Care Transitions: How Can You Help?

Care Transitions:

How Can You Help?

presented by:

Anne Elwell, RN, MPH

Principal and Vice President, Qualidigm

Better Health: It’s Your Health, Take Charge

Objectives

Define care transitions (CT)

Explain the challenges to care transitions

What are Care Transitions?

A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing

What is a Discharge?

Healthcare in the US

• Total health care spending in the United States is expected to reach $48 trillion in 2021, up from $2.6 trillion in 2010. • Health care spending will

account for nearly 20% of the gross domestic product (GDP), or one-fifth of the U.S.

Bloomberg Best (and Worst)

Data on Readmissions

Roughly 20% of Medicare patients are readmitted within 30 days of hospital discharge

Many hospital readmissions are thought to be

preventable

Many re-hospitalizations result from problems at care transitions

Impacts approximately 2.6 million patients and costs approximately $26 billion per year

Nursing Home Readmission Data

Hospital Readmission Penalties

• Based on 30 day readmission rates of Medicare patients

• Index hospitalization for o Heart failure

o AMI

o Pneumonia o COPD

FY 2015 National Programs Penalties

• 2,610 hospitals were assessed penalties ranging from 0.01% to 3% of Medicare revenue in FY 15

o Readmission rates are assessed on three prior years of performance: July 2010 – June 2013

• Total penalties = $428 M vs. $280 M in FY 13

o Nationally, average fine increased from to 0.38% to 0.63%

Hospitalizations can cause many

complications:

Distress and discomfort for residents and families Delirium

Polypharmacy Falls

Incontinence

Hospital acquired infections

Data on ED Visits

Misuse of EDs accounts for $4.4 billion in waste

annually and contributes to the high cost of American health care*

Why Do We Really Care?

Care Transitions Challenges

individuals

Health Care in the 1950s

In the 1950s people

went to the hospital,

then they went

Definition of Communication

…a process by which information is exchanged between individuals through a common system of symbols, signs, or behavior also : exchange of information.*

Types of Communication

Written

Face to Face

Phone

Non-verbal

Reasons for communication breakdown

Expectations differ between senders and receivers of patients in transition

Culture does not promote successful hand-off (e.g., lack of teamwork and respect)

Inadequate amount of time provided for successful hand-off

Lack of standardized procedures in conducting successful hand-off, e.g. use of SBAR (situation, background, assessment,

recommendation

What is a hand-off?

A hand-off, also known as a “handover” or “patient care transfer,” is an interactive process of transferring patient-specific information from one caregiver to another or from one team of caregivers to another for the purpose of

Hand-off Objective

To provide accurate information about a patient’s care,

Consequences of a “bad” hand-off

 Delay in treatment

 Inappropriate treatment  Adverse events

 Omission of care

 Increased hospital length of stay  Avoidable readmissions

 Increased costs

 Inefficiency from rework

A CT Community Story

2010 – Now

Qualidigm Communities

of Care

o Goal: to reduce preventable

readmissions of patients with heart failure

25 hospitals

o 15 hospitals, 83 NHs, 40 HHAs

o Interactive workshops,

Things to Consider

Summary

Define care transition

Explain the challenges to care transitions

Care Transitions Challenges

individuals

Anne Elwell, RN, MPH

Principal and Vice President Qualidigm

aelwell@qualidigm.org