1. Effective and Supportive Transitions of Care: The Care Teams Role in Reducing Admissions Jim Kinsey, Planetree Presented to Texas Center for Quality and Safety January 2013

2. Setting the Stage The term "transitions of care" refers to a patient leaving one care setting and moving to another as their condition or healthcare needs change. The care transition often involves multiple persons including the patient, family or other caregivers... An optimal transition should be well planned with the involvement of the patient and family, and adequately timed. More often, however, the communication between settings and the coordination among caregivers, patients and healthcare professionals fail to provide all the information needed for optimum quality of care

3. Just the Facts

4. Cost $25 billion dollars annually Most patients are on 6+ medications at time of discharge Limited access to post-hospitalization follow-up care Preventable transition errors (mostly medication related) Penalties: $280,000,000 in 2012 Including over 2, 000 hospitals 1,910 of those hospitals receiving less than 1% penalty Penalties increase to 2% in 2013 and 3% 2014 NQF 2010-2012

5. It is not just about reimbursement…

6. So where do we begin… Communication Collaboration

7. Communicate: Patient and Family Activation Care Partner Programs Clear concise advance directives Diagnosing patient preferences

8. Preference Diagnosis: First Step to Effective Transitions Drawn from Mulley, A.G., Trimble, C. and Elwyn, G. “Stop the silent misdiagnosis: patients’ preferences matter.” BMJ, 2012, 345. TEAM TALK Inform the patient that choice exists. Differentiate between the doctor’s medical expertise and the patient’s expertise on what matters most to him/her. Invite the patient to form a team to explore options. OPTION TALK List options and risks, benefits and side effects. Engage patient in deliberations. Observe patient’s reactions. Follow patient’s lead as guide for continuing option talk or moving to decision talk. DECISION TALK Ask: Do you feel ready to make a decision or receive a recommendation? Assess whether patient’s decision is consistent with stated priorities. If yes, offer support; if no, propose additional option talk If asked to make a recommendation, doctor should confirm understanding of patient’s priorities

9. Collaborating for Positive Patient Outcomes Physician Follow-Up Scheduled for 24 hours or less Patient Care Narrative or Personal EMR Coordinated Discharge Plan Consistent Care Philosophy Medication Reconciliation Social Support Evaluation Verbal Report Shared Electronic Record Discharge Instructions

10. Care Team Activities Home Care Receive verbal report, preferably in person with patient Equipment delivered in advance Medication reconciliation Skilled Care Standing orders collaboration Medication Availability Doctor Visit within 24 hours Consistent treatment plan Evaluate Social Support Prepare for discharge Acute Care Preference Diagnosis/Social Support Comprehensive Medication Review Care Partner Program Personal MR Narrative Discharge Planning Verbal report to next provider

11. Creating a Collaborative Patients Voice Tell me about your recent transition of care? Tell me how we may have done that better? Provider Voice: Who are the players in your community? What is working? What isn't working? How to we create standard work and processes between our service lines? How can we standardize treatment philosophies while maintain focus on patient preferences? Most importantly put down the history and focus on providing exceptional patient experiences

12. “…the thought is that we are here to provide service to patients and their families, understanding that patients are not isolated individual units, but they function as part of a social system, so involving family also in access to information, education and care is very important.” Susan Frampton, President Planetree

13. Jim Kinsey, Planetree 610.733.5140 jkinsey@planetree.org www.planetree.org