1. Building Healthiest Communities By Aligning Forces For Quality (AF4Q) A Community Collaboration

2. The AF4Q Collaborative is focusing on Develop and Implement a –Integrated, –High-quality, –Patient-centered system of care that is Accessible to all North Coast residents. that is Accessible to all North Coast residents.

3.  Consumer Advocacy by creating Public Measurement & Reporting on the performance of health care providers  Consumer Engagement by Promoting Self Management Skills  Regional Quality Improvement by improving Transitions in Care across the provider network.

4. Building Healthiest Communities: AF4Q

5. Our Contribution: Improving Care Transition Management Building Healthiest Communities: AF4Q

6. Building Healthier Communities: Care Transition Management TRANSITIONS  a. Passage from one state, stage, subject, or place to another :  a. Passage from one state, stage, subject, or place to another : Change b : a movement, development, or evolution from one form, stage, or style to another. b : a movement, development, or evolution from one form, stage, or style to another.  To integrate care systems between the hospital and community providers as the client transitions.

7. Building Healthier Communities: Care Transition Management AIM  To improve client outcomes (clinical & quality of life) in transferring from one care setting to another.  To provide a new area for collaboration between for collaboration between St Joseph Hospital, the primary care provider network and Humboldt State University for nursing education. St Joseph Hospital, the primary care provider network and Humboldt State University for nursing education..

8. Building Healthier Communities: Care Transition Management PROGRAM OBJECTIVES 1.Improve hospital success in achieving PI goals in relation to perfect care, patient satisfaction, physician engagement and healthiest communities. 2.Decrease by 5% the number of hospital readmissions and ED visits in the target population over a 12-month time period. 3.Spread medication reconciliation into the community.

9. Building Healthier Communities: Care Transition Management PROGRAM OBJECTIVES 4.Facilitate development of clients to be “co-managers” of their health needs. 5.Provide a sustainable platform for: Patient Empowerment Patient Empowerment Health Care Self- management Health Care Self- management Self-advocacy skills Self-advocacy skills 6.Provide a learning environment for senior nursing students to improve their clinical and patient advocacy skills.

10. Building Healthier Communities: Care Transition Management AF4Q & SJHS GOAL ALIGNMENT 1.Perfect Care = Quality Improvement 2.Sacred Encounters = Consumer Engagement 3. Healthiest Communities = Consumer Advocacy

11. Public Reporting  Hospitals reporting process measures to federal and state governments for >5 years. AIM = improved outcomes.  Struggle to find measures that have meaning to public not just the providers.

12. Quality Improvement   Primary focus is on improving coordination of service as patients move across the continuum of care.   Continuum of care refers to levels of service intensity includes primary care, acute care and home care.   Problems occur most often in the hand offs between service providers.

13. Quality Improvement  Improving that coordination leads to better outcomes, decreased utilization of service and decreased costs.  In particular we wanted to improve the coordination between the hospitals and the primary care provider network.  Challenge now is that the majority of PCP don’t see their own pts in the hospital so coordinating the hand off back to the PCP after ACF admission is vital.

14. Quality Improvement  Research reveals 4 main reasons for hospital readmission: 1.Lack of follow up w/ Primary Care Provider 2.Medication management problems 3.Not knowing when to seek help 4.Lack of follow up on tests and treatments.

15. Quality Improvement  Our goal was to improve the coordination between the PCP Network and the hospitals by improving transitions in care.  Long term goal is that every patients who is seen in the hospitals will receive some kind of contact after receiving service to ensure follow up care needs are met.

16. What Is the Care Transitions Program  Innovative model of service, site in the country using model.  Collaborative effort w/ SJHS-HC & HSU Dept of Nursing  Provides transitional follow up care for patients not receiving service from other community providers such as Home Health or Hospice  Service free. Community benefit  Service is free. Community benefit  Service model = coaching vs. doing.

17. CTP Model Coleman Transition ModelColeman Transition Model –Program Coordinator and the senior level baccalaureate nursing students serve in a Transition Coach Role Serve as an Advocate versus “Doer”RoleServe as an Advocate versus “Doer”Role Promotes Self ReliancePromotes Self Reliance & Self Management of Chronic Disease

18. MODEL BASIS Four Pillars of Service Personal Health Record Personal Health Record Medication Record Medication Record Red Flags Red Flags Follow-Up Needs Follow-Up Needs

19. MODEL BASIS Coaches see the clients in the hospital or ED and introduce program and PHR. Coaches see the clients in the hospital or ED and introduce program and PHR. At least one home visit is done w/ in 3 days of discharge. At least one home visit is done w/ in 3 days of discharge. Home visit: Review of PHR, medication list, red flags and help develop questions for PCP. Home visit: Review of PHR, medication list, red flags and help develop questions for PCP.

20. MODEL BASIS Continue to do home visits or phone coordination for up to 90 days. Continue to do home visits or phone coordination for up to 90 days. Ensure that clients are connected back into the PCP system, managing their medications effectively, following up on tests & TX. Ensure that clients are connected back into the PCP system, managing their medications effectively, following up on tests & TX. Build skill sets within clients & their families to manage their care as partners w/ the system providers Build skill sets within clients & their families to manage their care as partners w/ the system providers

21. TOOLS FOR CLIENTS TO MANAGE CARE: The Personal Health Record (PHR) One of the unifying themes between all AF4Q Partners is the use of the PHR. One of the unifying themes between all AF4Q Partners is the use of the PHR. Fundamental building block to develop consumer engagement. Fundamental building block to develop consumer engagement. The purpose of the PHR is to be a communication tool for the client and their providers. The purpose of the PHR is to be a communication tool for the client and their providers. Initially CTP started w/ a paper model. Initially CTP started w/ a paper model.

22. TOOLS FOR CLIENTS TO MANAGE CARE: The Personal Health Record (PHR) Received Additional grant $ from Blue Cross & the Cardinal Health Foundation to initiate use of an electronic record. Received Additional grant $ from Blue Cross & the Cardinal Health Foundation to initiate use of an electronic record. The focus of the electronic record is on medication management and communication between providers. The focus of the electronic record is on medication management and communication between providers. Patient control, web based tool that the CTP coaches teach clients how to use. Patient control, web based tool that the CTP coaches teach clients how to use.

23. TOOLS FOR CLIENTS TO MANAGE CARE: The Personal Health Record (PHR) Patient control, web based tool that the CTP coaches teach clients how to use. Patient control, web based tool that the CTP coaches teach clients how to use. Coaches are working with local providers and hospitals to orient them to the tool. Coaches are working with local providers and hospitals to orient them to the tool. Future evolution is to develop a community based tool. Future evolution is to develop a community based tool.

24. CONCLUSIONS  Quality of care is improved by facilitating transitions across the continuum of care.  Readmissions and unnecessary utilization of resources are decreased when clients are assisted or coached through the transition process.  Strengthening the linkages between the PCP network and the acute care settings improves outcomes of care and the client experience.  The CTP and the PHR are two tools that are proving to improve patient outcomes, decrease resource utilization, promote consumer engagement, promote self management skills and building a healthier community.