marge houy senior consultant bailit health purchasing, llc patient-centered medical homes: managing...
TRANSCRIPT
Marge Houy
Senior Consultant
Bailit Health Purchasing, LLC
Patient-Centered Medical Homes: Managing Patient Transitions of Care
1
Objectives
■ Provide background information about Massachusetts’ PCMH Initiative
■ Provide examples of how practices are developing the infrastructure to successfully manage transitions of care
■ Provide an opportunity to share experiences and learn among themselves
2
Background
■ 49 adult and pediatric practice sites participating in EOHHS-sponsored PCMH Initiative
■ Undergoing intensive 2-year training to: Implement population management approach to
providing evidence-based care Create team-based care with each team member
performing “at the top of their license” Integrate primary care and behavioral health services Partnership with patient in managing health conditions Provide patient-centered practice – enhanced access,
cultural sensitivity, etc.
3
Key Measures of Success
Practices have opportunity to share savings generated from reduced inpatient days and ED visits while meeting key quality benchmarks
4
Transitions of Care Infrastructure/Processes■ Identify nursing resources to function as practice-based
care manager
■ Key functions– Work with practice teams to stratify patients and identify high risk
patients: necessarily includes patients with ED or IP admission
– Create high risk patient registry; outreach and engage patients
– Contact discharged patients within 2 days of discharge and bring in for f/u visit, as appropriate
– Contact patients with chronic condition-related ED visit within 2 days and bring in for f/u visit as appropriate
– Work with patients to promote self-management skills
– Function as member of patient’s care team
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Example and Discussion
■ Lee Family Practice
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Key Changes to Achieve an Ideal Transition from Hospital (or SNF) to Home
I. Perform Enhanced Assessment for Post- Hospital
Needs
II. Provide Effective Teaching and Enhanced Learning
III. Conduct Real-Time Patient and Family-Centered
Handoff Communication
IV. Ensure Post-Hospital Care Follow-Up:
Completing the Transition into Care Settings within the Community
Office Practices Home CareSkilled Nursing
Facilities
• Provide timely
access
• Reconcile meds and
plan of care
• Coordinate care
with other community
clinicians
• Reconcile meds
• Reinforce self-care
plan
• Communicate as
indicated with
primary care provider
and specialists
• Assure staff are
capable to care for
patient’s needs
• Reconcile meds and
plan of care
• Provide timely
consultation when
patient’s condition
changes
Aligning PCMHI and STAAR
STAAR ProgramPerform an Enhanced
Assessment of Post Hospital Needs
■ Involve the patient, family, caregiver(s) and community providers(s) as full partners in completing a needs assessment of the patient’s home-going needs.
■ Reconcile medications upon admission
■ Identify the patient’s initial risk of readmission
■ Create a customized plan of care and discharge plan based on the assessment
PCMHI InitiativeEmpanelment
■ Primary care practitioner takes responsible for knowing his/her panel of patients and managing care across the care continuum
Aligning PCMHI and STAAR
STAAR ProgramProvide Effective Teaching and
Facilitate Enhanced Learning
■ Identify and involve all learners on admission
■ Customize the patient education process for patients, family caregivers, and providers in community settings
■ Redesign patient education process and patient teaching print materials
■ Use Teach Back daily in the hospital and during follow-up calls to assess the patient’s and family caregivers’ understanding of discharge instructions and ability to perform self-care
PCMHI InitiativePatient-Centered Care■ Make sure the patient understands
and agrees to care
Team-based Care■ Maximize provider-term
communication
■ Tracking of care transitions
Aligning PCMHI and STAAR
STAAR ProgramProvide Real-Time Handover
Communications■ Give and review with patient and
family members a patient-friendly post-hospital care plan which includes a clear medication list.
■ Provide customized, real-time critical information to next clinical care provider(s).,
■ For high-risk patients, a clinician calls the individual(s) listed as the patient’s next clinical care provider(s) to discuss the patient’s status and plan of care.
PCMHI InitiativeCare Coordination■ Two-way communications with other
providers
■ Tracking of care transitions
■ Transitional care within 48 hours
Enhanced Access■ Planned care at every visit
Aligning PCMHI and STAAR
STAAR ProgramEnsure Post-Hospital Care
Follow-up■ Reassess the patient’s medical and
social risk for readmission
■ Prior to discharge, schedule timely follow-up care and initiate clinical and social services as indicated from the assessment of post-hospital needs.
PCMHI InitiativeCare Coordination
■ Two-way communications with other providers
■ Tracking of care transitions
How-to Guide:Completing the Transition to the Clinical Office Practice
Getting Started
■ Step 1. Form a Team
■ Step 2. The Team Identifies
Opportunities for Improvement
■ Step 3. Develop an Aim Statement
Getting Started
■ Step 1. Form a Team
Consider choosing team members from the following:
• Patients and family members
• Physicians
• Nurse practitioners
• Nurses
• Office managers
• Schedulers
Getting Started
■ Step 2. The Team Identifies Opportunities for Improvement
– Diagnostic review of the last 5 patients from your practice that were rehospitalized within 30 days of discharge
– Review patient satisfaction data regarding communication and preparations for self care
Getting Started
■ Step 3. Develop an Aim Statement
– Analyze data
– Select target patient population
– Write an aim statement
Clinical Office Practice Key Changes
1. Provide Timely Access to Care Following a Hospitalization
A. Review on a daily basis information received from the hospital about admissions and anticipated discharges.
B. Provide appropriate level and type of follow-up for high risk, medium risk and low risk discharged patients
Clinical Office Practice Key Changes
2. Prior to the Visit: Prepare Patient and Clinical Team
A. Review discharge summary
B. Clarify outstanding questions with sending physician
C. Make reminder call to patient or family member
D. Coordinate care with home health care nurses and case managers if appropriate
Clinical Office Practice Key Changes3. During the Visit: Assess Patient and Initiate New Care Plan or Revise Existing Plan
A. Ask the patient about his/her goals for visit; what factors contributed to hospital admission or ED visit; and what medications he/she is taking and on what schedule
B. Perform medication reconciliation with attention to the pre-hospital regimen
C. Determine need to adjust medications or dosages, follow-up have on test results, do monitoring or testing; discuss advance directives; discuss specific future treatments
D. Instruct patient in self-management; have patient repeat backE. Explain warning signs and how to respond; have patient repeat
backF. Provide instructions for seeking emergency and non-emergency
after-hours care
Clinical Office Practice Key Changes
4. At the Conclusion of the Visit: Communicate and Coordinate on-going Care plan
A. Print reconciled, dated, medication list and provide a copy to the patient, family caregiver, home health care nurse, and case manager (if appropriate.)
B. Communicate revisions to the care plan to patient, family caregiver, home health care nurse, and case manager (if appropriate.)
C. Ensure that the next appointment is made, as appropriate
Model for Improvement
Use Model for Improvement to test changes
– Aims
– Measures
– Changes - Plan-Do-Study-Act
Implement
Spread