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www.HQOntario.ca
Post-Transition Risk Assessment and Appropriate
Follow-up
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2
Presenter Disclosure
www.HQOntario.ca
Presenter(s)
• Dr. Tara O’Brien
• Quality Improvement Coaches, HQO
Relationships with commercial interests:
• Grants/Research Support: Not Applicable
• Speakers Bureau/Honoraria: Not Applicable
• Consulting Fees: Not Applicable
• Other: Not Applicable
3
Disclosure of Commercial Support
www.HQOntario.ca
• This program has received no commercial or financial
support
• This program has received no in-kind commercial or
financial support
• Potential for Conflict(s) of interest:
No speaker has received payment or funding from
any for-profit organization
No organization has a product that will be
discussed in the program
How to Participate Today
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Asking a Question on the Webinar
All participants are muted but you can ask a question
or comment by:
Typing a question or comment
into the chat box located here
6
Objectives• To understand why post-transition risk assessment &
activating appropriate follow up is important to
transitions in care
• To understand what the risk assessment tool (LACE)
is and how to use it
• To describe some best practices/examples in Risk
Assessment and follow-up in Ontario
• Identify how using RA tools can improve continuity of
care for their patients to improve patient experience
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Background
• Care transitions – transfer of a patient between different
settings and providers
• Continuity of care - related to both the quality of care and
the experience of care
• Seamless transition - coordination of services and
providers, effective sharing of relevant information, and
proper post-transition follow up.
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POLL # 1
Working on improving Transitions?
A. We have worked on improving transitions in the past.
B. We are currently working on improving transitions.
C. We are in the planning phase of working on improving
transitions.
D. We don't have any plans yet to work on improving
transitions
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Hospital Readmissions
Poor coordination at discharge
Increased cost of care
Patient Dissatisfaction
Provider Frustration
Compromised Safety
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HQO Improvement Packages
Supporting
Health
Independence
www.HQOntario.ca
Transitions
of Care
Chronic Disease
Management
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Transitions improvement package
www.HQOntario.ca
Individualized care planning
Health literacy
Risk assessment and follow-up care planning
Medication Reconciliation
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Where could we be?
Best Ontario hospitals
reach 85-90% on some
quetions.
Optimizing Transitions from hospital to Home
www.HQOntario.ca
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59
80
83
70
64
52
62
80
0 50 100
Patient experiene on continuity and transition of care in 2010/11; source NRC Picker provided by OHA
Hospital patients who knew whom to call if they needed help
ED patients who knew whom to call if they needed help
Hospital patients who knew when to resume usual activities
Hospital patients who knew side effects to watch for
ED patients who knew side effects to watch for
ED patients who knew how to take new medications
Hospital patients who knew the purpose of medications
Hospital patients who discussed danger signals to watch for
ED patients who knew danger signals to watch for
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Poll #2• What experience have you had using risk-assessment
tools to reduce readmissions
1. We are currently using a risk-assessment scoring tool
to assess our patients
2. We are investigating using risk-assessment scoring tool
to assess our patients
3. We would like to use risk-assessment scoring tools but
don’t know where to start
4. Risk-assessment scoring tools – do we need that?
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LACE Risk Scoring Tool
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Assessing Patient at Risk for Admission
High Risk Patients Moderate Risk Patients
Patient has been admitted 2
or more times in the past
year.
Patient has been admitted
once in the past year.
Patient is unable to teach
back, or the patient or family
caregiver has a low degree
of confidence to carry out
self-care at home.
Patient or family caregiver
has moderate degree of
confidence to carry out self-
care at home.
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Institute for Healthcare Improvement, How-to-Guide: Creating an Ideal Transition Home, 2009.
Risk Scoring – Why?
• Enables the development of a post-acute care plan
based on the assessed risks, needs and capabilities of
the patient and family caregivers
• Triage high-risk to more intensive forms of post-
discharge follow-up
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Objectives
• To identify risk factors for adverse outcomes after hospital discharge
• To critically analyze the evidence regarding post-discharge transitions
• To consider various strategies for improving transitions in care
Objectives
• To identify risk factors for adverse outcomes after hospital discharge
• To critically analyze the evidence regarding post-discharge transitions
• To consider various strategies for improving transitions in care
High risk time post-discharge
• Acute excacerbations of chronic illness
• Shorter inpatient stays
• Major drop off in care
Why post-discharge time period is high
risk
• Medication changes
• Physician communication
• Collaboration
• Poor patient education
• Lack of in-home support
• 21.1% of US Medicare patients with a medical hospitalization readmitted within 30 days of discharge
• Total cost to US Medicare of 30 day readmissions estimated to be $17.4 billion (in 2004)
• In 50% of cases with readmission within 30 days, no outpatient physician visit between discharge and readmission
Jencks et al, NEJM 2009; 360: 1418-28
• Two key points (in favour of GIM):
– No single disease accounts for more than 8% of readmissions
– Even in heart failure, there are more readmissions for conditions other than heart failure than there are for heart failure
Jencks et al, NEJM 2009; 360: 1418-28
• Why are patients readmitted?
– Patient characteristics
– Health care system characteristics
Dhalla, O’Brien, Ko and Laupacis, Healthcare Quarterly 2012
• Patient characteristics
– Medical• Heart failure, COPD, dementia, etc.
• Psychiatric illness and substance use disorder
• Polypharmacy
• Functional status
Dhalla, O’Brien, Ko and Laupacis, Healthcare Quarterly 2012
• Patient characteristics
– Medical• Heart failure, COPD, dementia, etc.
• Psychiatric illness and substance use disorder
– Non-medical• Low educational attainment, health illiteracy,
poverty, limited fluency in English/French, lack of a robust social network
Dhalla, O’Brien, Ko and Laupacis, Healthcare Quarterly 2012
• Health care system characteristics
– Fragmentation• E.g. hospitals don’t deliver home care
– Access to primary care• ~10% of Canadians do not have a family physician
– Information continuity• Discharge summary available < 30% of the time
– Provider discontinuity• Hospitals don’t see most patients after discharge
Dhalla, O’Brien, Ko and Laupacis, Healthcare Quarterly 2012
Health Care Systems Characteristics
– Fewer physician house calls• Massive decline (>70%) over last 100 years
- Lack of access to urgent care
A tool to estimate the risk of readmission
• The LACE index– Clinical prediction rule derived and internally validated using data
collected for the OAtH study (4812 patients at 11 hospitals)
– 48 potential predictors considered, including functional status (Walter index) and support at home (lives alone vs. not)
– Externally validated using data from 1 000 000 patient records from CIHI-DAD
L = length of stay
A = acuity of admission
C = Charlson comorbidity index
E = number of ER visits in last 6 months
van Walraven et al, CMAJ 2010
1/8/2014
Prediction of readmission using the LACE
index
0
15000
30000
45000
60000
75000
90000
105000
120000
135000
150000
165000
180000
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
LACE Index Score
Nu
mb
er
of
Ad
mis
sio
ns
0%
10%
20%
30%
40%
50%
60%
30-d
ay D
eath
or
Un
pla
nn
ed
Read
mis
sio
n (
%)
Van Walraven et al, CMAJ 2010
HARP tool
• Age (65-84, 85+)
• Place patient is discharged to (acute, home care, other)
• Number of Acute admissions, 6m prior (1/2/3/4+ vs 0)
• Number ED visits (last 6 months)
• Top Case Mix Groups: COPD, CHF, IBD, GI
obstruction, cirrhosis, diabetes
Objectives
• To identify risk factors for adverse outcomes after hospital discharge
• To critically analyze the evidence regarding post-discharge transitions
• To consider various strategies for improving transitions in care
1/8/2014
1/8/2014
• Population
– Single hospital in a very poor area of Boston
– 749 patients randomized
• Intervention
– Low-intensity pre-discharge visit (~45 minutes)
• coordination of care, medication reconciliation, education
– Discharge summary
– Post-discharge pharmacist telephone call
Jack et al, Annals of Internal Medicine 2009; 150: 178-87
• Control
– Usual care
• Results
– Reduced post-discharge hospital use
• 0.31 ER visits/hospital admissions per patient per month
compared to 0.45 in control arm
– Increased visits with primary care physician
• 62% in intervention arm vs. 44% in control arm
Jack et al, Annals of Internal Medicine 2009; 150: 178-87
• Population
– Single hospital in Colorado
– Patients with any one of 11 conditions
– 750 randomized
• Intervention
– Pre- and post-discharge visits with a “transition coach”
– 3 telephone calls over one month
– Medication reconciliation, education
Coleman et al, Archives of Internal Medicine 2006; 166: 1822-28
• Control
– Usual care
• Results
– Reduced readmissions
• 8.3% in 30 days in intervention arm vs. 11.9% in control arm
• 25.6% at 180 days vs. 30.7% at 180 days
– Reduced costs
Coleman et al, Archives of Internal Medicine 2006; 166: 1822-28
Virtual Wards
Method of providing care to people in the community
“Ward” – Borrows elements of hospital care (team-based, shared notes, single
point of contact)
“Virtual” - Patients remain at home (nothing “high-tech” about it)
Acute Care
Hospital #2
Acute Care
Hospital #1
Communicate with non-
Virtual Ward care
providers (family doctor,
non-Virtual Ward CCAC
staff, social supports,
specialists, etc.)
Discharge to primary care
Virtual Ward
• Housed at Women’s College
• Multidisciplinary team hired by
CCAC
• Dedicated general internist, family
physician or geriatrician
Acute Care
Hospital #3
Discharge to primary
care occurs quickly if
all supports in place
TGH TWH
The Toronto Virtual Ward
Randomized controlled trial
• P = Population– High-risk adults (LACE ≥ 10) discharged to home or long-term
care
• I = Intervention– Virtual Ward
• C = Control– Usual Care
• O = Outcome– Primary: readmission or death within 30 days
– Secondary: readmission, death, ER visits, death at 30, 90, 180 and 365 days
Case
• 60 yr old woman with multiple medical
problems
• In and out of hospital with gout. Admitted
with hypercalcemia and stay complicated by
MI and emphysematous cystitis
• Lives alone, supportive friend, CCAC
supports
Case cont..
• Patients mobility limited
• PCP not conveniently located
• On discharge summary: follow up with PCP
in one week to have calcium checked
• In next few weeks patient had severe flare
of gout involving multiple joints and had
fever.
What we did
• Increased in-home supports with PSW and
physio
• Medication reconciliation
• Managed her gout on an urgent basis
• Linked her to new PCP closer to her house
Hospital Admission Prevented
1/8/2014
Qualitative study – key findings
• Main activities– Rounds – very important
– Home visits – very useful
– Documentation/administration challenging and cumbersome given the lack of an integrated, electronic record
• Patient benefit– Better coordination of care
– Better management of medications
– Home visits very helpful
• Educational benefit– Excellent learning environment
– Change in physician perspective
1/8/2014
Qualitative study – key findings
• Challenges
– Communication with family physicians
– IT challenges
– Purchaser/provider split in home care
– Hard to standardize care given heterogeneity of patients
– Physical access to health care settings for functionally limited patients
– Professional boundaries (e.g., Virtual Ward physician and patient’s primary care physician)
– Lack of primary care for complex patients
– Suboptimal hospital discharges
CONFIDENTIAL: Please do not distribute without permission
Objectives
• To identify risk factors for adverse outcomes after hospital discharge
• To critically analyze the evidence regarding post-discharge transitions
• To consider various strategies for improving transitions in care
• Two questions to think about
– What can you do as an individual physician to improve post-discharge outcomes for yourpatients?
– What could the health care system do to improve post-discharge outcomes for allpatients?
• What can you do as an individual physician?
– Personalized discharge plan for those at high risk
• Medication reconciliation
• Patient education with teach back
• Instructions re. red flags, instructions on how to respond
• Booked follow up with PCP
What Physicians Can Do
– Information continuity• Timely discharge summaries with clear follow up
instructions (personalized discharge plan)
• Standardized discharge summaries with key information
• Phone calls to PCP
• Electronic discharge notification
Physician
– Provider continuity• Post-discharge clinics
• Follow up phone calls to patients
• House calls
– Caveat: relatively weak evidence
• What could the health care system do?
– Primary care for everyone
– Primary care with capacity for urgent assessments
– Shared care (e.g., primary care and GIM)?
– Better integration of primary care, home care and hospital care?
– Urgent access to subspecialty care
– IT compatibility(web access to discharge summary)
Healthcare System
– Payment models that facilitate the care of complex patients?
– Other strategies?
– Caveat: relatively weak evidence …
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