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PAVE Project Status Report November 16, 2011. Innovative Regional Solutions Reduce Readmission Rates by 10% Increase Patient & Family Engagement Improve.

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Presentation on theme: "PAVE Project Status Report November 16, 2011. Innovative Regional Solutions Reduce Readmission Rates by 10% Increase Patient & Family Engagement Improve."— Presentation transcript:

1 PAVE Project Status Report November 16, 2011

2 Innovative Regional Solutions Reduce Readmission Rates by 10% Increase Patient & Family Engagement Improve Transitions of Care Engage Providers Across the Continuum Care Transitions Workgroup Personal Health Record Workgroup Medication Management Workgroup

3 PAVE Project Participants 3  Forty-six (46) participating organizations  Hospital/Healthcare Systems  Specialty Hospitals  Home Care  Payers  Primary Care Practices  Others  Over 140 individual participants on the Project’s Workgroups Representing Nursing, Physicians, Pharmacists, Administrators, and Executives

4 Medication Management Workgroup 4  Key Deliverable:  Medication Passport, a set of standards for all medication reconciliation/ transfer forms  Endorsed by workgroup participants  Shared with all PAVE Project participants

5 Use both generic and brand names No abbreviations Indicate changes Indicate when next dose is due Use plain language Discontinued medications Provider’s information

6 Care Transitions Workgroup 6  Five sub-groups created based on identified gaps  Risk Assessment  Communication & Coordination with the Primary Care Providers  Coordination with Insurers  Issues Related to the Discharge Process  Patient Education/Health Literacy

7 Care Transitions Workgroup 7  Key Deliverables:  Teach Back Session (Jan 2011)  Payor Passport  Patient Activation Measure TM (PAM TM ) Pilot Project Evaluation (to be completed December 2011)  Care Transitions Passport  In development  To include contact information of key care transitions departments and description of the care transitions process at each hospital  Set of standards identifying the critical components of an effective care transition at hospital discharge

8 PAVE Payor Passport 8

9 Personal Health Record Workgroup 9  Key Deliverable:  Personal Health Tracking Form  One sign or symptom (e.g., daily weight, blood sugars, etc.)  One behavior (e.g., walk a specific number of steps per day, eat more fish/less meat, etc.)  Being finalized for dissemination

10 Project Measurement  Baseline measurement conducted in August and September 2010  Transitions of Care Survey  Retrospective chart reviews of readmitted patients  CTM-3 Survey of readmitted patients  Tracking of readmission rates  Transitions of Care Survey repeated recently 10

11 Transitions of Care Survey 11 Sample Questions  Inventory of strategies/ interventions  32 questions in total  Four sections  During hospitalization  At discharge  Post-discharge  Measurement  Pre- and post-project

12 Transitions of Care Survey Results 12 Re-survey conducted in October 2011  Improved coordination of care among care providers and across settings  More formalized approaches around care transitions within hospitals – care teams, transitions coaches  More coordination with patients and their families – follow-up appointments, testing, etc.  More focus on appropriate patient education at discharge – Teach Back, discharge checklists, red flags

13 Readmission Rates for PAVE Hospitals 13 Source: Delaware Valley Healthcare Council

14 What Worked?  Learning from other hospitals/organizations  Discussion of best practice  Networking, brainstorming and sharing of ideas  Ability to collaborative across institutions and settings  Gained a broader perspective of the care transitions issues  Teach Back session  PAM Pilot 14

15 Lessons Learned  Willingness to share among participants was key to success of the project.  Scope needs to be clearly defined and reasonable.  Not a lot of literature identifying best practice at project start  Workgroups and sub-groups need to be manageable in size and with reasonable expectations.  Sharing of progress among the workgroups was a challenge.  The momentum and desire to collaborate will extend beyond the “formal” end of the project. 15

16 High-Level Project Timeline 16

17 17 Contact: Patricia Yurchick Phone:


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