1. Lee Memorial Health System Our Journey Through Transitions of Care
Joan Carroll RN, BA, CDMS, CCM
Director Care Transitions

2. Lee Memorial Health System

3. Lee Memorial Health System
1,423 Acute Care Operational Beds
Not For Profit Public Hospital System with 10 Member Elected Board of Directors
10,000 Employees, 4,300 Volunteers & 1,200 Staff Physicians, 85 Employed Physicians
6 Hospitals, Sub Acute, Physician Group, Convenient Cares, Home Health, Skilled Nursing Facility, Rehabilitation, Regional Cancer Center, LPG united Way House
81,531 Admissions Annually

4. Care Transition Coaching
CT is a 4 week program to help patients transition from hospital to home, while learning how to manage their chronic condition
The LMHS model for Care Transition Coaching is a combination of the Coleman Model, Project RED, BOOST
5 basic areas of our coaching program include
Patient self management assessment
Medication Management
Personal Health Record
Diagnosis / Red Flags / Actions
Communicating with health care professionals

5. Discoveries Didn’t know their diagnosis Had no idea what it was
No understanding of acute or chronic
Believed the hospital cured them
Recovery is a rest period
No knowledge of their role
No knowledge of red flags
Reverted to meds they already paid for
No medication management system
Couldn’t remember 3 of their meds and their purpose or side effects

6. Discoveries
Patient had prescription meds that were not on the discharge instructions
Patient had no prescriptions for new meds on the discharge instructions
Patient had no idea of their limitations
DME had not been delivered
BIPAP not delivered / patient in trouble
Patient extremely SOB 1days post discharge/ ankles still showing extreme edema / Poor discharge
Home not safe
Patient depressed or lonely

7. Discoveries Couldn’t find their discharge instructions
Didn’t remember anyone going over them
Had not filled their new prescriptions
Taking OTC meds unapproved
Believed the salt shaker (which they didn’t use) was the only source of sodium
Had not scheduled their PCP appointment
Drank glasses of water a day (per Dr. Oz)
Used their inhalers incorrectly
Couldn’t read and/ or follow direction
Were unstable on their feet

8. Even More discoveries Had 50 feet of Oxygen tubing
Nebulizer was filthy
Alcoholics?
No money for meds or groceries
No transportation to the doctor
No caregiver assistance
Couldn’t get an appointment for 1 month
Caregiver was worse than the patient
Depression
Electricity had been turned off
No food

9. AHA. Could these possibly be the root causes for re-admissions
AHA! Could these possibly be the root causes for re-admissions? Where do we begin?

10. Next step/ collect data
Patient Activation Assessment
Discharge Evaluation
Medication Discrepancies
Readmissions

11. Results
Patient Activation Assessment showed patients prior to discharge– Scores 1-3/10
Discharge Evaluations March %
Med Discrepancies – 92% in January of 2011

12. What Next? Communicate and Collaborate
Hospitalists and Specialists
Case management
VP of Nursing
Discharge Nurses
Staff Nurses
Nursing Education
Pharmacists
Respiratory Therapists
Physical Therapists
Nutritionists

13. What did we do in Acute Care?
Discharge order sets for CHF and COPD/ simplified / disease specific
CHF Unit opened and certification completed
Physicians include specific discharge orders for screening for balance/ medication review
Improved cognitive assessment
Palliative Care Training
Increased Home Health Referrals
Teach Back education
Standardized Handouts
Caregivers are identified in the EMR

15. LMHS System Initiatives
Acute Care
System Wide Risk Stratification Tool
Tracking Readmission reasons
Care Transitions
Care Management Website – Community Resources
Teach Back and F/U appointment
Pharmacy Collaboration on Medication Discrepancies
CHF Unit / Cardiac Decision Unit for Obs patients
Readmission work groups- Pulmonary & CHF

16. System Accomplishments
CHF Unit opened / Certification completed/ readmissions reduced at HP
Pharmacy providing Medication prior to discharge
EPIC update of Discharge orders improved
Rounding initiated at ¾ facilities
COPD Management Program
GC Reduce LOS/ Readmissions Committee
CCH Readmissions Committee
Home Health protocols for diuresis in home completed
Home Health Telehealth using 400 units in the community
Home Health frontloading
Nutrition Assessment with Food Bank Vouchers

17. Home Health Agencies/ Coalition Work Group
SNF Administrator and DON
Case Management & Medical Social Workers
Hospitalist
ED Physician
SNF Medical Directors
ED Nurses
Care Transitions Director
Infection Control
Educator
Palliative Care

19. SNF Coalition and workgroup/ Quarterly meetings
Review Lee County readmission data
Discuss 2 facilities Readmissions initiatives
Create Readmission Task Force
Developed a tool to collect transfer data for SNF on CHF, COPD and MI
Root Cause Analysis completed
Action Plan completed
Completed INTERACT Training
Training 13 facilities

20. Readmission Root Cause Analysis

21. Small Tests of Change Discharge Summary faxed to SNF 24- 48 hr
Updating the automated referral near discharge
INTERACT II utilized at a few SNFs
Include Transition of Care with all new physician Orientation
Nurse to Nurse Hand off communication
Epic transfer information printed and sent to SNFs
Standardized PT / OT post acute recommendations
Pharmacy completes Medication Reconciliation all SNF transfers

23. System Wide High Risk Assessment
Age 70 or greater
Chronic Conditions (CHF, AMI, Pneumonia, Diabetes, etc.)
Polypharmacy
Takes Anticoagulants, ASA, Plavix, Insulin, Digoxin
Previous Admissions within last 3, 6 or 12 months
Living Situation
Health Literacy & Language
Cognitive Impairment
Patient Self-Health Rating
Fall Risk
Palliative Care
Psych/Social- Depression

24. Chronic Disease Self-Management Program
An evidence-based health promotion program for persons with chronic diseases
Teaches participants self-management techniques
Brings community agencies together to tackle chronic illness in a unified manner; thus, maximizing utilization of resources and minimizing overlap of initiatives
Train-the-trainer format to improve self-management and build self-confidence
Generic enough to cover a variety of different conditions

25. CDMP Program Overview Six weekly 2.5 hour sessions
Each class is led by two trained lay leaders
Focusing on:
- Nutrition and exercise
- Using community resources
- Learning about medication use
- Relaxation techniques
- Solving health-related problems

26. Care Transitions Update
The Personal Health Record and handouts are available in Spanish
Expansion to all the hospitals (7 coaches, 2 RT, 1 MSW)
HPC+RC / PT CT Coach
Provided Teach back education for several HHA / acute care units
CHF handouts available in Spanish
See patients twice, at discharge and 15 days
May add Grand Aides
Developing a Caregiver Assessment tool
Nutritional assessment program with supplementation

27. What is a successful transition?
Discharge education begins on admission
Providers are alert to all the possible care needs after discharge
Compassionate teach back is provided by all disciplines
Literacy and health literacy are assessed and education is provided at the patient‘s level of understanding
Appropriate caregivers are included in the discharge education

28. What is a successful transition?
Care Transitions coaches follow the patient for 30 days
Patients are referred to appropriate agencies for additional services
The patient has transportation to the PCPs office within 8 days of discharge
The patient has food and has obtained his medications
The patient has knowledge of his medications and self management details
The Patient’s primary caregiver knows about the hospitalization

29. Finally DONE!!
Thank you for your attention. Transition home safely!