addition to the traditional medical according to the LewinGroup’s patients’ functional needs, we cannot diagnoses, medications, treatments, analysis of the same 2006 Medical provide these patients the care they and hospitalizations. The breadth of Expenditures Panel Survey, people deserve. this health record enables our care with multiple chronic conditions managers to monitor and address and instrumental Activity of Daily Background the full array of issues as they relate living and/or Activity of Daily Living SeniorBridge is a national care to the medical concerns that impact limitations are seven times more likely management company with an 11- chronic care needs. Furthermore, the to be among the top five percent most year heritage of managing the care electronic health record facilitates costly to treat. of people with complex chronic real-time communication between Chan et al. reported in the conditions in their homes. The care managers and health care Archives of Physical Medicine and
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Rehabilitation in 2002 that these unmet functional needs (a modifiable Clients on service for a year increases in cost are attributed to an characteristic) may affect the or longer have 82 percent fewer increase in the frequency of hospital occurrence of early readmission in hospitalizations and 91 percent fewer admissions, outpatient visits, and community-dwelling older adults.” emergency room visits than the typical other events rather than an increase Regardless of socio-economic Medicare beneficiary – and our in the intensity or cost of those status, older adults often have low clients are among the most complex events. Repeated hospitalizations health literacy, live with multiple beneficiaries. A typical client is older arise from issues such as medication Activity of Daily Living (ADL) and than 80 and has multiple chronic management errors, inability to access Instrumental Activities of Daily Living co-morbidities, often including follow-up care with physicians, (IADL) deficits and lack social support congestive heart failure, COPD, stroke, inability to comply with nutrition and and resources necessary to comply pneumonia, and cognitive changes such hydration regimens, falls related to with plans of treatment – all of which as Alzheimer’s or a related dementia. environmental hazards, and/or a social are likely to be the most prominent According to Anderson, et al. the support system that lacks the presence, determinants of early readmission. general Medicare population has an knowledge, and/or information to annual average 1.2 hospitalizations and assure proper care. SeniorBridge has a tradition of 1.1 emergency room visits respectively care management teams that have Furthermore in 2008, Arbaje, et per year. The ability to significantly served individual older adult clients al. showed that, “PDE (post discharge reduce in-hospital and emergency environment) and SES (socioeconomic with multiple complex chronic room usage leads to improved patient status) were related to an increased health and functional needs and their satisfaction, improved quality of life, likelihood of early readmission (to families. Attempts to coordinate the and reductions of costs for both the the hospital). Unmet functional complexity of needs and their inability healthcare system and the individual. needs may be associated with limited to successfully manage all aspects of availability of assistance, which the plan of care, these individuals and The Solution: In- presents challenges to implementing families increasingly look to private home Integrated Care a post discharge regimen, complicates care managers to help with care Management giving activities. As a private Care the care transition, and increases the As already stated, SeniorBridge Management Company, the population risk of early readmission,” according has demonstrated significant that we serve is often as complex in to their study. Arbaje et al. go on to improvements in the delivery of their care needs as those of the most state that, “having any ADL or IADL healthcare services by working with need may be significant for affecting complex and expensive Medicare health care utilization. Providing for beneficiaries. continued on page 16
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Transitioning Care to provider; transportation; dietitian; that the lifestyle, preferences, and the Home: Reducing rehab professionals; pets; and faith traditions of the care recipient Rehospitalization Among other invested individuals or have to become the springboard Frail Elders organizations. from which all care emanates. continued from page 15 2. Engagement and communication This, of necessity, includes the available financial resources to with the involved team in a manner meet the needs of the care recipient clients in their home and across that respects the expertise and and his or her family situation. settings when necessary. The Care leadership of each component This also requires a commitment to Management Team focuses on of care. This may include the the strengths and dignity of the care assuring or compensating for the use of mediation techniques to recipient to avoid excess disability IADLs and ADLs that are significant help assure that each member through the creation of unnecessary contributing factors to the incidence of the team is committed to the dependence. of rehospitalization. This is done in agreed upon plan of care. This partnerships with organizations that can be a sensitive area, especially 4. Improving the health literacy of the share the concern for lowering both when there may be conflicting consumer and the entire support hospital and emergency room usage organizational, personal, or value- system is crucial to successful for the purposes of improving quality based goals among team members. coping in the community. Both the care recipient and his/her support of life, preserving scarce resources, Continuous communication, system need to understand the and moving care from the acute care including the necessity of in- diagnoses, treatments, and options setting to the home and community person team meetings is critical to for care in each disease process. setting. the coordination and consistency of It is especially important to help care, especially as circumstances The Care Management tasks that care givers (both family and paid) change over time for the care enable SeniorBridge to successfully know what signs and symptoms intervene with complex client needs recipient. Engagement and might mean in terms of a specific include the following key components. communication are especially diagnoses and when to call the important at points of transition 1. Partnering with the entire formal Care Manager should they have a to assure that there are no gaps in and informal support system of concern about the health status of service when moving from one the client. This includes: family the care recipient. Creating health level of care to another or when members; involved friends; literacy is a continuous process moving from one provider of care physicians; hospitals; social based upon the changing needs and to another. services; legal and financial changing complexion of the care advisors; paid caregivers; other 3. A commitment to a consumer- recipient’s biopsychosocial status, service personnel; the Medicare centered perspective toward the their ability, and readiness to learn. home healthcare provider; DME provision of services. This means 5. Continual adjustment of the plan
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of care based upon the daily include therapeutic interventions health professionals treating each needs of the client over time. The to help the individual cope with patient and to improve quality of individualization of the care plan their health challenges, losses, and care, an electronic health record is means that the Care Manager uncertainty brought about by the created for each participant to manage is expected to modify the plan disease process, including chronic and organize ongoing assessments, of care to meet variations in grief. medical and professional notes, need throughout the course of f. Exercise, as tolerable and clinical and medical analyses, as our engagement with the client appropriate. To prevent further well as care plans. This unique system. Some clients start off with physical decline that may lead to electronic record is created intensive services because they are preventable disability. through SeniorBridge’s proprietary coming from an acute episode from information system. This system also which rehabilitation is expected. g. Opportunities for enjoyment. makes it possible for SeniorBridge Just as likely is that others will Whether or not the person is to aggregate client information for start with limited care and need able to continue to enjoy former the purposes of understanding from a increasing support as their health hobbies, interests, or activities, it more objective perspective the nature status declines over time. is important that the care recipient of client needs based upon service 6. Manipulation of the environment to have activities or interactions to usage, length of service engagement meet the needs of the care recipient anticipate with joy. The ability to and the constellation of services used, situation. This can relate to any engage in activities that enhance and the overall health outcomes. A number of structural or concrete our lives, relationships, well-being, critical component of our health record tasks that help the care recipient to or sense of productivity can be key is its ability to track a 360-degree function in an environment that is to successful coping. view of clients’ hospitalizations safe and conducive to their needs. Naturally, all of the tasks including when they occur, the facility This can include such complex described above are done in a manner at which the client is treated, length tasks as: that is consistent with the primary of stay, reason for admission, and the a. Medication management. functional domains of the care discharge plan. Especially for those individuals management process, namely: This system allows the care who may have medical conditions • Intake/engagement managers to identify patients with that are frequently in flux and functional limitations who are at risk cause the necessity of careful • Assessment of a rehospitalization and implement management of medication dosing. • Care Planning an evidence-based approach to b. Environmental modification. • Care Implementation supporting them. The system goes These might be relatively common • Care Monitoring and Adjustment beyond medical needs and explores modifications such as grab bars physical and cognitive functional or more complex needs such as • Quality Assurance/Patient Satisfaction limitations that put them at risk for reconfiguration of the home itself. adverse events and rehospitalizations. c. Nutritional/dietary supports. • Termination Does the patient have food in the To assure an appropriate diet For each client this professional refrigerator to ensure adequate consistent with their medical team develops, in concert with the nutrition and hydration? Is the patient needs, cultural background, and person’s physician, an individual taking medications or vitamins you faith traditions. Since eating is care plan tailored to the functional, don’t know about? Are their support also a social activity, it may be medical, and emotional needs of limitations preventing them from important to identify opportunities the care recipient. Home safety complying with a discharge plan? for socialization within the home assessments and evaluations of As can be seen in the screen or the community to enhance the medical, functional, and psychosocial shot below, the ability to input ability to participate in healthy status identify basic factors that leave comprehensive data about each client, nutritional habits. older patients vulnerable to falls, while is a hallmark of the success that our d. Transportation needs. This is monitoring for more critical issues care managers are able to achieve. The important for maintaining the such as cognitive decline that may not system allows for the accumulation delivery of both medical and social be readily apparent in a doctor’s office and aggregation of client information needs. or over the phone. Other services that facilitates the tracking of trends. available in the home include tele- e. Psychosocial supports. To prevent Some of the most critical trends health care monitoring and on-call isolation and the potential for include: information about referral care management support 24 hours per depression and cognitive decline sources, client demographics and day, seven days per week that often accompanies the lack of health status, length of stay, and human interaction. This might also To ensure collaboration between continued on page 18
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Transitioning Care to Lessons Learned 3) Real time communication the Home: Reducing with the entire team facilitates Rehospitalization Among 1) Providing an integrated team team building and efficient use Frail Elders of health and social services of resources. The use of an continued from page 17 professionals in the community electronic health record that is setting facilitates improved available in real time has enabled service usage. Furthermore, data continuity of care. Addressing the communication between the is accumulated in real time, which comprehensive needs of patients community-based care managers allows for more accurate tracking of empowers the individual and and the physician to assure client needs and predictions about the social support to maintain a health that adjustments to the plan of treatment are made in the home business pipeline. regimen in the home. The team of physician, nurse, and social and at the primary level of care. The Outcomes & worker allows for environmental Notes from the care managers’ interventions assure that the team Lessons Learned safety, more efficient use of is informed and become part of the community resources, emotional physicians’ chart in the primary As previously stated, support for improved coping, care setting. Use of community SeniorBridge is able to demonstrate and health education to create improved health outcomes, reduced resources and education is thereby care partnerships and health reinforced by all members of the use of emergency room visits, and maintenance. team, supporting education and decrease in the hospitalization and compliance by the care recipient rehospitalization rate of its clients. 2) Education of healthcare consumers and his/her support system. This is attributable to the following is crucial to positive outcomes. lessons that have been learned Approximately 50 percent of the 4) Maintenance of a relationship over time and that can provide a time that care managers spend with the entire team provides the roadmap for other care teams that with clients is in health education patient with a virtual “safety net” are able to bridge the gap between and counseling to cope with their that they can immediately access locations of service and focus care complex care needs. Improved when changes occur in health on the most appropriate and least outcomes result from behavioral status or function. When the client restrictive locales, namely the home changes that are accomplished over and his/her support system have an and the office of the primary care time, in the home, when the patient on-going trusted relationship with physician. In addressing the care at and support system are not in a team of providers, they are more home, it will be imperative to focus crisis and therefore more available readily able to identify appropriate on building upon client strengths and emotionally and intellectually for supports for help when there are compensating for functional deficits. learning. changes in status. This assures
page 18 of Winter 2011 Geriatric Care Management
clients that they can receive care in community with a focus on improving Post Discharge Environmental and their home setting and experience function and empowering client Socioeconomic Factors and the Likelihood fewer barriers to accessing health systems may be one of the most of Early Hospital Readmission Among and social services. This also effective means of meeting these Community-Dwelling Medicare assures that care is provided at the increasing challenges. Beneficiaries, Alicia I. Arbaje, MD, MPH, appropriate level of services rather Jennifer L. Wolff, PhD, Qilu Yu, PhD, than waiting for the crisis to occur, References Neil R. Powe, MD, MPH, MBA, Gerard F. Anderson, PhD, and Chad Boult, MD, which in turn results in care being Jencks SF, Williams MV, Coleman EA. MPH, MBA; The Gerontologist, Vol. 48, provided at the most expensive and Rehospitalizations among Patients in the No. 4, 495-504, p. 502 sometimes excessive level of care. Medicare Fee-for-Service Program. New 5) The integration of technology with England Journal of Medicine, 2009; 360: Anderson T et al. High-Cost Medicare consistent interpersonal support 1418-28. Beneficiaries. Congressional Budget Office, May 2005 facilitates service delivery. It is the “The Medicare Beneficiary Population combination of “high-tech” with Fact Sheet”, AARP, 2007 http://assets.aarp. “high-touch” services that enables org/rgcenter/health/fs149_medicare.pdf the integration of care across the Rona Bartelstone is Senior Vice “Medicare Hospital Stays: Comparisons professional team, across settings President of Care Management between the Fee-for-Service Plan and and with the client. The electronic for SeniorBridge. From 1981 - Alternative Plans: Statistics Brief #66,” health record, along with tele- Healthcare Cost and Utilization Project 2008 she owned Rona Bartelstone monitoring devices and other http://www.hcup-us.ahrq.gov/reports/ Associates an integrated care software systems to track clinical statbriefs/sb66.jsp management and home care interventions are enhanced when business. Rona is a founding the healthcare professional can “Hospital Discharge Information and Older member and the longest termed teach the consumer to make the Patients: Do They Get What They Need?” past President of NAPGCM, and best use of standards of care in the Flacker J, Park WS, Sims A. J Hosp Med. is also a founding member and home over time. The educational 2007: 2(5): 291-6. Vice President of NACCM. Rona process and counseling for Jencks SF, Williams MV, Coleman EA. is a family care giver. emotional coping improve when Rehospitalizations among Patients in the the consumer feels that they are a Medicare Fee-for-Service Program. New partner in the process of their own England Journal of Medicine, 2009; 360: care. 1418-28. 6) Care in the community setting The Robert Woods Johnson Foundation that addresses function of patients analysis of 2006 Medical Expenditures can reduce hospitalizations and Survey, 2010 improve patient satisfaction. The positive health outcomes LewinGroup analysis of Medical reported above demonstrate that Expenditures Panel Survey, 2010 it makes good business sense and Chan L, Beaver S, Maclehose RF, Jha A, good social policy to encourage Macrejewski M, Doctor JN. Disability and increased use of care in the Care Costs in the Medicare Population. community for those Medicare Archives of Physical Medicine & beneficiaries who have complex Rehabilitation, 2002 care needs. In addition to improved health outcomes, patient satisfaction with their care and their functional status demonstrates the success of community-based care teams. National health care reform, changing reimbursement systems, the recognition of the need to partner with patients (rather than just treat them), and changes in the workforce and in the economy all are incentives for pioneering new approaches to health care delivery. The provision of quality, coordinated care in the
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risk populations. Transitional care pro- grams focus on maintaining continuity, fostering communication, and educating Evidence-Based patients so that health care is effectively managed across levels of care access Transitional while identifying and addressing reasons for adverse outcomes (Naylor, Aiken, Care for Chronically Ill Kurtzman, Olds & Hirschman, 2011). Nationally there are four main Older Adults and Their approaches that address transitions of care: Project Re-Engineering Discharge (RED), the Care Transitions Program Caregivers (CTP), Better Outcomes for Older Adults through Safe Transitions (Proj- M. Brian Bixby, MSN, CRNP ect BOOST), and the Transitional Care Model (TCM). RED is a research group based at Boston University Medical Cen- Summary ter developing and testing strategies to improve the hospital discharge process to The Community- An estimated 90% of promote patient safety and reduce read- Based Care Transitions hospital readmissions mission rates. CTP addresses the needs Program (CCTP) of patients and caregivers while also authorized by Section occurring within 30 days of encouraging the adoption of technol- 3026 of the Affordable discharge are unplanned. ogy to increase communication between Care Act of 2010 aims These readmissions, most often providers and settings. Project BOOST to reduce hospital is a hybrid developed by the Society of preventable, cost Medicare readmissions, test Hospital Medicine. BOOST addresses sustainable funding $17.4 billion in 2004 physician training and mentoring to streams for care (Jencks, Williams & Coleman, 2009). improve patient outcomes at discharge. transition services, BOOST toolkits are utilized during maintain or improve hospitalization to identify post-discharge quality of care, and care needs and augment standard dis- document measurable savings. A readmissions is only one negative charge planning and is used as a comple- multidisciplinary research team effect of a health care system in need ment to the more intensive transitional developed the Transitional Care Model of realignment. The human cost of care programs CTP and TCM. (TCM) to address the needs of very repeated disease exacerbations can be While each program has its unique high-risk chronically ill older adults equally costly in terms of deterioration approach to addressing the transition transitioning from hospital to home in function, reduced symptom-free between hospital and home, all of these post-acute illness. Three completed days, and loss of faith or satisfaction transitional programs focus on inten- National Institute for Health-funded with the health care system previously sive inpatient education that targets the randomized controlled trials testing trusted to maintain or improve health. admitting diagnosis, symptom identi- TCM have consistently demonstrated Health care errors and adverse events fication and management, scheduling results compatible with CCTP goals often associated with transitions needed follow-up care, and medication and indicating utility of TCM in in spite of care only increase knowledge and reconciliation. These successfully addressing each of the dissatisfaction and distrust of a poorly programs focus on addressing problem aims. performing system. medications and streamlining the plan of Transitional Care, defined as a care based on current practice guidelines. Evidence-Based All transitional care models provide Transitional Care for range of time-limited services and en- vironments that complement primary telephone support after hospitalization Chronically Ill Older to reinforce the discharge plan. CTP and Adults and their care and are designed to ensure health care continuity and avoid preventable TCM provide post-discharge in-home Caregivers poor outcomes among at-risk popula- follow-up of varying intensity that aids An estimated 90% of hospital tions as they move from one level in reinforcing the plan of care, in addi- readmissions occurring within 30 days of care to another, among multiple tion to telephone support. The TCM will of discharge are unplanned. These providers and across settings, has been be discussed in depth as a model to ad- readmissions, most often preventable, identified as one solution with strong dress the mandate of the CCTP initiative. cost Medicare $17.4 billion in 2004 evidence of effectiveness in avoid- The TCM was originally developed (Jencks, Williams & Coleman, 2009). ing preventable negative outcomes, in the 1980s by Dr. Dorothy Brooten The financial toll of preventable including readmissions, in the most at- The success of the model in achieving
page 20 of Winter 2011 Geriatric Care Management positive outcomes clinically, the episode of care. Utilizing the The Geriatric Depression Scale – Short financially, and most importantly, “point person” facilitates information Form (GDS) is a useful tool to assess satisfying patients and caregivers, exchange and assures timely depressive symptoms in the past weeks. led to the testing of this approach communication that spans settings. Four or more active coexisting health to address the transitional needs of Unique features of the TCM are that conditions or treatment with six or other populations.of Philadelphia to care is provided by APNs specializing more prescribed standing medications address the needs of very low birth in the care of high risk elders and their have been found though our RCTs weight infants and their caregivers caregivers. Follow up occurs across and literature review to increase risk making the transition from hospital hospital and home settings by the of rehospitalization. Two or more services to home with the support of same APN who individualizes the plan hospitalizations within past six months of care. With the exception of a few a discharge team led by a Clinical or a hospitalization within the past 30 critical junctures that are described days increases the all-cause risk of Nurse Specialist. The success of the below, the TCM guidelines allow readmission. This risk is significantly model in achieving positive outcomes for flexibility to let the APNs use increased for those hospitalized clinically, financially, and most their clinical judgment to determine having baseline dementia or treated importantly, satisfying patients and frequency, intensity, and nature of for delirium (or both). Lack of formal caregivers, led to the testing of this contact – in-person or telephone. or informal family caregiver support approach to address the transitional APNs are expected to visit the patient has ramifications for short- and long- needs of other populations. Since within 24 hours of identification, daily term outcomes especially in areas of the early 1990s, a multidisciplinary during hospitalization, and within treatment adherence and completion research team also based at the 24 hours of discharge to prevent of needed follow-up care. Low University of Pennsylvania and led by any potential adverse clinical events health literacy is often described as a Dr. Mary Naylor developed and has associated with the transition. variable affecting outcomes, especially been refining and demonstrating the Through the completed RCTs nonadherence to the therapeutic effectiveness of the TCM in meeting the Penn team has identified and regimen. It is important in assessing the needs of chronically ill older refined a high-risk profile of patients your patient to not take reports of other adults. Findings of three completed characteristically in increased need clinicians at face value unless well National Institute of Nursing Research and identified those most likely to documented. Willful nonadherence funded randomized control trials benefit from the intervention (Bixby & is rare. Often the nonadherent patient (RCTs) and a National Institute of Naylor, 2009). These high-risk criteria has valid reasons for skipping or Aging study have demonstrated that have been augmented by findings missing medications, therapies, and TCM improves health outcomes, from reviewing the clinical literature. appointments. These causes need to be decreases and delays readmissions, Attaining the age of 80 or being carefully assessed in a non-judgmental and reduces overall health care costs older combined with other criteria manner to address and attempt to when compared with usual care. may increase risk of poor transitions. disrupt nonproductive behaviors. In This body of research has resulted in Moderate to severe functional deficits our clients we find social issues that collaborations with insurers, health and the inability to manage daily need to be addressed around costs of systems, providers, consumers, tasks or complete self-care will medications, access to food, and the and other concerned stakeholders complicate discharge planning and ability to physically obtain medication. to translate the model into practice require short- or long-term problem Solutions can be mutually worked as (Naylor, Brooten, Campbell, solving to address the deficit and part of the TCM follow up. any subsequent continued decline. Jacobsen, et al., 1999, Naylor, If two or more of the above Brooten, Campbell, Maislin, et al., Functional status can be measured by the Hospital Admission Risk Profile findings are present, further 2004, Naylor, Brooten, Jones, et al., investigation is warranted and formal 1994). These RCTs document the (HARP), Katz Index of Independence in Activities of Daily Living (ADL), collaborative assessment of discharge TCM’s ability to: increase time to or The Lawton Instrumental Activities planning–transitional care needs first readmission or death, improve of Daily Living (IADL) Scale. Pilot should be initiated if not already physical function, improve quality work has been completed using the completed. As noted above, cognitive of life, increase patient satisfaction, TCM to meet the needs of patients impairment significantly impacts – and decrease total all-cause readmissions, with active behavioral or psychiatric complicates – discharge planning and and decrease total health care costs. health issues. Large scale testing of the assessment of transitional needs and The TCM is an advanced TCM’s efficacy in meeting the needs heightens risk for all-cause risk for Practice Nurse (APN)-led model of this population is currently being readmission and is often overlooked utilizing a holistic person and family completed. For our work we screen or unknown. In our pilot work of 145 care centered approach. A tested for documented depression and only patients who completed the screening, and refined protocol guides and exclude those with severe depression 65% (n = 94) had no evidence of streamlines care with the APN acting receiving treatment as their primary or cognitive impairment and 35% (n as the single “point person” across secondary reason for hospitalization. continued on page 22
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Evidence-Based Transitional expectations are that a patient will be visit. This plan addresses what to Care for Chronically Ill Older visited at the hospital within 24 hours do during those hours when the Adults and their Caregivers of study enrollment; daily throughout APN is unavailable; it also lays continued from page 21 the hospitalization; within 24 hours the groundwork for longer term = 51) had evidence of cognitive of discharge to home; at least weekly understanding of symptoms, early impairment; in 65% (n = 33) of the during the first month; and at least identification, and intervention. latter group, cognitive impairment was semi-monthly through the duration The APN relies on their clinical identified only by using the screening of the intervention. The APNs are judgment and each patient’s unique instruments (Naylor, Stephens, strongly encouraged to attend the circumstances to determine the actual Bowles, & Bixby, 2005). A useful tool first discharge physician follow-up number and nature of contacts. to quickly assess patient cognitive appointment if a transition in provider It is informative for the APN to status is the Mental Status Assessment (hospital-to-home) is occurring. In accompany the patient on their first of Older Adults (Mini-Cog). This addition to in-person visits the APNs post-discharge visit with their pro- tool (along with those recommended monitor their patients via telephone. vider. During the visit, the APN helps earlier) is available from the John The APNs are available via telephone the patient and caregiver(s) to achieve A. Hartford Institute for Geriatric daily Monday-Friday and on an their visit goals by coaching the pa- Nursing (http://consultgerirn.org) and on-call basis on weekends to answer tient to develop a list of questions and is in the scope of practice for nursing physician, patient, and caregiver triage it prior to the visit so the most to administer. As with any tool, the questions. APNs initiate telephone important issues are addressed. The Mini-Cog represents a point in time contact with a patient during any week APN will also provide the patient with and indicates current status and not a that a patient is not visited at home. copies of their hospital discharge and diagnosis. It does, however, direct the The purposes of these calls will range any tests for their providers review. from monitoring patient’s health status clinical team towards a needed work- The APN may act as an advocate for to reinforcing skill acquisition. up. Any suspected or documented the patient and importantly assists the cognitive impairment with or without Patients are visited in the acute patient in understanding the provider’s the above screening criteria should inpatient setting within 24 hours of instructions and need for additional independently trigger post-discharge enrollment in the TCM program. follow up. Ideally they will have also been intervention to assure appropriate Per the standard definition, enrolled within 25-36 hours of information transfer and follow-up transitional care is time limited and admission. The APN conducts a after discharge to home or other care from the initial assessment the APN comprehensive assessment of the setting. It is imperative that either a patient’s health status. This assessment should be continually assessing well-informed caregiver be actively continues, completed, and amended discharge readiness and ability for involved during the discharge process after discharge to reflect hospital and self-management. Probable reasons or a referral for visiting nurse services home findings. Priority needs and for readmissions should be discussed is made (with preference for both services are defined with the input of and plans to monitor each set of symptoms are discussed with the being involved). the patient and caregiver(s) throughout patient. Needed referrals for social the patient’s stay. Goals inform the The TCM protocol schedule is services, specialist care, or other emerging plan of care. The APN very straightforward. There are a few services should be initiated early collaborates with provider and other minimal expectations but no rigid in the follow-up period. The APN members of the health care team to assures continuity of care through guidelines. The APNs are not held to streamline the plan of care. Home communication with the provider(s) productivity standards, but rather are visits should begin within 24 hours of who will continue to follow the given the time to address the complex discharge from the hospital. This is a patient. Discharge summaries and needs of this most at high risk group critical time to assess understanding letters are written to each provider and to address their needs ameliorable and patient implementation of the plan and a specific discharge plan created to intervention and long-term patient of care. Any delay in visiting is clearly for the patient with a revised action benefit. While 30-day rehospitalization documented and outcomes tracked. plan included and personal health rates need to be radically addressed After the initial visit, a minimum record. These summaries provide a we also look to make changes that of one home visit per week is made progress update on meeting goals and affect the long-term outcomes of not during the first month. Bimonthly on-going/unresolved issues with the only the primary diagnosis but also visits continue until discharge from plan of care or social services requests of co-morbid conditions. The APNs the program. Telephone contact is that are wait-listed. The APN will are instructed to use their clinical made with the patient, as needed, and facilitate access to palliative care or judgment to determine the frequency in each week an in-person visit is not hospice services, assisted living, or (number) and intensity (length) scheduled. An explicit, personalized chronic case management, as needed, of patient and caregiver visits and plan for emergency care is developed and within their scope of practice. The telephone contacts. The minimal during hospitalization and the initial APN remains available to the patient
page 22 of Winter 2011 Geriatric Care Management for questions after discharge but does distention with the head of bed for medication regimen – Prior not re-open the care episode. elevated at 90 degrees. medication use consisted of Current barriers to widespread He reported being in his usual medications of limited duration adoption of the TCM include the state of health until approximately one (antibiotics, antacids, etc.). In TL’s organization of current systems of care, month prior. Since that time he has past experience he was required regulatory barriers, lack of quality and noted an increased weight gain and to use eye drops for the remainder financial incentives, and culture of decreased exercise tolerance which of his life as the result of a poor care issues. The CCTP demonstration he attributed to decreased workload surgical outcome during cataract program offers a unique opportunity for at home and lack of activity due to removal. He could not easily shake the Penn team and health care systems seasonal change. He was treated with the idea that the physicians had to redefine care through adopting and intravenous diuretics and admitted to somehow misdiagnosed or poorly adapting the TCM widely. As noted telemetry for further evaluation where treated him thus requiring these before, the RCTs greatly informed our was diagnosed as having new onset new medications for life. understanding of interventions needed heart failure (HF) with an ejection 5. Probable lack of follow up with to improve the transitions of older fraction of 25%. He lives with his wife cardiologist care, worsening HF adults from hospital to home or other in a one-bedroom apartment in a three- and rehospitalization, followed settings and importantly has informed story urban home. TL was independent by significant morbidity (includ- our partnerships with health systems, in all daily activities of living. His past ing decreased functional status), insurers, and other key stakeholders medical history included: glaucoma, and possible mortality (if HF not in conducting ongoing translational bilateral cataracts, and colon cancer managed optimally) – TL was efforts (Naylor, Bowles, et al., 2011). successfully removed ten years prior followed by a generalist who may These experiences have been critical to admission. have attempted to manage his HF in our development of an educational but active cardiology involve- program for the nurses and other TL’s case could have providers who will be called upon to ment was essential to limit disease followed two different progression. TL was unhappy to lead the implementation efforts and trajectories: opportunities provided by the CCTP be assigned a female cardiologist and have also informed our “next Without APN services: despite clinical reputation and did not entirely believe he had HF or steps” in the refinement of the TCM 1. No Visiting Nurse (VN) or with new populations. that his condition was as critical as Physical Therapy services – TL diagnosed. At discharge he would was not referred as he was not Case Study not have been scheduled for fol- “homebound” thus did not qualify low up nor would verification of TL was enrolled in the TCM for services despite need. attendance at appointments been program during his acute episode of 2. Poor patient education – Nursing assured. care. He was followed by the advanced staff utilize non-customized practice nurse (APN) for 85 days. He 6. Caregiver hospitalization for pre-printed medication and received twelve visits – ten in his home untreated/under treated conditions dietary teaching forms which do and two at his physician’s office. The – It was apparent that Mrs. L also not incorporate individualized visits were front loaded with greater had some unrecognized or under- behaviors, needs, literacy level, than six occurring in the first 30 days treated health issues. During the or learning style. Teaching is post-discharge. Telephone calls to the initial home visit the APN offered routine with handoff of learning patient served as reminders and status to check her BP and discovered it responsibility to the patient during checks during the follow-up period. was elevated as she had run out of the acute episode. No mechanism prescribed medications and was TL is a 78 year-old African- for reinforcement and validation American male with a primary waiting until her husband was of learning provided for those not well to seek follow up. The APN diagnosis of heart failure. TL was receiving VN services. admitted to the acute care facility via encouraged Mrs. L to schedule the emergency room after arriving 3. Caregiver exclusion from teaching follow-up and, luckily, during the at an unrelated routine follow-up and development of the plan of intervention was able to arrange appointment acutely short of breath care – Mrs. L, the primary caregiv- for her to seen by her husband’s after walking three city blocks at a er, was unable to visit the hospital cardiologist for treatment of her moderate pace in winter temperatures regularly thus unable to participate hypertension. At discharge she - a normal walking distance in his in educational activities or identify was adherent to treatment and usual state of health. At the time needs. Lack of inclusion limited normotensive. of emergency room evaluation he opportunities to reinforce teaching 7. Low satisfaction with care was found to be volume overloaded and need for follow up and adher- 8. Increased/reinforced suspicion of with +3-4 pitting edema to his lower ence with the plan of care. health care system. extremities, severe shortness of breath, 4. Probable poor medication a (+) S3 and frank jugular venous adherence given distrust of need continued on page 24
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Evidence-Based Transitional and current clinical evidence was 9. No rehospitalizations during 52 Care for Chronically Ill Older high. On telephonic contact at 26 weeks of follow up. One rehos- Adults and their Caregivers and 52 weeks after discharge from pitalization following follow up continued from page 23 APN follow up he remained stable for cataract removal. Continues to without subsequent rehospitaliza- receive care from his cardiologist With APN services: tion. and continues to do well at age 87. 1. Mutually developed goals which respected patients perspective, 5. Cardiology involvement- limited References incorporated his ability to learn progression of disease, and no re- Bixby MB & Naylor MD. The Transitional and develop trust for APN and hospitalization – TL denied sever- Care Model (TCM): Hospital discharge collaborating – providers and ity of HF diagnosis but was willing screening criteria for high risk older adults. physicians. – after developing trusting relation- In Try This: Best Practices in Nursing Care ship with the APN – to receive care to Older Adults, issue 26 (2009). 2. Medication adherence – On TL’s from cardiologist and was willing Jencks SF, Williams MV & Coleman EA. enrollment the APN discussed to continue after APN follow up Rehospitalizations among patients in the case challenges with the attend- ended as a trusting relationship fos- Medicare fee-for-service program. N Eng J Med. 2009; 360(14):1418-28. ing cardiologist and collaborated tered between physician, patient, to develop a simplified discharge and caregiver by the APN. Naylor MD, Aiken LH, Kurtzman ET, Olds plan. On discharge the patient was DM & Hirschman KB. The importance of prescribed three medications for 6. APN-MD care collaboration to transitional care in achieving health reform. Health Affairs. 2011; 30(4):746-754 HF and had struck a deal with the patient benefit - The APN worked APN and cardiologist to adhere for closely with the cardiologist to Naylor MD, Brooten D, Campbell R, one month if reevaluation of need develop a trusting relationship Jacobsen B, Mezey M, Pauly M & Schwartz and obtained her buy-in to work JS. Comprehensive discharge planning and would be made at that point. An home follow-up of hospitalized elders: A appointment to evaluate progress closely with the patient to reinforce randomized controlled trial. JAMA. 1999; and medication need was sched- the need for his medications and 281(7): 613-620. streamline his treatment plan. At uled prior to discharge from the Naylor MD, Brooten DA, Campbell RL, facility with goal of the patient, 12 months post-enrollment the Maislin G, McCauley KM & Schwartz JS. caregiver, and APN to work on the patient remained adherent to his Transitional care of older adults hospitalized plan with the cardiologist. treatment plan and was in close with heart failure: A randomized clinical follow up with the cardiologist. trial. Journal of the American Geriatrics 3. Dietary adherence – Mrs. L. Society.2004; 52(5):675-684. 7. Physical Therapy (PT) assessment reported serving a near-perfect diet Naylor MD, Brooten D, Jones R, Lavizzo- despite ample evidence of high and resumption of ADLs/IADLs Mourey R, Mezey M & Pauly M. sodium foods in the kitchen and - Prior to admission, TL was very Comprehensive discharge planning for the pantry. As she did all cooking and active maintaining his home, two hospitalized elderly: A randomized clinical grocery shopping the APN ad- apartments, and a large flower and trial. Annals of Internal Medicine. 1994; 120(12):999-1006. dressed teaching related to label vegetable garden. In a typical day reading and dietary principles he climbed two to three flights of Naylor MD, Bowles KH, McCauley KM, toward her. This teaching was also stairs up to six times a day often Maccoy MC, Maislin G, Pauly MV & carrying tools. In the summer he Krakauer R. High-value transitional care: repeated to TL stressing basics translation of research into practice. Journal such as avoiding adding salt at the was very active in digging, carting, of Evaluation in Clinical Practice. 2011; table, avoiding high sodium fare and planting large plants. Given doi: 10.1111/j.1365-2753.2011.01659.x degree of symptoms and severity when out of the home, and need to Naylor, MD, Stephens, C, Bowles, KH & limit fluid intake to less than two of HF, APN requested PT evalu- Bixby, MB. Cognitively Impaired Older liters a day. The couple reported ation during hospitalization and Adults: From Hospital to Home. AJN eating out rarely but was able to insisted on PT evaluation in home – American Journal of Nursing. 2005; identify restaurants which they given TL’s prior level of activ- 105(2):40-49. enjoyed. The APN worked with ity. The APN worked with TL to each to identify favorite items and implement PT plan of care and Brian Bixby is an Advanced reviewed selections and triaged gradually add more activity into his Practice Nurse at the University them as to be totally avoided, routine while being monitored for of Pennsylvania School of rarely consumed, or enjoyed in response. TL was able to resume Nursing in Philadelphia. Since moderation and marked these his prior level of activity without 1998 he has been a member of menus accordingly. onset of HF symptoms or untoward reaction to his medications. He the multidisciplinary team testing 4. Appropriate prescription of was happily working in his garden application of the Transitional diuretic, beta-blocker, and ace when discharged. Care Model and translating the inhibitor – Despite minimizing the Transitional Care Model into regimen, APN-cardiologist adher- 8. High patient, caregiver, and physi- practice. ence to guidelines for HF treatment cian satisfaction with APN services
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Helping Reduce Hospital Readmissions Using Seven Key Elements By Cathy Jo Cress, MSW
Introduction the continuum of care smoothly, and coordinate care. This article discusses the Geriatric care elements of transition in care based All these skills are needed during on the National Transitions of managers can become hospitalization but are critical before admission and at discharge. The Care Coalition’s evidence-based an essential part of the “Crosswalk” of transitions of care geriatric care manager coordinates program. It documents how geriatric long-term care system transitional care. Yet so often, because of hospital policy, geriatric care care managers can implement all and the hospital- seven transition elements, thus saving management is not implemented in the patients, aging families, the long-term to-home team. hospital or when patient and family care system, and hospitals money. It transition to home, thus contributing to covers how GCMs can help prevent unnecessary readmission (Cress, 2009). unnecessary hospital readmissions, Discharge planners, usually nurses discharged responsibly with adequate implement Medicare savings, and and social workers, are overwhelmed by follow-up care. ensure adequate follow-up care. heavy case loads, so they do not have Geriatric Care Managers time to give individual service to pa- CMS 2012–2013 Penalty Can Be an Integral Part tients. Skilled GCMs can render highly for 30-Day Hospital of the Long-Term Care individualized service, 24/7, making the Readmissions System discharge planner’s job easier. The Centers for Medicare & Med- icaid Service (CMS), a branch of the Geriatric care managers can become Seven Tasks That GCMs U.S Department of Health and Human an essential part of the long-term care Can Perform to Prevent Services, will penalize doctors and system and the hospital-to-home team. Readmissions hospitals that have high 30-day read- That team can provide the necessary National Transitions of Care Coali- mission rates starting in FFY 2013. coaching and support to patients and tion put together an evidence-based their families so that patients are not A recent study in the New Eng- “Crosswalk” of seven key elements of readmitted, stay in the community, and land Journal of Medicine (Jencks, Wil- a transitions of care program based on save everyone money. liams & Coleman, 2009) demonstrated transition intervention research (Nation- that within a month of discharge, over To make this difficult transition al Transitions of Care Coalition, 2011). 20 percent of Medicare beneficiaries successful and support the family Task 1: were rehospitalized for the same con- caregiver, geriatric care managers dition they had been treated for earlier. should have a significant role with Medication Management— This is very costly for Medicare and families and elderly patients before, A method to ensure the U.S. taxpayers. The NEJM article sug- during, and especially after discharge safe use of medications gests that patients are being released, from the hospital. by patients and their families, based on patients’ before they are fully stabilized, to a The role of the geriatric care plans of care home situation unable to cope with manager with an elderly client in the the demands of their serious condi- hospital mirrors care management The first task the GCM does before tion. The penalty is designed as an tasks in general: educate, assess, hospitalization is to update routine risk incentive to be sure patients are being advocate, move the client through continued on page 26
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Helping Reduce Hospital disorienting. The patient often cannot health agency about the family and the Readmissions Using Seven speak for him- or herself. The family level of dysfunction that will affect a Key Elements often lacks some degree of health transition to home. continued from page 25 literacy and might not be included Because of the ongoing assessments, including depression in the plan of care. This, coupled relationship, the GCM can distinguish screening, home safety, psychosocial with hospital understaffing, makes who represents the patient’s family, who will be caregivers, who will be and functional assessment, and current the GCM valuable in making sure the main spokesperson communicating medications, which GCMs routinely transitions are planned and executed. with the discharge planner and others. do with new clients. This medication The initial full assessment and If the client does not have mental care plan that the GCM creates can risk assessment is then integrated into capacity, the GCM can smooth the be shared with the hospital doctor the patient’s updated care plan before transition to home by organizing the and all care professionals throughout hospitalization. The GCM can then family around this spokesperson. share this information with hospital hospitalization. The GCM can also To further engage the family, the staff at admission with the patient’s assess the family caregiver and GCM can arrange a family meeting in and other providers’ permissions, in a identify skill level and training needs, the hospital. Family communication HIPAA-compliant environment. so that at discharge there is a workable can break down in the hospital, transition plan coordinated with The GCM can transfer medication especially for dysfunctional families. the discharge planner, home health information to a computer disc or The GCM can ask the hospital staff agency, and the health care provider USB drive and give it to the hospital and attending physician to schedule admissions department and family team. a family conference. A plan of care director, under HIPPA compliance. Before discharge, the GCM can should come out of the meeting, which At discharge the GCM updates the alert hospital discharge planners the GCM will create and submit to the medication list. The GCM ensures to problems in the patient’s home family and the attending physician for that the patient has a realistic plan for environment such as lack of grab consideration. The GCM can help the getting the medications and can pick bars, loose wires, or steps. The GCM family add an ongoing list of questions them up if necessary to make sure the can solve problems before discharge, they wish to ask staff about regarding patient has them. greasing the wheels of the transition care, procedures, and problems. For families who wish the GCM through the home safety assessment. The GCM can assist the family to provide a high level of support, The GCM can also refer families with health literacy. This can include condition-specific information in this is an excellent way to educate to the hospital social worker for ad- multimedia formats (print, DVD, the patient’s family at any transition ditional support and access to services discs, internet sites, and so on). of care, especially at discharge, when in the hospital. This helps the family meds are often changed. The GCM be more prepared to take on the care, The GCM can interpret and counsels the family about medications, post discharge, increasing the chances enhance the health information given explaining what medications are that the patient will not cycle back into to the family about hospital procedures being taken, emphasizing any changes the hospital within thirty days. and the post-acute care that will be in the regimen, and reviewing each needed for a successful transition to medication’s purpose, how to take Task 3: home. each medication correctly, and Patient and Family Task 4: important side effects to watch for. Engagement/Education— Family meetings in the Information Transfer— Task 2: hospital Sharing of important care information among patient Transition Planning— Embracing a family-centered family, caregiver, and health A formal process that perspective is critical to achieving care providers in a timely facilitates the safe quality of care and engagement for and effective manner transition of patients from people with chronic or disabling one care setting to another, The GCM always shares patient conditions. This perspective helps the or from one practitioner to care information across the continuum another GCM, along with the hospital staff and others on the health care team, of care in a timely and effective A GCM’s job is to do transitions successfully engage and organize manner. The GCM can give a copy planning. Transition from one setting the patient, family caregivers, and of the disc or USB drive with the to another, especially into and out of friends through all transitions. At patient’s health record to the hospital the hospital, can be perilous for older the transition from home to hospital admissions and family director, people and their families. The change admission, the GCM can be a valuable under HIPPA compliance, to ensure in surroundings, new providers, conduit of information to the discharge that updated patient information and new medications can be very planner, physician, and rehab or home is transferred and shared at every
page 26 of Winter 2011 Geriatric Care Management transition. The personal health record planning. The GCM’s approach is with local, state, and national agencies can include a copy the GCM’s client that it is not the care recipient who is on aging to arrange condition-specific data sheet with meds, diagnosis and the client, but the “client system”— information and training on post-acute care plan, and medical history. including the family, the family tasks at discharge. For example, if Throughout the hospital stay, the caregiver, and friends—that is the the client has had a stroke, the GCM geriatric care manager encourages client. The GCM can encourage the contacts a local or national American the family to use the personal health “unit of care” to be actively involved Heart Association for information record. This record can be managed in the discharge plans, ensuring safe (multimedia, DVD, web, print, if transition to home. with the GCM’s support and helps possible) about aftercare. The GCM to formulate the patient’s and family The care manager also alerts the contacts the local stroke association caregiver’s questions. These questions family that if they feel the discharge is to find out if they have training for may include reasons for taking premature, the family and patient have family members to care for family at medications, reason for a worsening a right to appeal the decision, thus home and if they will come to the hos- ensuring that the patient goes home condition, and problems in the pital pre-discharge to do the training. hospital. This helps the family to share only when it is safe. The GCM can ask the physician clear information with the hospital Hospitals are required to give and to collect shared information from every Medicare patient or family if the hospital has a checklist of hospital providers. caregiver a copy of the statement specific information about the medical A personal health record can about appealing discharge decisions, conditions and needs of the elderly be as simple as a piece of paper in a “An Important Message about patient during the transition to file folder. GCMs can encourage the Medicare.” They must make sure home. This involves the family and family to transfer the information to the family and patient, if competent, caregivers in discharge and helps to a computer disc or USB drive, and understand the process. This document make the transition to home smooth. there are many personal care record spells out the patient’s rights to The GCM can also request that the products and programs on the market. all needed hospital care and post- physician, discharge planner, or RN The GCM shares the critical discharge follow-up. The hospital must review the checklist with the patient legal documents and care information also give a written notice explaining and family to make sure the family with the hospital admissions (with the discharge, a “Hospital-Issued understands the home care needs of HIPAA compliance), such as power Notice of Non Coverage” or HINN. the patient. of attorney for health care, durable The HINN includes the phone number of the local peer review organization If the physician or the hospital has power of attorney for health care, a not taken steps to involve the fam- living will, or a do not resuscitate (PRO) and other organizations that ily in the unit of care, the GCM gets order. The GCM gets this information review contested cases. Care managers the family involved through follow- at intake, before a medical crisis can help the family understand that and hospitalization occur. This legal the hospital cannot force family up training. The GCM can ask the information, already checked and caregivers to take patients home or physician if the PT and OT can train shared, helps the hospital and ensures pay for continued care before the PRO family members in transfers and use that the kind of care the older patient makes a decision. The GCM works of medical equipment pre-discharge. wants delivered is delivered. supportively, not adversarially, with If this does not happen, the patient has the discharge planner and physician to a much greater risk of readmission Task 5: mediate the situation and answer the because the family caregiver did not know how to render care. In addition Follow–Up Care—Facilitating family’s or patient’s questions about the safe transition of a nonreadiness for discharge to try to family members could injure them- patients from one care resolve the disagreement so that the selves by lifting, giving injections, or setting or care provider to patient family and discharge planner managing complex machines that they another through effective get what they need. Physicians and are not trained to manage. follow-up activities discharge planners are pushed by Task 6: The GCM’s family-centered DRGs and too many patients. So the approach ensures safe transitions, GCM’s extra support can provide a Heath Care Provider especially at discharge, and effective way to get the patient to the point of Engagement follow-up activities. The GCM helps safe discharge. GCMs work with the patient’s organize the family into a unit of care The GCM is key, post discharge, primary care physicians, specialists, to help with all transitions. to keeping the patient from readmis- home care agencies, and local Unit of care is a term that means sion. At discharge, the family’s health caregiver organizations at admission, the focus of a plan of care. Including literacy becomes critical to follow-up while the patient is in the hospital, the family was originally a major care. While the older family member and at discharge to ensure health care goal of hospitalization and discharge is in the hospital, the GCM networks continued on page 28
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Helping Reduce Hospital Task 7: Sources Readmissions Using Seven 1. Jencks SF, Williams MV & Coleman Key Elements Shared Accountability Across Providers and EA. ( 2009) Re-hospitalizations among continued from page 27 Organizations—Enhancing patients in the Medicare fee-for-service the transition process program. N Eng J Med. , 360(14):1418– provider engagement and to help the through accountability of 28. http://nationaljournal.com/njonline/ physician support the family caregiver. care of the patient by both penalties-for-high-readmission- The GCM can arrange caregiver the healthcare provider (or rates-20090721 training for post-acute tasks (bathing, organization transitioning) lifting, injections, and self-care for and the one receiving 2. Cress C, (2009) Care Manager’s Navigating Families Through the Hospital caregivers). the patient to Home, Care Managers, Working With It is critical for the GCM to assess Involving a Home Care the Aging Family, First Edition. (pp. the patient’s home before the patient 1–25). Sudbury, MA: Jones and Bartlett Agency goes home. This risk assessment Learning. http://www.amazon.com/Care- Another key health care pro- ensures shared accountability, a key to Managers-Working-Aging-Family/dp/ vider is the private duty home care preventing hospital readmission. The 0763755850 \. agency. Except for very brief cover- GCM will have done this assessment 3. National Transitions of Care Coalition age for post-hospitalization, Medicare as part of the original assessment. (2011). Care Transitions Bundle: 7 does not cover home care or what it Before the older patient is released Essential Intervention Categories. defines as long-term chronic care. So from the hospital, the GCM revaluates Retrieved from the Internet 10/25/11 at the patient and family must pay for the home assessment in terms of http://www.ntocc.org/Portals/0/PDF/ home care unless they have long-term the patient’s changed condition as a Compendium/SevenEssentialElements.pdf. care insurance. The GCM will have result of the hospitalization and shares assessed whether the patient can af- this information with the discharge ford home care as part of the initial planner, family, and Medicare agency, Cathy Cress holds an MSW assessment. The GCM can share the if they are involved. This increases in Aging from U.C. Berkeley. patient’s financial information with the shared accountability by putting Her book Mom Loves You Best, discharge planner. If the patient needs everyone on the same page about a Forgiving and Forging Sibling 24/7 care, with the help of the dis- safe discharge. For instance if the Relationships (New Horizon charge planner and the hospital staff, patient could climb stairs before the Press) came out in October 2010. the GCM can assess the patient’s pres- hospitalization and now cannot, the Cress’s Handbook of Geriatric ent level of care and help the patient, GCM may have to investigate a ramp Care Management, 3rd edition discharge planner, and family find the or first-floor bedroom. Alternative (Jones and Bartlett, March 2011) correct affordable care. All these ar- housing or placement will have to is the bible of geriatric care rangements can be the key to keeping be made if modifications are not management. Care Managers, someone at home as opposed to send- possible. The family must be involved Working With the Aging Family ing him or her back into the hospital. in either case. The GCM sharing this (Jones and Bartlett, 2008) is one The GCM and the discharge information with all players creates of the few major books on the aging family. Ms. Cress is the planner evaluate whether the family shared accountability and a safe founder of GCM Consult, which member who plans to render care can transition to home and helps prevent works with local and national really do so. If the GCM compares readmission. groups that want to add or launch the family members’ abilities (such In summary, the GCM is a GCM businesses. She is on the as ability to lift, ability or willingness professional who can carry out faculty of the online master’s to be trained in injections and in key elements of transition in care program in geriatric care managing medical equipment such based on the National Transitions management at the University of as a Hoyer lift or wheelchair) with of Care Coalition’s evidence-based Florida. the patient’s condition at discharge, “Crosswalk” of seven key elements the GCM and the discharge planner of a transitions of care program. can help the family member decide The GCM can and should be a key whether the family member can render team player in the long-term care care safely. If not, the GCM can system that works together to meet help build a support system that may CMS mandates to avoid unnecessary involve informal support from other hospital readmission. family members, close neighbors, or friends who can give injections or be trained to give injections.
page 28 of Winter 2011 Geriatric Care Management
Reducing Hospital Readmissions—One Hospital’s Journey to Implement Safer Transitions in Care By Robin Jones, RN
The passage of the Afford- for our facility. Project Red able Care Act (ACA) and the (see table on next page) fo- release of the $500 million in This was long before the time of cuses on ensuring the patient/ CMS (Centers for Medicare the glitz and glam that successful family has and understands & Medicaid Services) funding readmission initiatives have now, the vital medical information have catapulted preventable needed to care for the patient. so you can imagine the difficulty in readmissions into the forefront At this point you may be of healthcare agendas across engaging the key stake holders within asking, how does this relate the nation, posing the question the hospital and even worse – the to me? The answer is COM- for us all to ponder – How can local medical community as a whole. MUNICATION, and it does we make discharging patients not matter from what part of from the hospital safer? As you the medical community you probably already know, there come from. It is all about is no simple answer or quick issues plaguing the patients in our the patient – patient communication, fix. Besides managing the medical local community. We soon discovered education, understanding, and experi- condition, you must factor in person- this was not a one-man dog-and-pony ence. First of all, does the patient know alities, family members, education, show. It was going to take a village, a and understand what disease or condi- socio-economic status, religion, and very large village, to put together all tion they have? If they do not, either readiness to engage. This involvement the pieces in this complicated puzzle. educate the patient and their family or is not only with the patient, but the Step #1 • Figuring out where to find a resource that could assist them. downstream providers and the com- start was the first challenge: patients Help the patient to understand what munity as a whole. were coming back, when were they symptoms are normal for their condi- coming back, why were they coming tion, which symptoms they should Working In My Silo back, who was sending them back, and be contacting their physician for, and Valley Baptist Medical Center which returns were preventable? which symptoms warrant a trip to the – Brownsville was first approached emergency department. Patients should about working on a little known CMS Deciphering The always have the contact numbers to demonstration project in the fall of Medical Maze all of their healthcare providers and 2008 by TMF Health Quality Insti- Step #2 • Once we had some should know which one they should tute. TMF is the Quality Improvement concrete readmission data about our contact for any questions, depending Organization contracted by CMS patients and medical community, we on their symptoms. for the State of Texas. This was long were able to dive into working on Make sure the patient understands before the time of the glitz and glam solutions. Our first conclusion was that when their next appointment is and that successful readmission initiatives communication was one of the biggest has transportation to get there. Once have now, so you can imagine the factors in this whole equation. Com- patients go to appointments, it is very difficulty in engaging the key stake municating with EVERYONE was important to follow-up with any testing holders within the hospital and even of the utmost importance, including or procedures they have pending. En- worse – the local medical community patients, families, doctors, therapists, sure the patient or family knows how as a whole. The general mentality pharmacies, and downstream provid- to make these arrangements, and again, at the time was “Once they leave ers. We decided that Boston Univer- make sure they can get there. If any here—they’re out of my control!” So sity’s Medical Center’s Project RED testing or procedures are done, make with lots of hand holding, TMF gently (Re-Engineered Discharge) was the sure the patient follows up to get any pushed us into the sea of readmission most appropriate intervention model continued on page 30
page 29 of Geriatric Care Management Winter 2011
Reducing Hospital Read- missions—One Hospital’s Components of the Re-Engineered Discharge (RED) Journey to Implement Safer Transitions in Care 1. Educate the patient about his or her diagnosis throughout the hospital stay. continued from page 29 2. Make appointments for clinician follow-up and post discharge testing and • Make appointments with input from the patient regarding the best time and date of the appointment. pending results if they are not immedi- ately given. Does this patient have any • Coordinate appointments with physicians, testing and other services. services – home health, palliative care, • Discuss reason for and importance of physician appointments. meals on wheels, healthcare provider, • Confirm that the patient knows where to go, has a plan about how to get to the appointment; review rehabilitation? Ensure the patient un- transportation options and other barriers to keeping these appointments. derstands what benefits they have, the 3. Discuss with the patient any tests or studies that have been completed in the hospital and discuss services each provider is responsible who will be responsible for following up the results. for supplying, and how to reach them 4. Organize post-discharge services. when they need them. • Be sure patient understands the importance of such services. Do not forget one of the biggest • Make appointments that the patient can keep. parts: The Medication List. Make sure • Discuss the details about how to receive each service. the patient has a current medication list. They need to understand why they take 5. Confirm the Medication Plan. the medication, how to take it, its side • Reconcile the discharge medication regimen with those taken before the hospitalization. effects, and, most importantly, we need • Explain what medications to take, emphasizing any changes in the regimen. to make sure they are able to obtain all • Review each medications purpose, how to take each medication correctly, and important side effects of their medications. Create a realistic to watch out for. plan for patients to obtain medica- • Be sure patient has a realistic plan about how to get the medications. tion whether it is from a pharmacy 6. Reconcile the discharge plan with national guidelines and critical pathways. that delivers, getting samples from a 7. Review the appropriate steps for what to do if a problem arises. physician’s office, or having a medica- tion changed to a more affordable one. • Instruct on a specific plan of how to contact the PCP (or coverage) by providing contact numbers for Patients should understand that they evenings and weekends. own their medication list. They are not • Instruct on what constitutes an emergency and what to do in cases of emergency. a courier of the medication list between 8. Expedite transmission of the Discharge Resume (summary) to the physicians (and other services healthcare providers. It is essential that such as the visiting nurses) accepting responsibility for the patient’s care after discharge that includes: they understand the importance of this • Reason for hospitalization with specific principal diagnosis. list, taking it with them to every single • Significant findings. (When creating this document, the original source documents -- e.g. laboratory, medical appointment and keeping it radiology, operative reports, and medication administration records - should be in the transcriber’s updated. immediate possession and be visible when it is necessary to transcribe information from one document to another.) Patients should be taught how to • Procedures performed and care, treatment, and services provided to the patient. keep and manage a personal health record as well. As time goes on and • The patient’s condition at discharge. memories fade, it becomes very hard to • A comprehensive and reconciled medication list (including allergies). remember what conditions, procedures, • A list of acute medical issues, tests, and studies for which confirmed results are pending at the time of and surgeries you had done, where you discharge and require follow-up. had them done, and which physician • Information regarding input from consultative services, including rehabilitation therapy. did what. Keep a running list that can 9. Assess the degree of understanding by asking them to explain in their own words the details of the be easily added to or updated. plan. Every time a patient has been pro- • May require removal of language and literacy barriers by utilizing professional interpreters. vided information, assess the patient’s • May require contacting family members who will share in the care-giving responsibilities. degree of understanding and provide 10. Give the patient a written discharge plan at the time of discharge that contains: reinforcement for any instructions they • Reason for hospitalization. did not understand. The more patient- centered you can make your interven- • Discharge medications including what medications to take, how to take them, and how to obtain the medication. tions, the more successful you will be. There are several free helpful websites • Instructions on what to do if their condition changes. available for medication schedules, • Coordination and planning for follow-up appointments that the patient can keep. electronic calendars, and personal • Coordination and planning for follow-up of tests and studies for which confirmed results are not health records. Most older adults available at the time of discharge. continue to like using paper schedules 11. Provide telephone reinforcement of the discharge plan and problem-solving 2-3 days after discharge. and lists. Most of these websites have
page 30 of Winter 2011 Geriatric Care Management an electronic version that are easy to to use and update in your and your follow-up call from our intervention update and print. A great resource for patient’s daily routine. group to ensure they understood their medications is My Medication Sched- discharge instructions and medication ule at http://www.mymedschedule. Outcomes—Did This list. You may be asking yourself, is com/. You can update & print medica- Actually Work? this replicable? It is. Our sister facility tion schedules or pill box organizers CMS’s goal was to reduce in another community reduced their in English or Spanish, even in wallet readmissions by two percent in two readmission rate by three percent. As size, and adjust settings so you can years in 14 communities across long as you know what issues cause even send text or email reminders of the nation. Our facility and our your readmissions, you can reach out when to take medications and set up community both succeeded. Our and partner with the entities that can refill reminders automatically. The facility dropped our readmission rate help provide the solutions for your TMF website @ http://caretransitions. by six percent and our community patients. tmf.org/ has several helpful forms and dropped it by two percent. links for patient and the community, as We also defined our success in Next Steps well as patient self management tools several other areas. We saw that the Step # 3 • Engage your local for personal health records and advance number of patients who were actually community. One of the most important directives. Lots of Helping Hands is a seen by their physician between things you can do for your community free web-based community to organize discharge and readmission nearly is set up and sustain the necessary in- family and friends during times of doubled. Additionally, we saw our frastructure and support to care for this need at https://www.lotsahelpinghands. patient satisfaction scores increase frail and vulnerable patient population. com/. It can even be as simple as using for discharge instructions, medication No one person or health care entity the electronic calendar already pro- explanation, and communication. can provide the type of collaboration grammed on your computer or cellular Our data shows that readmission and partnerships necessary to accom- phone to schedule appointments and rates dropped into the single digits modate every aspect of a person’s total reminders. Incorporate what is easiest for patients who received a 2-3 day needs. Establish a community coalition meeting to discuss issues, barriers, and successes within your community. Use CT Project Results this forum to increase communication between providers and eliminate issues Hospital Disposition After Inpatient Hospitalization at each stage of a patient transition. Quarter 4, 2010 based on Medicare Claims Data Set up a charter for your Region & Number of Percentile Discharges Percent of community coalition establishing your Provider Setting Discharges of All with a 30-day Discharges with a mission, vision, objectives, goals, and Discharges Readmit 30-day Readmit meeting requirements. Always remind community providers that we are here Harlingen Home Health Agency (HHA) 770 17.1% 102 13.3% for a common mission. Providing the Region patient with the best and safest care Home 2,677 59.4% 595 22.2% needs to be first on everyone’s list. There is always a fear of transparency Inpatient Rehabilitation Facility (IRF) 301 6.7% 49 16.3% amongst competitive providers in the community. Please always keep in mind Long-Term Acute Care (LTAC) 220 4.9% 41 18.6% that patient safety is not a competition and can never be compromised. There Skilled Nursing Facility (SNF) 537 11.9% 121 22.5% are so many other things that the medical community can compete on, All 4,505 100.0% 908 20.2% such as who has the best CT scanner in town, who has the best Core Measures Your Home Health Agency (HHA) 96 16.2% 8 8.3% rates, or the shortest wait time. Work Hospital with your local medical community Home 322 54.3% 56 17.4% to develop “best practice” providers. Provide patients and families with Inpatient Rehabilitation Facility (IRF) 51 8.6% 3 5.9% local resources that best fit their needs and who care for their loved ones as if Long-Term Acute Care (LTAC) 49 8.3% 10 20.4% they were their own family members. Opening these lines of communication Skilled Nursing Facility (SNF) 75 11.9% 12 16.0% is vital to providing safe, optimal
patient care. All 593 100.0% 89 15.0% continued on page 32
page 31 PRE-SORTED STANDARD US POSTAGE PAID Tucson AZ 3275 West Ina Road, Suite 130 Permit No. 630 Tucson, Arizona 85741
Reducing Hospital Read- discharge planning, and post- missions—One Hospital’s discharge telephone reinforcement. in Brownsville, Texas. Ms. Jones Journey to Implement Safer is the lead Care Transitions Transitions in Care • TMF Health Quality Institute project facilitator at VBMC-B. continued from page 31 http://caretransitions.tmf.org/ Care She led the Hospital’s Transitions is a Medicare Quality implementation of Project Conclusions Improvement program under the RED components resulting in Centers for Medicare & Medicaid a 5.8% reduction in all cause In essence, the best thing that Services. Its goal is to reduce the rate readmission rates and a final you can do is get out of your comfort of avoidable re-hospitalizations by rate that exceeds the national zone and form alliances with the gold improving the transition of patients average. She has spoken on Care standard achievers in your commu- Transitions and Project RED for across care settings. nity. Do everything possible to ensure several conferences and webinars, that your patients receive the best • My Medication Schedule http://www. including a National CMS Care possible care by working with provid- mymedschedule.com/ Free website for Transitions Conference, Texas ers who step outside the boundaries medication schedules & reminders. Hospital Association, Healthcare of their four walls to provide patients Coalition of Texas, and Case in • Lots of Helping Hands https://www. Point. As a Quality Improvement with safe transitions at each step of lotsahelpinghands.com/ Free web- Coordinator, Ms. Jones oversees their medical journey. based community to organize family VBMC-B’s Joint Commission (JC) • Re-engineered Discharge (RED) & friends during times of need. re-accreditation for the hospital http://www.bu.edu/fammed/ and lab and re-certification projectred/index.html strives stroke program. Additional Robin Jones, RN, has over to minimize post- discharge projects include a Six Sigma seventeen years of experience hospital utilization by using Greenbelt Certification, Change in the hospital setting and is a Agent Training and initiative a standardized discharge Quality Improvement Coordinator on anticoagulation, medication intervention that includes patient at Valley Baptist Medical Center reconciliation, and readmissions. education, comprehensive