Transitions and the Primary Care Home Stacy Moritz, RN, MBA - - PowerPoint PPT Presentation

Care Setting Transitions and the Primary Care Home

Stacy Moritz, RN, MBA Acumentra Health October 8, 2013

Welcome! Type questions into the Questions Pane

Patient-Centered Primary Care Institute History and Development

• Launched in 2012
• Public–private partnership
• Broad array of technical

assistance for practices at all stages of transformation

– Learning Collaboratives – Website (www.pcpci.org) – Webinars & Online Learning

• Ongoing mechanism to support

practice transformation and quality improvement in Oregon

Oregon’s PCPCH Model is defined by six core attributes, each with specific standards and measures:

• Access to Care

– “Be there when we need you”

• Accountability

– “Take responsibility for us to receive the best possible health care”

• Comprehensive Whole Person Care

– “Provide/help us get the health care and information we need”

• Continuity

– “Be our partner over time in caring for us”

• Coordination and Integration

– “Help us navigate the system to get the care we need safely and in a timely manner”

• Person and Family Centered Care

– “Recognize we are the most important part of the care team, and we are responsible for our overall health and wellness”

Read more: http://primarycarehome.oregon.gov

PCPCH Model of Care

Care Setting Transitions and the Primary Care Home

Stacy D. Moritz, RN, MBA Acumentra Health October 8, 2013

Objectives

• Identify typical transition communication

failures that occur when a patient transfers across settings

• List effective strategies a primary care home

can use to improve care transitions

• Translate the best practices into meeting PCPCH

standards for specialized care setting transitions and for referral and specialty care coordination

Meeting PCPCH Standards 4.E.0 Continuity

• Specialized Care Setting Transitions

– Written agreement with your usual hospital providers – Must Pass = Yes – Points = 0

It’s a Partnership Problem

It’s a Partnership Problem

Common Fallacies About Care Transitions

• One-time task!
• One size fits all!
• Everyone is clear on their roles and

responsibilities

• Medication reconciliation has been taken care of

by the sending provider

• Everyone has access to the information the need

It’s All About Communication!

• Patients and families are often the only

source of information

• EMRs are often not compatible
• No follow-up appointment scheduled with primary

care, or it is too far out

• Discharge or transfer plan is

not timely or complete

• No emergency plan, including a telephone number

for whom the patient should call first!

Polling Question

How long after patient discharges from the hospital before your clinic typically receives a discharge plan?

• a. 24 hours
• b. 48 hours or less
• c. 72 hours or less
• d. Greater than 72 hours
• e. Too long to make it useful in care coordination

Best Practices

• Develop a plan for communicating

with the hospital or sending provider.

– Model communication plan/agreement between hospital and medical home

• Ask your patients to bring the

discharge plan and educational materials to their follow-up visit.

• Support the discharge plan!

Red, Yellow, Green

Your Goal Weight:

Green Zone: All Clear

 No shortness of breath  No swelling  No weight gain  No chest pain  No decrease in your ability to maintain your activity level

Green Zone Means:

 Your symptoms are under control  Continue taking your medications as ordered  Continue daily weights  Follow low -salt diet  Keep all physician appointments

Yellow Zone: Caution

If you have any of the following signs and symptoms:  Weight gain of 3 or more pounds in 2 days  Increased cough  Increased swelling  Increase in shortness of breath with activity  Increase in the number of pillows needed  Anything else unusual that bothers you

Call your physician if you are going into the YELLOW zone Yellow Zone Means:

 Your symptoms may indicate that you need an adjustment of your medications  Call your physician, nurse coordinator, or home health nurse. Name: ______________________________________ Number: ____________________________________ Instructions: _________________________________ ____________________________________________

Red Zone: Medical Alert

 Unrelieved shortness of breath: shortness of breath while at rest  Unrelieved chest pain  Wheezing or chest tightness while at rest  Need to sit in chair to sleep  Weight gain or loss of more than 5 pounds in 2 days  Confusion

Call your physician immediately if you are going into the RED zone Red Zone Means:

This indicates that you need to be evaluated by a physician right away

 Call your physician right away

Physician: ____________________________________ Number: _____________________________________

Another Example

• Patient tool from University
• f North Carolina Health

Literacy program – Guides patients in adjusting diuretic dosage

• r calling provider when

weight varies from target (green)

Best Practices

• Identify early in the process the date

the patient is likely to be discharged

• Consider open access for

appointment scheduling

• Designate a call-in period when patients can

call in to talk with their primary care provider

• Engage patients and family to be

proactive in care

Roles of Ambulatory Practices

AMA report: There and Home Again, Safely: 5 Responsibilities of Ambulatory Practices in High Quality Care Transitions

5 Responsibilities for Safe Care Transitions

• Assessments
• Goal setting
• Supporting self-management
• Medication management
• Care coordination

Medication Reconciliation

Try a “brown bag” review:

• Identify a few patients to call the day before

their appointment. Ask them to bring all their medicines when they come in.

• Review each item and ask them how and

when they take it and for what.

• Provide written documentation for the

patient.

• Discuss your findings and confirm

understanding.

5 Principles

Collaborative Person-Centered Structured Flexible Iterative

Meeting PCPCH Standards 5.E.1 Coordination & Integration

• Referral & Specialty Care Coordination

– Track referrals to consulting specialty providers – Include referral status and if consultation results have been communicated to the patient and clinicians – Must Pass = No – Points = 5

Referral & Specialty Care Coordination

Step 1: Improve internal office communication. Step 2: Engage the patient in scheduling. Step 3: Facilitate the appointment. Step 4: Track referral results. Step 5: Analyze data for improvement opportunities. Step 6: Gather patient feedback.

No Place Like Home Campaign

www.noplacelikehomeor.org

• Resources

– 5 Key Areas – Medication reconciliation – Teach-back tools – Primary care tools

Acumentra Health Patient Engagement Resources www.acumentra.org

• “Resources for managing your health”

– Living Well with Chronic Illness program – Specific conditions (including heart failure patient guides) – Smoking cessation, falls prevention, managing blood pressure and medications – Caregiver resources – Hospital, nursing home, home health “compare” tools

Acumentra Health Patient Engagement Resources www.acumentra.org

• “Be a partner in your health care”

– Three questions to ask your doctor – Patient decision aids – Speaking up about hand washing and safety concerns – Avoiding a return to the hospital – Making your end-of-life wishes known

Questions?

Resources

• No Place Like Home Campaign, and

specifically resources for primary care providers

• Sample hospital agreement letter
• Archives of Internal Medicine Report -

Communication Discrepancies Between Physicians and Hospitalized Patients

• Exacerbation Action Plan and Protocol (Red

Yellow Green sheets)

Resources

• American Medical Association (AMA) Report - There and

Home Again, Safely: 5 Responsibilities of Ambulatory Practices in High Quality Care Transitions

• Medication Brown Bag Review, Health Literacy Universal

Precautions for Primary Care

• Patient handout - “What can I do to live as well as I can

with my health condition?” which links patients to these resources

• Patient handout “How can I partner with my doctor on my

health care?” which links patients to these resources

For More Information

Stacy Moritz, RN, MBA Director of Medicare Quality Services Acumentra Health 503-382-3918 smoritz@acumentra.org “The conductor of an orchestra doesn’t make a

• sound. He depends, for his power, on his ability

to make other people powerful.” — Benjamin Zander

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