Presentation on theme: "For the Healthcare Provider"— Presentation transcript:
1For the Healthcare Provider Transitions of CareAtrial Fibrillation
2Table of Contents What is Transitions of Care? Efficacy of Transitions of Care ApproachProject ScopeThe Role of the ProviderThe Role of the PatientResourcesAction Requested and TimelineFeedback Survey
3Background and CHallenges Most commonly diagnosed arrhythmia disorder2.3 million people in U.S. living with AF- 160,000 new cases annuallyPatients with multiple chronic conditions can visit ~16 physicians annuallyAF is responsible for 88,000 deaths per year- $16 billion in healthcare costsChallenge of coordinating basic information (e.g., test results, prescription medications, diagnosis)Poor coordination often leads to adverse clinical outcomes, increased re-admissions, over-utilization of health care services, and untimely follow-up
4Transitions of Care Definition Transitions of Care refer to the movement of patients between health care locations, providers, or different levels of care within the same location as their conditions and care needs change.Specifically, they can occur:Within settingsBetween settingsAcross health statesBetween providers
5Care coordination definition Care coordination is a function that helps ensure the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time. Coordination maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and high-quality patient experiences and improved healthcare outcomes.
6Principles Care coordination is important for everyone Some populations are particularly vulnerableCare coordination measures may be appropriate at the clinician-level; others may be appropriate at the group, practice or organizational-levelPatient/family surveys are essential to measure care coordination; performed within close proximity to the healthcare event
7Elements of transitions of care Medication reconciliationFollow-up tests and servicesChanges in plan of careInvolvement of team during hospitalization, discharge, follow-up, etc.CommunicationTransfer of all information when site of care changesEducation of the patient and family
8National care coordination goals Healthcare organizations and their staff will continually strive to improve care by soliciting and carefully considering feedback from all patients and their families regarding coordination of their care during transitions.Medication information will be clearly communicated to patients, family members, and the next healthcare professional and/or organization of care, and medications will be reconfirmed at each transition.All healthcare organizations and their staff will work collaboratively with patients to reduce 30-day readmission rates.All healthcare organizations and their staff will work collaboratively with patients to reduce preventable emergency department visits.
9Efficacy of transitions of care Hospital to Home – ACC & IHI national quality improvement initiative to reduce cardiovascular-related hospital readmissions and improve the transition from inpatient to outpatient status for individuals hospitalized with cardiovascular disease (e.g., heart failure)Medication managementFollow-upSymptom management
10Transitions of Care AND Provider Payment Provider payments are shifting toward the key elements of Care Quality and Care CoordinationBy 2015, providers will be required to document quality improvement indicators or face decreases in reimbursementBy 2017, Medicare reimbursement will be adjusted based on documented quality outcomes for all physiciansCapturing those indicator data will aid in either enhancing existing care protocols or developing new ones
11Afib transitions of care goal Project Goal:To develop practical resources to encourage best practices in clinical decision-making, patient-provider communication, and patient self-management.
12role of the Care provider Engaging Mended Hearts VolunteersMaking a referral to post-ablation patientsReview Patient Care PathwayPatient Care PlanReview Patient Discharge Checklist (provided in patient kits)Review AF Educational Resources (provided in the patient kits)
13Role of the Mended hearts volunteer Understand the Patient Care PathwayPeer-to-peer patient supportPatient Care Plan (No interpretation of orders/prescriptions)And what is it and why is this important?Patient Discharge Checklist (General)Atrial Fibrillation Educational Resources
14role of the patient and caregiver Understand the Patient Care PathwayPatient Care PlanAnd what is it and why is this important?Patient Discharge ChecklistAtrial Fibrillation Educational Resources
15Provider/patient Kit resources Provider Resource KitBest practicesPatient care planelementsDischarge checklistTransition record checklistMended Hearts InfoPatient Resource KitElements of a care planPatient discharge checklistRole of the caregiverGuide to AFib brochureAFib Patient DVDMended Hearts Info
16Feedback surveys Healthcare Provider Mended Hearts Volunteer Patients Web-based / monthly survey - 4 questionsMended Hearts VolunteerTelephone / Web-based surveys – Monthly/QuarterlyPatientsPostcard / Received during visit – 4 questions for 30 days post event