Post-Transition Risk Assessment and Appropriate Follow-up - - PowerPoint PPT Presentation

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Post-Transition Risk Assessment and Appropriate Follow-up

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Presenter Disclosure

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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

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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

• r comment by:

Typing a question or comment into the chat box located here

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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

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Transitions

• f Care

Chronic Disease Management

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Transitions improvement package

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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

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51 59 80 83 70 64 52 62 80 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

• r more times in the past

year. Patient has been admitted

• nce in the past year.

Patient is unable to teach back, or the patient or family caregiver has a low degree

• f 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%

• f 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

15000 30000 45000 60000 75000 90000 105000 120000 135000 150000 165000 180000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 LACE Index Score Number of Admissions 0% 10% 20% 30% 40% 50% 60% 30-day Death or Unplanned Readmission (%)

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
• bstruction, 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
• f 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 your patients? – What could the health care system do to improve post-discharge outcomes for all patients?

• 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 …

Acknowledgments

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