MULTIDISCIPLINARY
CARE COORDINATION
FOR
SOLID ORGAN TRANSPLANT
PATIENTS
Gail Stendahl, DNP, RN, CPNP-PC/AC, CCTC Heart Transplant Nurse Practitioner Children’s Hospital of Wisconsin NATCO Annual Meeting August 2014
Background on Care Coordination
Importance of an Organized Proactive Approach
Effective Care Coordination and Skills Needed
Reducing Avoidable Hospital Stays
Quality and Safety Outcomes
Health Care Transformation
Case Study
Questions and Comments
OVERVIEW
Case Scenario
A family call earlier this year,“who is the care coordinator? ”
Our initial response: “you don’t really have one…”
PCP asked family who his care coordinator was due to patient ’s multiple comorbidities
Nurse practitioner af ternoon huddle: discussion on care coordination
In many cases, most ef fective way, (dif ferent models) transplant coordinators can best serve as the care coordinator, because we know our patients best
WHO IS MY CARE COORDINATOR?
BACKGROUND
Care Coordination
Referred to as the “glue” ofour healthcare system
Key ingredient in our national agenda for improving quality and affordable healthcare
The process between patients, families, and the healthcare team to organize care and to assure that everyone is aligned and working toward the same common goals
BACKGROUND
Lamb, G. (2014). Care Coordination: The Game Changer
Care coordination is the organization of patient care activities
between two or more participants (including patient) involved in a patient’s care tofacilitate the appropriate services needed Organizing care includes marshaling of personnel and other
resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care
BACKGROUND
(McDonald et al., 2014)
DEFINITION
Communication and mobilization of appropriate people and resources
Connects the pieces of health care to make it manageable for patients and providers
Effective relay of information between providers across settings
Leads to less repetition of information and tests
Transplant evaluations-patients transferred from another center
Transplant patients seen in ER More cost effective
BACKGROUND
Lamb, G. (2014). Care Coordination: The Game Changer
EXPECTATION
All solid organ transplant patients regardless of the severity of their illnesses or social situations, will have pertinent information communicated with other providers in a timely and effective manner
All patients have a care coordinator
Coordinate care and communicate with PCP at some level
BACKGROUND
Case
Management Transitional Care
BACKGROUND
Care Coordination
Lamb, G. (2014). Care Coordination: The Game Changer
The Relationship among Care Coordination
Not new to our healthcare system
Transitional
Care
Process of linking care across settings
Case
Management
More extensive care coordination Patients with multiple
services Multidisciplinary teams
Individuals with complex physical & social health needs at risk of adverse outcomes & expensive
care
BACKGROUND
Transplant patients discharged from hospital to home
Transplant patients
Lamb, G. (2014). Care Coordination: The Game Changer
IMPORTANCE OF CARE
COORDINATION
Increase incidence of chronic illness
Currently consumes 17% of the nation’s gross domestic product Projected to increase to 20% by end of the decade
Rising healthcare costs are unsustainable
25% of all Americans are diagnosed with multiple chronic conditions (MCC)
Individuals with MCC account for over 66% of total healthcare spending
Due to MCC, there has been an increase in preventable hospital admissions, med errors, and duplication of care
Current healthcare system is unable to provide high quality care for these individuals
IMPORTANCE OF CARE COORDINATION
The Changing Population
Compliance Driven
Multidisciplinary Team
IMPORTANCE OF CARE COORDINATION
Regulatory requirements Pre (listing) Transplant Prior to discharge Pharmacy consult Dietary consult Social work/psych consult Program specific
Palliative for Vads
Subspecialty Challenges Review Current Practices &
Protocols
Rethink Utilization Multidisciplinary Consults
Patient Specific
IMPORTANCE OF CARE COORDINATION
Oncology (PTLD) Histocompatibility lab Pulmonar y Gastroenterology Pathology
Cardiac catheterization lab Electrophysiology Immunology Infectious disease Laborator y Ser vices CT Surger y General Surger y
EFFECTIVE CARE
COORDINATION AND
SKILLS NEEDED
Targeting
Staffing
PCP
Collaboration
Information
Technology
Training &
Feedback
EFFECTIVE CARE COORDINATION
COMPONENTS AND PRACTICES
Lamb, G. (2014). Care Coordination: The Game Changer
•Identify patients with multiple chronic conditions (MCC) who were hospitalized one or more times in the previous year, or at risk for admission within the next year
Targeting
•Multidisciplinary team
•PCP, transplant MD, social worker, pharmacist, PT, and patient •Care Coordinator delivers majority of the intervention
•Caseload of 40-80 patients with monthly face-to-face clinic visits
Staffing
•Strong rapport with PCP and transplant team •Care coordinator present on rounds and all clinic visits •Assign all patients to the same care coordinator
PCP
Collaboration
EFFECTIVE CARE COORDINATION
COMPONENTS AND PRACTICES
Lamb, G. (2014). Care Coordination: The Game Changer
• Electronic heath record
• Alert system that notifies when patient in ER or admitted
Information
Technology
• Initial training of all team members in care coordination
• Provide feedback to care coordination team on process and program outcomes
Training &
Feedback
EFFECTIVE CARE COORDINATION
COMPONENTS AND PRACTICES
Population heath management
Comprehensive assessment and care planning
Interpersonal communication
Education/coaching
Health insurance and benefits
Community resources
Research and evaluation
SKILLS NEEDED FOR EFFECTIVE CARE
COORDINATION
(Felt-Lisk & Higgins, 2011, McSharry, Bishop, Moss-Morris, & Kendrick, 2013, Lamb. G. 2014.) Essential skills to participate in the development of an effective program
Change from single provider caring for individual patient to focus on the health care team managing the health of a group of patients
Goal is to keep that population as healthy as possible, minimizing the need for extensive interventions and procedures
Identifying gaps in care Stratifying risks Self-management Measuring outcomes
SKILLS NEEDED FOR EFFECTIVE CARE
COORDINATION
Population Health Management
Felt-Lisk & Higgins, (2011). Issue brief: Exploring the promise of population health management programs to improve health
Thorough knowledge of chronic disease management and EBP guidelines and protocols
CHF, COPD, diabetes, heart transplant
Dual diagnosis leads to poor health and outcomes
SKILLS NEEDED FOR EFFECTIVE CARE
COORDINATION
Comprehensive Assessment and Care Planning
McSharry, Bishop, Moss-Morris, & Kendrick, (2013). The chicken and egg thing: cognitive representations and self-management
Ability to use different communication style, including active listening, to counsel, resolve conflict, build relationships, and develop effective multidisciplinary teams
Understanding of family and group dynamics is essential
SKILLS NEEDED FOR EFFECTIVE CARE
COORDINATION
Interpersonal Communication
Lamb, G. (2014). Care Coordination: The Game Changer
Myers-Briggs Type Indicator MBTI
Assesses personality type, providing a framework used for personal and career development, leadership, teamwork, team building, and workplace diversity
Enhances collaboration, interpret responses, anticipate outcomes and identify strategies for better communication
Personality Assessment
SKILLS NEEDED FOR EFFECTIVE CARE
COORDINATION
Tools for Improving Teams
http://www.myersbriggs.org
ENTJ-Field Marshall
ENFJ-Teacher
SKILLS NEEDED FOR EFFECTIVE CARE
COORDINATION
Steven Zangwill, MD
Medical Director Heart Transplant Me Tools for Improving Teams
http://www.myersbriggs.org
Population heath management
Comprehensive assessment and care planning
Interpersonal communication
Education/coaching
Health insurance and benefits
Community resources
Research and evaluation
SKILLS NEEDED FOR EFFECTIVE CARE
COORDINATION
Improved
patient
experience
Improved
population
health
At lower costs
EMPHASIS ON CARE COORDINATION
Improved care coordination is essential in achieving the “Triple Aim”
Centerpiece of the CMS Accountable Care Organization Model for Medicare Patients
RECOGNIZING CARE
COORDINATION IN YOUR
PRACTICE
RECOGNIZING CARE COORDINATION IN
YOUR PRACTICE
Work with patients to identify their goals (group appts)
Identify patients who do not have services to care for themselves (state programs)
Communicate with patients and team members about plan of care
Managing plan of care
Difference in having a plan of care that meets regulatory requirements and one that is a living, breathing tool to address patient needs
Monitor that services have been identified, arranged, and delivered (home nursing, oxygen)
Assist patients and families to prepare a list of questions for upcoming visits with their PCP’s
RECOGNIZING CARE COORDINATION IN
YOUR PRACTICE
You are coordinating care when you are:
Lamb, G. (2014). Care Coordination: The Game Changer
In many settings, general care coordination activities carried out by staff nurses are supported and augmented by “nurse coordinators”, APRNs, and other professionals (social worker) who specialize in care coordination
RECOGNIZING CARE COORDINATION IN
YOUR PRACTICE
Special opportunities to advance care coordination by:
Able to identify the gaps in the continuity of care and are positioned to lead improvement efforts both within their care team and system-wide
Write prescriptions, place orders due to independent role
RECOGNIZING CARE COORDINATION IN
YOUR PRACTICE
Advanced Practice Nurses
Many nurses unaccustomed to taking additional time from their busy day to review and reflect on their work with patients
Barriers not always staff or patient personalities, rather are the system; processes limits finding solutions
Overcome some barriers by justifying your job with care coordination
Staffing weekend in CICU for equity amongst NP Bill for your services
RECOGNIZING CARE COORDINATION IN
YOUR PRACTICE
Barriers
Ebright, P. (2004). Understanding nurse work. Clinical Nurse Specialist
EHR- Heart Transplants
Previously had manualsystem (flow sheets and shadow charts) for tracking appointments, levels, and medications
Now with Epic, able to spend time working with patients and members of the care team to develop an effective care plan
FK506 levels
RECOGNIZING CARE COORDINATION IN
YOUR PRACTICE
Technology Support for Care Coordination Practice
REDUCING AVOIDABLE
HOSPITAL STAYS
Background
Unnecessary hospitalizations are extremely expensive In 2010, Medicare spending for inpatients as a results of readmissions was $17.5 billionIn 2013, CMS gives penalties for 30 day readmissions
3 of the most common ambulatory sensitive conditions (heart attack, heart failure, and pneumonia)
Significance
REDUCING AVOIDABLE HOSPITAL STAYS
(Boutwell et al., 2009, Brennan, 2012)
REDUCING AVOIDABLE HOSPITAL STAYS
Medical Care (2005)
Review the Literature
Hospital-Initiated Programs
Developed tool to better understand care coordination
From the patient’s perspective
You may think you did a great job but it’s the patient perspective that really matters
REDUCING AVOIDABLE HOSPITAL STAYS
Pediatric Transplantation (2011)
1st to use the TCM in pediatrics and transplant
Parents who had their care well coordinator did better at home
Identify parents who are ready to go home and opportunity for additional services
Hospital-Initiated Programs
Review the Literature
REDUCING AVOIDABLE HOSPITAL STAYS
Pediatric Transplantation 2014
Parent responses provided awareness to specific stressors when their child was discharged and ways we can give support
Parents really rely on their coordinators
Review the Literature
Hospital-Initiated Programs
New Interactive Study
Discharge to Home &
Chronic Illness Care
Pilot in Solid Organ
Transplant Recipients
To gain an increase understanding of hospital of home transition.
Parents of hospitalized children are often times overwhelmed and unprepared
Randomized study, myFAMI intervention
Ipad
REDUCING AVOIDABLE HOSPITAL STAYS
Stacee Lerret, Principal Investigator and Children’s Hospital of Wisconsin
QUALITY AND SAFETY
OUTCOMES FOR PATIENTS AND
FAMILIES
Essent i al i nter vent i o ns i dent i fi ed by t he A gency fo r Heal t hcare Research
and Qual i t y
Baseline comprehensive needs assessment
Periodically update needs assessment
Develop an individualize plan of care
Routinely update plan of care Facilitate access to medical care and home based services
Regularly monitor and communicate
QUALITY AND SAFETY OUTCOMES FOR
PATIENTS AND FAMILIES
Source AHRQ, 2012a
The Guided Care Model
Increase in patientphysical and mental health, quality of care, and satisfaction with care
Decrease in caregiver strain Increase in PCP satisfaction Increase in RN job satisfaction Reduction in preventable rehospitalization
QUALITY AND SAFETY OUTCOMES FOR
PATIENTS AND FAMILIES
Interventions Process Goals Outcomes (examples)
Monitoring and Coaching 85% of patients have contact each month for monitoring and coaching
Physical & Mental Health Quality of Life Patient Satisfaction Caregiver Support 75% of caregivers are
contacted every 3 months Caregiver satisfaction Caregiver strain Education on Advance
Directives
100% of patients have written advance directives
Patient and family Satisfaction Communication with
Healthcare Team
Contact with each team member every 2 months
Medication adherence Provider satisfaction Transitional Care 100% of pts visited within
2 days of admits 100% pts seen within 2 days of discharge Reduction in hospital readmissions Reduction in hospital costs
QUALITY AND SAFETY OUTCOMES FOR
PATIENTS AND FAMILIES
Based off the Guided Care Model by Dr. Chad Boult in Lamb, G. (2014). Care Coordination
Children’s Cincinnati Liver Transplant Program: discharge only M-Thurs, back to clinic within 24hrs with RN/pharm to reduce readmits and overall costs
Medication Management
Assessment of patient and family’s understanding of medications Dosage, when and why they are needed, how they work, and side effects
“Teach back”
Care coordinator communicates with pharmacist
Electronic Health Record
Measurement of Outcome
QUALITY AND SAFETY OUTCOMES FOR
PATIENTS AND FAMILIES
Lamb, G. (2014). Care Coordination: The Game Changer
HEALTH CARE
TRANSFORMATION
Enables communications between different locations
Reduces unnecessary and costly duplication of services
Prevent med errors
Allergy alerts
Care coordination with the electronic health record has the potential to reduce cost and improve outcomes, most impressively in high-the risk population with complex health issues
HEALTH CARE TRANSFORMATION
National Quality Form (2010). National quality forum-endorsed definition and framework for measuring care coordination.
Electronic Health Record
Coordinator Activities Electronic Health Record Examples
Establish accountability Tracking patient consent forms
Communicate Lab results
Facilitate Transitions Access to discharge summaries Assess needs and goals Problem List based on admissions Proactive plan of care Input from all members Supports self-management Patient goals into EHR Link to the community resources Easy access to EHR and community
HEALTH CARE TRANSFORMATION
Care Coordination and the Electronic Health Record
Lamb, G. (2014). Care Coordination: The Game Changer
No longer the number of visits as the measure of success Value is assessed as the patient
receiving the right care at the right time from the right provider The Af fordable Care Act of 2010
introduced many new initiatives to lower costs
Hospital-Value-Based Purchasing (VBP) incentives, receive payments for CMS patients based on how well they perform
Readmissions for health failure, acute MI, pneumonia
HEALTH CARE TRANSFORMATION
CARE COORDINATION CASE
STUDY
Patient Profile
11 year old boy born withhypoplastic left heart syndrome, status post fontan
Admitted with heart failure, placed on Milrinone
Listed for heart transplant 10/2012
Kidney and liver dysfunction
Heartware HVAD placed 12/2012
Clinically improved- 100% sensitized
Densensitization- minimal response
Patient wanted to go home!
CARE COORDINATION CASE STUDY
How do we get our patient
home?
Develop a new program
CARE COORDINATION CASE STUDY
Heartware HVAD newer device in pediatric patients
Reached out to the adult program and other pediatric home vad programs (very few nationwide)
Developed new home vad program at Children ’s Hospital of Wisconsin
Care Coordinator Andrea Bobke, APNP Heart Failure/Home Vad NP
Multidisciplinary Team
Effort
Heart Failure/Vad Coordinator (Care Coordinator) CICU primary RN Transplant NP Transplant MD CICU MD Cardiothoracic Surgeons Immunology Infectious Disease Hematology School RNEMS in the community
CARE COORDINATION CASE STUDY
Andrea Bobke APNP - Care Coordinator Gail Stendahl DNP, RN - Transplant NP Stacey Fischer, MSN, RN- CICU Nurse
Transplanted 5/20/2013
5 months on vad
3 months at home
Virtual crossmatch negative
Retrospective tissue crossmatch negative
Discharged home 11 days post transplant
CARE COORDINATION CASE STUDY
CARE COORDINATION CASE STUDY
Transferring of the care coordinator role post transplant
1 year post transplant excellent graft function -2 admits within first year (1 rejection and 1 infection)
Shared Goals Clear Roles Mutual Trust Effective Communication Measurable Processes and Outcomes
CONCLUSION
Working Effectively as a Team-Partnering with Physician Colleagues
Mitchell, P et al. (2012). Core principles and values of effective team-based health care. IOM
Patient education
Self-management of patients and families
Communication within care teams
Nurse-patient interactions
Research and Innovation
Measurement of care coordination outcomes
CONCLUSION
Transplant Coordinators play a pivotal role in the following:
Significant impact on reducing length of stay and readmission rates
