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
PCPCH Model of Care 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
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 Green Zone Means: No shortness of breath Your symptoms are under control No swelling Continue taking your medications as ordered No weight gain Continue daily weights No chest pain Follow low -salt diet No decrease in your ability to maintain your activity level Keep all physician appointments Yellow Zone: Caution Yellow Zone Means : If you have any of the following signs and symptoms: Your symptoms may indicate that you need an adjustment of your medications Weight gain of 3 or more pounds in 2 days Increased cough Call your physician, nurse coordinator, or Increased swelling home health nurse. Increase in shortness of breath with activity Increase in the number of pillows needed Name: ______________________________________ Anything else unusual that bothers you Number: ____________________________________ Instructions: _________________________________ Call your physician if you are going into the YELLOW zone ____________________________________________ Red Zone: Medical Alert Red Zone Means : Unrelieved shortness of breath: shortness of breath while at rest This indicates that you need to be evaluated by a physician Unrelieved chest pain right away Wheezing or chest tightness while at rest Need to sit in chair to sleep Call your physician right away Weight gain or loss of more than 5 pounds in 2 days Physician: ____________________________________ Confusion Number: _____________________________________ Call your physician immediately if you are going into the RED zone
Another Example • Patient tool from University of North Carolina Health Literacy program – Guides patients in adjusting diuretic dosage or 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.
Person-Centered Flexible Collaborative 5 Principles Iterative Structured
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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