Preparing Patients and Caregivers to Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: Participate in Care Delivered Across Settings:

 The Care Transitions Intervention The Care Transitions Intervention

Monique Parrish, Dr.PH, MPH, LCSW

Background: Coleman Care Transitions Background: Coleman Care Transitions ModelModel

Qualitative Studies– Inadequately prepared for next setting– Conflicting advice for illness management– Inability to reach the right practitioner– Repeatedly completing tasks left undone

The “Silent” Care CoordinatorsThe “Silent” Care Coordinators

By default, older patients and family caregivers function as their own care coordinators

First line of defense for transition related errorsModel explicitly recognizes their role as

integral members of the interdisciplinary team

Randomized Controlled TrialRandomized Controlled Trial

Variable Intervention Control P-Value

Age (years) 76.0 76.4 0.52

Female (%) 48.2 52.3 0.26

Married (%) 58.2 53.8 0.23

Lives alone (%) 30.9 30.8 0.99

Sad or Blue (%) 30.3 26.4 0.24

CHF (%) 16.5 12.9 0.17

COPD (%) 17.0 18.5 0.61

Arrhythmia (%) 12.8 19.0 0.02

CAD (%) 14.1 13.5 0.81

Chronic Disease Score

6.8 7.1 0.31

Variable Intervention Control P-Value

Prior Hosp (%)

1+ past 6 mo

29.3 26.1 0.36

Prior ED (%)

1+ past 6 mo

40.3 38.9 0.69

D/C Destin.

Home (%)

Homecare (%)

SNF (%)

Other (%)

50.8

24.7

21.0

3.5

52.9

25.9

19.3

1.9

0.71

Friday D/C (%) 14.6 16.5 0.48

Variable Intervention Control

Adjusted

P-value

Re-hospitalized

w/in 30 days 8 % 12 % 0.048

Re-hospitalized

w/in 90 days17 % 23 % 0.04

Re-hospitalized

w/in 180 days26 % 31 % 0.28

Variable Intervention Control

Adjusted

P-value

Readmit for Same Dx w/in 30 days

3 % 5 % 0.18

Readmit for Same Dx w/in 90 days

5 % 10 % 0.04

Readmit for Same Dx w/in 180 days

9 % 14 % 0.046

Care TransitionsCare Transitions

“Care Transitions” refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.

The Care Transitions Intervention:The Care Transitions Intervention:

Designed to encourage older patients and their caregivers to assert a more active role during care transitions

The Four PillarsThe Four Pillars

Four PillarsFour Pillars

Medication Self-Management Patient Centered Health Record (PHR)

Primary Care Provider/Specialist Follow-Up

Knowledge of Red Flags

Pillar #1:Pillar #1: Medication Self-ManagementMedication Self-Management

Focus: reinforcing the importance of knowing each medication – when, why, and how to take what is prescribed, and developing an effective medication management system

Pillar #2:Pillar #2: Personal Health Record (PHR)Personal Health Record (PHR)

Focus: providing a health care management guide for patients; the PHR is introduced during the hospital visit and used throughout the program

Key Elements of the Personal Health Key Elements of the Personal Health RecordRecord

Record of patient’s medical historyRed flags, or warning signsMedication list and allergies Advance DirectivesStructured Checklist of critical activities

(instructions, f/u appointments)Space for patient questions and concerns

My Medications are:Medication Dose______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________Allergies: _____________________

Reason Side Effects______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

____________________________________________________________Remember to take this Record with youto all of your doctor visits

PersonalPersonalHealthHealthRecordRecord

The Personal Health Record of:

Josephine Patient

Personal Information:

Address:

Home Phone#:

Birth Date:

Patient ID#

PCP Name:

Advanced Directives?:

Hospitalization Information:

Admitted: _/_/_ Discharged: _/_/_

Reason for Hospitalization:

___________________________________________

Caregiver Information:

Name:

Phone #:

Relation to Patient:

Personal History

Please check any illnesses or health

problems listed below that you have

ever experienced.

Arthritis

Abnormal Heart Rhythm

Cancer

Diabetes

Hardening of the Arteries

Heart Disease

Heart Failure

High Blood Pressure

Hip Fracture

Lung Disease

Medical/Surgical Back conditions

Pneumonia

Stroke

Other: ____________________

After I leave the hospital…

1. I will write down questions I have about my condition.

2. I will take all bottles of medicine I am using to each doctor visit.

3. I will call _________________

immediately at (XXX) XXX-XXX if I experience any of the following:

• Temperature above 101° F

• Uncontrollable pain

• Increased confusion

• Increased redness or d

drainage around wound

• Questions about which

medications to take

Before I leave the hospital…. I have the instructions I need to

keep my health condition from becoming worse.

I know what symptoms to watch out for.

I know the name and phone number of who to call if I see any of these symptoms.

My family or someone close to me knows what I will need once I leave the hospital.

I know what medications to take, how to take them, and possible side effects.

I will schedule a follow up appointment with my primary care doctor.

I will have a clear and complete copy of my discharge instructions.

Goal AttainmentGoal Attainment

“What is one personal goal that is important for you to achieve one month

after you get home?”

Response CategoriesResponse Categories

1. I have not worked on it

2. I have not met that goal, but am working on it

3. I have met the goal as well as I expected

4. I have met the goal better than I expected

FindingsFindings

Patients who worked with the Transition Coach were more likely to achieve their goals around symptom control and functional status

Pillar #3:Pillar #3: Primary Care Primary Care

Provider/Specialist Follow-UpProvider/Specialist Follow-Up

Focus: enlist patient’s involvement in scheduling appointment(s) with the primary care provider or specialist as soon as possible after discharge

Pillar #4:Pillar #4: Knowledge of Red FlagsKnowledge of Red Flags

Focus: patient is knowledgeable about indicators that suggest that his or her condition is worsening and how to respond

Key Elements of InterventionKey Elements of Intervention

“Transition Coach” (Nurse or Nurse Practitioner)– Prepares patient for what to expect and to speak up– Provides tools (Personal Health Record)

Follows patient to nursing facility or to the home– Reconciles pre- and post-hospital medications– Practices or “role-plays” next encounter or visit

Phone calls 2, 7 and 14 days after discharge– Single point of contact; reinforce, ensure follow up

Intervention ActivitiesIntervention Activities

– Hospital Visit*– Home Visit– 2-Day Follow-Up Call– 7-Day Follow-Up Call– 14-Day Follow-up Call

First Interaction (Hospital or First Interaction (Hospital or Home Visit)Home Visit)

Introduce the Program– Structure of the intervention: visits and calls– Role and purpose of the coach– Accessibility of the coach

Introduce and complete the Personal Health Record

Assure Coverage of Intervention Activities Checklist (Four Pillars)

2, 7 and 14-Day Phone Calls2, 7 and 14-Day Phone Calls

Follow-up on issues discussed during hospital/home visit.

Review the Four Pillars as they apply to each patient at the appropriate stage in the transition (see Intervention Activities Checklist)

Anticipated Cost SavingsAnticipated Cost Savings

For 350 chronically ill older adults with an initial hospitalization, anticipated net costs savings over 12 months:

US$ 295,594US$ 295,594

CoachingCoaching

What is coaching?How does coaching differ from what

nurses, social workers, and community workers do to help patients?

Key Attributes for the Key Attributes for the Transition CoachTransition Coach

Ability to shift from a “doing” role to a coaching role

Skill and knowledge to manage and reconcile medications

A strong enough sense of empowerment to empower a patient and/or caregiver

Ability to engage in critical thinking within the framework of a care plan

Took Kit for CoachesTook Kit for Coaches

Medication Discrepancy Tool (promoting Medication Safety)

Intervention Activities ChecklistPHR

Introducing the Medication Introducing the Medication DiscrepancyDiscrepancy Tool (MDT) Tool (MDT)

Patient-centeredApplicable across a variety of health settingsIdentify patient- and system-level factorsItems need to be actionable at point of care

Non-Intentional Non-ComplianceNon-Intentional Non-Compliance

Prior to hospitalization, a patient was prescribed Digoxin 0.25 mg daily

The patient’s discharge instructions read, “Digoxin 0.125 mg daily”

The patient had only the pre-hospitalization 0.25 mg Digoxin pills and had been taking these since discharge

Intentional Non-ComplianceIntentional Non-Compliance

A patient was admitted to the hospital for COPD exacerbation

Following discharge, he was not using his maintenance steroid inhaler because he believed that “that medication makes my breathing worse”

D/C Instructions D/C Instructions Incomplete or IllegibleIncomplete or Illegible

The patient’s hospital discharge instructions were written as follows:

“KCl 10 mEq BID”

14 Percent Experienced 14 Percent Experienced 1+ Med Discrepancies1+ Med Discrepancies

62 percent experienced one25 percent experienced two 8 percent experienced three 5 percent experienced four or more

Patient-Level Contributing FactorsPatient-Level Contributing Factors

Non-intentional non-adherence 34%

Money/financial barriers 6%

Intentional non-adherence 5%

Didn’t fill prescription 5%

Other 1%

Subtotal 51%

System-Level Contributing FactorsSystem-Level Contributing Factors

D/C instructions incomplete/illegible 16%

Conflicting info from different sources 15%

Duplicative prescribing 8%

Incorrect label 4%

Other 7%

Subtotal 49%

30-Day Hospital Re-Admit Rate30-Day Hospital Re-Admit Rate

Patients with identified med discrepancies 14.3%

Patients with no identified med discrepancies 6.1%

P=0.041

The lack of quality measures for The lack of quality measures for care transitions remains a care transitions remains a

significant barrier to quality significant barrier to quality improvementimprovement

Brief History of the Brief History of the Care Transitions Measure (CTM)Care Transitions Measure (CTM)

Qualitative studies shaped itemsTransition-specific items => Common set of itemsItems discriminate among facilitiesCTM endorsed by NQF in May 2006

Supported by The National Institute on Aging and The Commonwealth Fund

CTM ItemsCTM Items

The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital

When I left the hospital, I had a good understanding of the things I was responsible for in managing my health

When I left the hospital, I clearly understood the purpose for taking each of my medications

Demand for the CTMDemand for the CTM

Over 1400 requests for permission to use from 15 Countries

Adopted by WHO multi-national (Europe) hospital quality collaborative

Highmark Blue Cross Blue Shield P4PMaine to vote on statewide public reporting

Qualitative EvaluationQualitative Evaluation

To evaluate the efficacy of the intervention

To augment the quantitative findings

Conclusion: Qualitative DataConclusion: Qualitative Data

Patients appreciated the follow-up, expertise, support and accessibility of the Transition Coach.

Reception of the PHR was mixed, with ½ using it, and ½ not at 30+ days post-intervention.

Barriers to successful implementation of intervention

Transition CoachTransition Coach

Competence– “She was always able to answer my questions”

Accessibility– “There was somebody I could go to if I needed, if I had

any questions, I knew I had somebody I could call.” Security

– “I was pretty skeptical about it. But it turned out to be a real beneficial thing…the program gives you a real inner comfort—when you’ve confirmed that you’re doing it right and you know what to expect.”