Strategies to Improve Healthcare Transitions:Patient & Caregiver Engagement and Activation

Sara Butterfield, RN, BSN, CPHQ, CCM New York State Wide Senior Action Council, Inc.2011 Annual ConventionOctober 11, 2011

Centers for Medicare & Medicaid Services (CMS) Leads a national healthcare quality improvement program,

implemented locally by an independent network of Quality Improvement Organizations (QIOs) in each state

IPRO The federally funded Medicare Quality Improvement

Organization (QIO) for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS).

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CMS GoalsNational & Statewide LevelSix Priorities

Making care safer Promoting effective coordination of care Assuring care is person and family-centered Promoting the best possible prevention and treatment of the

leading causes of mortality, starting with cardiovascular disease

Helping communities support better health Making care more affordable for individuals, families,

employers and governments by reducing the costs of care through continual improvement

National Perspective

17.6% of Medicare beneficiaries are re-hospitalized within 30 days of discharge, accounting for $15 billion in spending

Estimates show that 76% of these readmissions may be preventable

Of Medicare beneficiaries re-admitted within 30 days, 64% receive no post-acute care between discharge and re-admission

Source: MedPAC:June 2007 Report To Congress: Promoting Greater Efficiency in Medicare

New York State 30-Day Hospital Readmission RatesMedicare FFS Beneficiaries Age 65 or Older

CY 2009 CY 2010All Cause 20.5% 20.9%Acute Myocardial Infarction 25.2% 23.8%Heart Failure 28.8% 28.6%Pneumonia 21.3% 21.1%Chronic Obstructive Pulmonary Disease 26.2% 26.4%Diabetes 24.3% 22.3%End Stage Renal Disease 37.1% 35.4%

Source: CMS ISAT Data

New York State Perspective

Consumer PerspectiveAARP Report: Chronic Care: A Call to Action forHealth ReformAccording to the results of the patient survey: Nearly one in four patients reported experiencing a medical error, and 61

percent of this subgroup said they had experienced a major problem as a result;

About one in five reported that their health care providers did not communicate well with each other about the their individual condition or treatment, which some said compromised their health;

Nearly one in seven said they didn't get a follow-up appointment after they were discharged or, if they did, it was more than four weeks later; and

Almost one in five said their transitional care was not well coordinated.

Contributing Factors

Patients are more chronically ill, more frail, and have more complex care needs

Multiple diagnoses May see several physicians Average 13-16 medications per day May be cognitively impaired May not have a Primary Care Physician Lack of involving a caregiver for safe transition to home Access to and/or lack of community services

Other Contributing FactorsNot remembering / understanding physician instructions Difficulty communicating with health professionalsUnrealistic expectations Difficulty arranging for assistanceFinances/affordabilityNot enough time for competing demandsLoss of mobilityLanguage barriers

(Source: Beyond 50.09 Chronic Care: A Call to Action for Health Reform, AARP, March 2009)

Dilemmas Focus is on discharge versus transition No ownership of transition Burden of coordination is placed on patient Caregiver may not be available / involved at discharge Absence of common medical record Absence of cross setting medication reconciliation Lack of advance directives & screening for palliative care No reassessment of patient and goals at each transition Communication gaps exist between disciplines and health

care settings

The Driving Forces….American Geriatrics Society Health CareSystems Committee Position

• Clinical professionals must prepare patients/caregivers to receive care in the next setting & actively involve them in decisions related to the formulation & execution of the transitional care plan

• Bi-directional communication between clinical professionals is essential to ensuring high quality transitional care

• The opportunity to collaborate with a coordinating health professional functioning across health care settings to reduce care fragmentation may enhance the care that these professionals deliver

Source: J Am Geriatric Soc 51:556-557, 2003

Centers for Medicare & Medicaid Services Care Transitions Initiative

August 2008-July 2011

New York Care Transitions Target Community

Five county region in Upper Capital Region of New York State with integrated referral patterns incorporating urban, suburban and rural communities within 84 zip codes

● Warren, Washington, Saratoga, Rensselaer & Saratoga

Fifty providers● Hospitals (6), Home Health (6), Skilled Nursing Facilities (28), Hospice (5),

Dialysis Centers (5), Multiple Physician Practices

Impacting 68,206 Medicare Fee for Service (FFS) beneficiaries

Where We Began Our Journey…

Cross-Setting Partnerships“Our Patient” “Patient Within Our Community”

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The Paradigm Shift: Discharge Versus Care Transition

Targeted Opportunities for ImprovementAssessment of patient / caregiver understanding of discharge medications & instructions using Teach-Back MethodIdentification and referral of high-risk readmission patients for follow-up careInclusion of 7-day follow-up physician visit appointment in discharge instructions with follow-up phone callCross setting medication reconciliation & educationSupport of patient / caregiver learning for self-management (signs / symptoms / red flags / action)Improved cross setting partnerships and communication for care coordination and managementStreamlined and standardized cross setting information transfer

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Patient Engagement / Activation

The person’s ability to manage their healthand health care

Self efficacy in managing their behavior Readiness to change - motivation Knowledge, skill, beliefs, and behaviors Linked to the person’s health outcomes

Patient Engagement / Activation

Patients who were not interested or less involved in care tended to:

Have more problems with transitioning between care settings Reported more problems with care Less confident with there ability to manage their chronic

condition Worse health status and more chronic conditions Required more assistance to arrange for care

(Source: Beyond 50.09 Chronic Care: A Call to Action for Health Reform, AARP, March 2009)

Key Practices Leading to ResultsCollaborated with target community providers and stakeholders to identify sites where seniors gather for social and health activities

• Senior Centers , Housing Units, Independent & Assisted Living Facilities, Churches, Libraries

Organized one hour beneficiary outreach sessions at each site• 20 educational sessions completed to date reaching over 315 Medicare beneficiaries in community

• 3 community caregiver outreach exhibits with over 160 attendees

• 2 senior health fairs with over 150 attendees

Developed large font, fifth grade level educational materials to share and reference during each session:

• Hospital Discharge Planning “Golden Rules”

• Medication Management “Golden Rules”

• Personal Health Record

• Caregiver Resource Handout

• United Hospital Fund Next Step In Care Resources

Opened sessions by asking seniors to share their health care experiences and then used their stories in conjunction with the educational materials to discuss importance of self empowerment & self-management skillsShared beneficiary feedback & perceptions with target community providers

Determine your zone every day!

Every day:Weigh yourself in the morning before breakfast, and enter your daily weight in a log. Take your medicine as directed by your doctor.Check for swelling in your feet, ankles, legs and stomach.Eat low-salt food.Balance activity and rest periods.

Green ZoneThis zone is your goal

Your symptoms are under control. You have:No shortness of breath.No weight gain of more than two pounds.No swelling in your feet, ankles, legs or stomach.No chest pain.

Yellow ZoneCaution: This zone is a warning

Call you doctor's office if:You have a weight gain of two or more pounds in one day or a weight gain of four pounds or more in one weekYou have increased shortness of breath.You experience more swelling of your feet, ankles, legs or stomach.You feel more tired and lack energy.You have a dry or moist hacking cough.You experience dizziness.You feel uneasy; you know something is not right.It is harder for you to breathe when lying down; you need to sleep sitting up in a chair.If any of the above symptoms is severe or getting worse, call 911 or go to your hospital’s emergency room.

Red ZoneEmergency

Go to the emergency room or call 911 if you have any of the following:Difficulty breathing; unrelieved shortness of breath while sitting still.Chest pain.Confusion or inability to think clearly.

Heart Failure Zones

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ADMISSIONHIPAA: Questions and Answers for Family Caregivers

Your Family Member’s Personal Health Record

Medication Management FormA Family Caregiver’s Guide to Advance Directives

PLANNING FOR DISCHARGEThe Next Step in Care: What Do I Need as a Family Caregiver?

Hospital-to-Home Discharge Guide

Next Step In Care Guides and Checklistshttp://www.nextstepincare.org

DISCHARGE

Family Caregivers’ Guide toMedication Management

Going Home: What You Need to Know

NEXT STEPS

A Guide to the ER

When the Next Step Is Home Care: AFamily Caregiver’s Guide When the Next Step Is Rehab: AFamily Caregiver’s Guide

Medicare Beneficiary Feedback Following IPRO Care Transitions Outreach SessionsAfter attending this session I now feel more prepared to….

Source: IPRO Medicare Beneficiary Outreach Program Evaluations

Medicare Beneficiary Feedback on IPRO Care Transitions Outreach Sessions

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I am a retired public health nurse that practiced before the times of Medicare and Medicaid. I think the guidance you shared here with us today on how to navigate the health care system and take charge of managing our health information has been very helpful. It is not our way to ask questions of the people who provide us health care…we often feel we do not have the right and quite often when we do our questions and concerns go unanswered. Thank you for giving us permission to become empowered!

After participating in this session I am now aware of today’s health care environmental routines/personnel and the fact that I need to be more aware of the details of my health care.

The information shared will be very helpful to organize my health information. I feel more comfortable knowing it is okay to ask the health care team questions to enable me to become more involved in my care.

Before today I never thought about involving my Pharmacist to answer questions and concerns I have about my medications. Thank you for the suggestion!

I was so anxious in the hospital I did not even think about what I needed to plan for once I got home. This information and my experience over the past year will help me plan ahead next time.

The information you provided regarding the Hospitalist role was very helpful. I had never heard about that before and had no idea that my doctor I have gone to for the past 16 years may not even know I was in the hospital to be involved in my care

Our Destination……Ten New Rules to Redesign & Improve Care

1. Care is based on continuous healing relationships2. Care is customized according to patient needs and values3. The patient is the source of control4. Knowledge is shared and information flows freely5. Decision making is evidence-based6. Safety is a system property7. Transparency is evident8. Needs are anticipated9. Waste is continuously decreased10.Cooperation among clinicians is a priority

Source: Adapted from the Institute of Medicine, 2001

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For more information

Sara Butterfield, RN, BSN, CPHQ, CCM518 426-3300 x104

sbutterfield@nyqio.sdps.org

http:caretransitions.ipro.org

CORPORATE HEADQUARTERS1979 Marcus AvenueLake Success, NY 11042-1002REGIONAL OFFICE20 Corporate Woods BoulevardAlbany, NY 12211-2370www.ipro.org

This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-NY-AIM8-11-07