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?
Hospital discharge is theHealthcare 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
• Consistency of Information • Communication across providers/patient/family • Care coordination • Patient/family education • Identification of high riskindividuals
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
Medical condition Social history Employment Living situation Family/caregiver MobilitySummary
Define care transition
Explain the challenges to care transitions
Care Transitions Challenges
• Consistency of Information • Communication across providers/patient/family • Care coordination • Patient/family education • Identification of high riskindividuals
Anne Elwell, RN, MPH
Principal and Vice President Qualidigm
aelwell@qualidigm.org