Improving Transitions of Care from Hospital to Home: A Health Care Reform Priority Gina Gill Glass, MD, FAAFP Barbara J. Roehl, MD, MBA, CAQ Geriatrics Underwood-Memorial Hospital Family Medicine Residency Woodbury, NJ STFM Annual Spring Conference April 28, 2011

Objectives At the end of this Lecture-Discussion, participant will be able to: Discuss evidence-based strategies which decrease incidence of undesired outcomes related to transitions of care from hospital to home. Identify modifiable Care Transitions deficits at participant’s own institution. Apply knowledge of effective interventions to develop strategies to improve Care Transitions at participant’s institution.

Background: Care Transitions Care Transitions refer to the movements patients make between health care providers and different care settings Care Transitions impact healthcare quality outcomes Inpatient Medical Team SNF Care Team Visiting Home Nurses Outpatient Clinic PMD

Healthcare Reform Issues for Acute Care Hospital System s Accountable Care Organization (ACO): Providers organized as ACOs that voluntarily meet quality thresholds can share in cost savings Providers organized as ACOs that voluntarily meet quality thresholds can share in cost savings Value Based Purchasing/Pay for Performance (P4P) Links Medicare payment to performance on quality measures Links Medicare payment to performance on quality measures Bundled Payment / Episode of Care Payment Single payment for a particular condition shared by multiple providers Single payment for a particular condition shared by multiple providershttp://

Evidence-Based Care Transitions Strategies Enhanced information transfer at discharge Follow-up care established at discharge  Improved medication management  Post-discharge plan of care Telephone follow-up  Telemedicine  Electronic health record (EHR)  Multidisciplinary team approach  Clinical protocols and regional guidelines  Enhanced palliative care consultation and support  Education (of patients and caregivers)  Coaching  Personal health record  Community supports 2 Ventura, T et al. (2010). Improving Care Transitions and Reducing Hospital Readmissions: Establishing the Evidence for Community-Based Implementation Strategies through the Care Transitions Theme. The Remington Report, 18(1), 24;

Enhanced Information Transfer at Discharge Systematic review of 55 observational studies 3 found that only 14.5% of discharge summaries and 53% of discharge letters were received by PCP within 1 wk of hospital discharge –PCPs estimated that their follow up care was adversely affected in ~24% cases by delayed or incomplete discharge information Systematic review of 18 controlled studies 3 evaluating efficacy of interventions to facilitate timely transfer of discharge information found improvement with use of electronic discharge document and with delivery of information to PCP via fax, , online access and patient courier 3 Kripalani S, LeFevre F et al. Deficits in communication and information transfer between hospital based and primary care physicians: implications for patient safety and continuity of care. JAMA Feb 28;297(8):

Follow-up Care Established at Discharge and Telephone Follow-up Randomized trial of 749 patients 4 had nurse discharge advocate arrange follow-up appts and create after-hospital care plan and had pharmacist provide telephone follow-up 2-4 days post-discharge to reinforce discharge plan and review medications –Reduced 30 day hospital utilization (ED visits & readmissions) by ~30% 4 Jack BW, Chetty VK, Anthony D et al. A Reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Ann Intern Med Feb 3;150(3):

Underwood-Memorial Hospital Family Medicine Residency Care Transitions Project In June 2010, a three-pronged intervention was implemented for patients discharged from the Underwood-Memorial Hospital (UMH) Family Medicine Residency inpatient service to their primary care provider (PCP) at one of six UMH-owned Family Health Centers: –Hospital Discharge Instruction Sheet and Medication Reconciliation Form were faxed to patient’s PCP office at discharge. –A hospital follow up appointment with patient’s PCP was scheduled prior to discharge. –Within hours after discharge, a nurse from PCP’s office conducted a hospital follow up call using a telephone script.

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Small Groups…

Wrap-up and Questions

For Further Information Gina G. Glass, MD Barbara J. Roehl, MD Acknowledgments Laurie Neblock, Librarian, Underwood-Memorial Hospital Romina Davarpanah, MD Amutha Sornaraj, MD

UMH Data - Patient Satisfaction

UMH Data - Readmission Rates

UMH Data - Hospital Follow-up Appointments

UMH Data - PCP Satisfaction