The Care Span: The Significance of Transitions Transitions: Handovers are vulnerable exchange points that contribute to unnecessarily high rates of health services use 2009 study reported 20% of Medicare beneficiaries discharged from hospitals were re-hospitalized within 30 days; 34% within 90 days. 13% of Medicare beneficiaries experience 3 or more provider handovers during a 30 day period Patient “churning” accounts for $15 billion in annual Medicare spending Transitional Care is a broad range of time-limited services designed to –ensure health care continuity – avoid preventable poor outcomes among at-risk populations –promote the safe and timely transfer of patients from one level or type of care setting to another
Hallmarks of Transitional Care Focused on highly vulnerable, chronically ill patients throughout critical transitions in health and health care Considers the time-sensitive nature of services Emphasizes the education of patients and family care-givers Compliments, but not the same as primary care, care coordination, discharge planning, disease management and case management
What Patient-Centeredness Should Mean Power and control shifts into the hands of patients, families, and communities Status quo: the cathedral of care is the hospital and health care professionals are the “hosts” New order: health care professionals are guests in the patients’ lives
CNS Role Re-design Re-engineered an existing resource to address the needs of patients at high-risk for failure after discharge Shifted the focus to high risk populations across multiple care settings or the patient home
Key Concepts Patient/Family control. Think of low acuity as being the home setting and high acuity being the intensive care unit. The patients lifetime of “Health” management occurs in the low acuity setting where the patient makes their health decisions. New skills for nursing in the low acuity setting include shared decision making, patient goal setting and self- management. The medical home provides the environment for the application of these skills The CNS identifies and assists the patient to manage risks during complex care transitions and facilitates exquisite coordination of handovers.
ElementTransitional Care Nurse (TCN)Blueprint Case ManagerHome Health Nurse Education Masters Prepared Clinical Nurse Specialist UPenn TCN trained RN BSN RN Setting All settings across the continuum Non-SVHC settings (Tertiary care, nursing homes, patient home) Single primary care practice Residence of referred patients that meet payer criteria Population High-Risk, high utilizers Complex patients with multiple providers or settings of care No payer referral required Primary care practice population Only home bound patients that meet payer criteria Key Functions Coordination and collaboration across multiple providers and care settings Identification of high-risk patients Intensive disease management and care coordination of individual patients Research on best-practice and outcomes Implementation and spread of evidenced-based practice across care setting Address systemic care transition process issues Assessment and risk identification Panel management Population management Wellness and prevention Chronic disease management Case management Patient education Patient goal setting Assessment and risk identification and referral Panel management Population management Wellness and prevention Chronic disease management Case management Patient education Patient Goal setting Service Duration Time limited (8-12 weeks per patient) The duration a patient is member of primary care practice panel Intermittent short episode of care. Number of visits limited
CNS Redesign Strategies Orientation to transitions across the continuum Identification of high-risk patients Focus on the patient not the disease Use of Patient self-management tools Use of Shared decision making Transitions Team includes community partners Communication with the primary care practice teams in medical homes Formal education in partnership with UPenn
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