PAVE Project Status Report November 16, 2011

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

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

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

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

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

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

PAVE Payor Passport 8

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

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

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

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

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

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

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

High-Level Project Timeline 16

17 Contact: Patricia Yurchick Phone: