texas council chc-adrc rev 6-8-17 wo...
TRANSCRIPT
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How Centers can Reduce Preventable Re‐hospitalization through Evidence
Based Care Transitions
Julie Myers
Lee Brown
Lindsay Lovelace
1. Identify role and populations served by the ADRCs.
2. Identify key partners associated with the ADRCs.
3. Explore the role of a transitional care coach or other non‐healthcare professionals in providing the continuum of care.
4. Identify core areas of Healthy At Home model for transitional care.
5. Explain the role of the transitional care model to assist in empowerment‐based patient care.
6. Provide strategies and skills necessary to create investment in personal healthcare needs.
7. Describe how to identify patient needs and link to potential community partners.
Objective
ADRC
Julie Myers
6/8/2017
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Long‐term services and supports (LTSS) are a spectrum of health and social services that support elders or people with disabilities who need help with daily living tasks. LTSS can be provided in the home and community or in a facility.
What are Long Term Services and Supports?
Welcome to LTSSEnroll Here
MissionThe mission is to serve as a highly visible, trusted resource for assistance with access to the full range of community‐based LTSS options for all individuals regardless of age income and disability.
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the ADRChas a presence in
all 50 states
22 ADRCsstatewide
22 ADRCsstatewide
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Core ADRC functions :• consumer information and referral
awareness services
• options counseling
• streamlined eligibility determination for public programs and access to services
• person‐centered transition support
• quality assurance and continuous improvement
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Who Should Call? (855) YES‐ADRC
By making the call, you will talk to a trained professional who will guide you to the right service options to help meet your needs.
You can call for yourself for a family member
You can call for a neighbor
You can call for a friend
You can call for a client you are helping
Reasons to call: (855) YES‐ADRC
Long‐term care resources:
• Someone to monitor your health or help you take medication
• Someone to help you bathe, dress or use the bathroom
• Someone to prepare or deliver meals
• Someone to help you clean or maintain your home
• Someone to drive you to doctor appointments
• Someone to provide a break (respite care) for people who care for you
Access to Long Term Services & Supports (855) YES‐ADRC
An LTSS screen will be completed
Simple, concise, easy to complete
Allows individuals to tell their story only once
Help to find the “right” help more easily
Help to receive assistance from programs for which they may be eligible
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Core partners generate & receive referrals:
ADRC
Area Agency on Aging
Local Intellectual & Developmental Disability Authority
DADS Regional Office
State Office Interest List
Local Mental Health Authority
“No Wrong Door”
ADRC and Transitions Programs
Lee Brown
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2012 – ACL: Business Acumen collaborative
10 partnerships were selected
Texas Aging and Disability Providers Network (TADPN)
ACL provided 2 years of technical assistance
TADPN MCOs re Evidenced Based Practices
ACL & Business Acumen
Texas Healthy at Home, LLC
A not for Profit, Limited Liability Corporation made up of
Area Agency on Aging (AAA) &
Aging & Disability Resource Centers (ADRC)
Currently utilizes Tejas Behavioral Health as the Accountable Care Organization
Texas Healthy at Home, LLC
Care Transitioning
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Institutional Support
Multidisciplinary Team or Steering Committee
Engagement of patients and families
Data Collection and reliable metrics
Specific aims or goals
Standardized discharge pathways
Policies and Procedures
Comprehensive education programs
Project BOOST
Bridge Model
Six key focus areas
Person Centered
Multi‐disciplinary
Social Worker led
Nurse practitioner and social worker meet with patient and caregivers in home
Primarily implemented with low‐income seniors
Interdisciplinary approach
Primary Focus: Chronic conditions, at risk senior populations, primary care integration, electronic medical record
GRACE‐ Geriatric Resources for Assessment and Care of Elders
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Transitional Care Model (TCM)
Skilled transitional care nurse
Targets older adults with chronic disease
2 months of service or longer
Guided Care ®
Trained nurse assesses the patient and caregiver at home
Creates an evidence‐based care plan for providers and action plan for patients and caregivers
Promotes patient self‐management
Monitors patients’ conditions
Interdisciplinary coordination
Goal: Smooth transitions between sites of care
Care Transitions Intervention
Lindsay Lovelace, LMSW
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Readmission‐ An admission to a hospital within 30 days of a discharge from the same or another (subsection) hospital
Adopted readmission measures for the following conditions: acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN);
Hospital Readmission Reduction Program
(Hospital Readmissions Reduction Program 2016)
Effective Program Year
Finalized in IPPSRule
30‐Day Risk Readmission Measures
• FY 2013 and FY 2014 • FY 2012 • Acute myocardial infarction (AMI)• Heart Failure• Pneumonia
• FY 2015 and FY 2016 • FY 2014 • AMI• HF• Pneumonia• Chronic Obstructive Pulmonary Disease• Total hip/total knee arthroplasty
FY 2017 FY 2015 AMIHFPneumoniaCOPDTHA/TKACoronary Artery Bypass
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Hospital Name Number of Discharges Number of Readmissions
Good Shepherd Medical Center 775 COPD 177 COPD
859 HF 205 HF
Wadley Regional 216 COPD 47 COPD
322 HF 77 HF
Palestine Regional 216 COPD 44 COPD
183 HF 30 HF
East Texas Medical Center 476 COPD 102 COPD
671 HF 150 HF
Discharges and Readmissions July 2011‐ 2014
(Hospital Readmissions Reduction Program 2016)
Impaired function
Exacerbation of multiple chronic illnesses
Five or more comorbidities
History of multiple hospitalizations
Inadequate discharge planning
Noncompliance with medication
Cognitive impairment
Discharged to location where patient’s needs are not met
(Park, Hain, Tappen, Diaz, Ouslander 2012)
Causes for Readmission
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give official authority or legal power to
provide with the means or opportunity
promote the self‐actualization or influence of
Empowerment
THE METHOD: Eric Coleman’s Four Pillars
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The goal is that the patient is knowledgeable about his/her medications and has a management system
The management system has to be realistic and individual to the person
Coach is non judgmental and realistic, i.e. Whatever the patient was doing before the Coach arrives is what they will continue to do when the Coach leaves
Pillar 1: Medication Self‐Management
Health Conditions
Medications
Self‐identified goal
Questions for follow up care
Red Flags
Pillar 2: Patient Health Record (PHR)
(Giri, Bafaloukos, Bhaumik, & Singh, 2015)
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Coach will encourage and remind patient to schedule a follow up with their primary physician once out of the hospital. Many patients do not realize that their physician may not be aware they were in the hospital
Coach can role play this with patient to build skills in effectively getting a quick appointment, i.e. “I was just in the hospital for my CHF and have some questions about my medication” may be more effective than simply “I need an appointment.”
This follow up appointment is when the physician will look at PHR & learn about a possible med error or concern
Pillar 3: Patient Follow up with Physician
Patients will identify and write down the indications that their condition is worsening…
i.e. “what were you feeling before you went to the hospital?”
Along with that – they will identify what their plan is when they experience these red flags
Pillar 4: Red Flags
What were some of the shared characteristics of these programs?
Core Components of Successful Programs
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Interdisciplinary Communication
Medication education and self‐management
Patient self‐advcocacy
Family and caregiver involvement
Core Components of Successful Programs
Elements of Successful Transitions
Knowing the resident
Critical knowledge and
skilled assessment
Positive relationships
Effective communication
Timeliness
Coaching Role
Coaching is not a replacement of any other current provider
It does not attempt to replace discharge planners or home health nurses
Coaching is intended to supplement any other service that a patient receives and enhance the patients effectiveness in utilizing these services and communicating with other providers
Coaching requires flexibility and letting go of rigid agendas
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Focusing on the individual’s wholistic needs
Individual, familial, social, political, cultural, and spiritual context
Strengths focused
Person‐Centered Approach
(Cloninger, 2013)
PROGRAM CENTERED PERSON CENTEREDPlanning For you Planning With you
Talking about you Talking with you
Doing things to you Doing things with you
Following the program Having a life
You live where you “fit” You choose who & where you live
We are in control We share control
Starting with what’s wrong Starting with what is important
Issues of health and safety
dictate where you live
Issues of health and safety
are addressed where you want to live
We “let”, “allow” and “place” We “support”, “assist” and “help”
We set your goals We suggest, you decide
Dead Plans‐
“Updated annually”
Living Plans‐
Change with the person
There are four core principles of MI:
Express empathy
Roll with resistance
Develop discrepancy Support self‐efficacy
(Wilkins, 2014)
Motivational Interviewing
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What is the phone number for the ADRC?
Questions for Audience
Name one of the 4 pillars of the Coleman Model.
Questions for Audience
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What is Person Centered?
Questions?
Julie Myers
Lee Brown
Lindsay Lovelace
Contact
"My Transitions Coach has helped me to feel more confident in managing my heart condition. I feel as though I am in charge of my health and I am less reliant on others.”
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Care Transitions Program. The care transitions measure. 2014. Available at: www.caretransitions.org/ctm_main.asp. Accessed June 2016.
Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trail. Arch Intern Med. 2006; 166 (17): 1822‐1828
Cloninger, C. R. (2013, July 3). Person‐centered Health Promotion in Chronic Disease. Retrieved September 5, 2016, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4556425/
Works Cited
Distel, E., BS, Casey, M., MS, & Prasad, S., MBBS, MPH. (2016, March). Policy Brief #43 Reducing potentially‐preventable readmissions in critical access hospitals. Retrieved August/September, 2016, from www.flexmonitoring.org
Gardner, R., Li, Q., Baier, R. R., Butterfield, K., Coleman, E. A., & Gravenstein, S. (2014, March). Is Implementation of the Care Transitions Intervention Associated with Cost Avoidance After Hospital Discharge? Journal of General Internal Medicine,29(6), 878‐884.
Giri, P., Bafaloukos, N., Bhaumik, A., & Singh, A. (2015). Personal health management The rise of the empowered consumer. Retrieved from http://www.pwc.com/us/en/advisory/customer/pwc‐experience‐radar.html
Works Cited
Hospital Readmissions Reduction Program. (2016, July 27). Retrieved from https://data.medicare.gov/Hospital‐Compare/Hospital‐Readmissions‐Reduction‐Program/9n3s‐kdb3
Lorig, K. (2012). Living a healthy life with chronic conditions: Self‐management of heart disease, arthritis, diabetes, depression, asthma, bronchitis, emphysema, and other physical and mental health conditions. Boulder: Bull Pub
Works Cited
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Miller, W. and Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change. Second edition. London: The Guilford Press.
Park, J., Hain, D. J., Tappen, R., Diaz, S., & Ouslander, J. G. (2012, December). Factors associated with 30‐day hospital readmissions among participants in a care transition quality improvement program. Journal of the Society for Social Work and Research, 3(4), 308‐328. Retrieved June 06, 2016, from www.jstor.org/stable/10.5243/jsswr.2012.19.
Wilkins, D. (2014, March 13). Motivational Interviewing: An Evidence‐Based Approach to Working with Families ‐ Social Work Helper. Retrieved September 10, 2016, from https://www.socialworkhelper.com/2014/03/31/motivational‐interviewing‐evidence‐based‐approach‐working‐families/
Works Cited