1. ACTion: An Interdisciplinary Approach to Outpatient-Based Transitions of Care ACTion: An Interdisciplinary Approach to Outpatient-Based Transitions of Care Mark Gwynne, DO; Sam Weir, MD STFM April 2012

2. Goals of this session: Identify the key components of coordinated care transitions Evaluate the evolution of the CRC (Complex Return Continuity) hospital follow-up visit and PDSA process Identify evolving roles for outpatient physician-led teams in transitional care Identify possible applications of the CRC visit or variations in your residency program 2

3. Transitions of Care: Costs $17.4 Billion to Medicare Medicare Readmission rate = 18% Patterns of re-hospitalization »19.6% within 30 days »34% within 90 days »67% within 1 year Risk of readmission without Primary Care »50% of readmissions at 30 days had no PCP visit »Timeliness of PCP visit Timely visit readmit rate = 3% Not timely re-admit rate = 21% 3

4. Transitions of Care: Barriers Coordination/communication with primary care Availability of discharge summary »12-34% at first post-hospital visit »57-77% at 4 week visit »Often lack vital information Often no knowledge of ancillary services Direct communication occurred 3-20% of time Patient self-management skills Medication errors/Medication reconciliation Health literacy and impaired cognition Patients are confused about who to contact with post- discharge questions 4

5. Successful transition programs Project RED (Boston) Transitional Care Model (Upenn) Care Transitions Program (Coleman, Colorado) Evercare (dually eligible) Kaiser Permanente Chronic Disease Coordination Heart Failure Resource Center (Atlanta) CCNC – Community Care of NC (Medicaid) Cambridge Health Alliance 5

6. Features of Successful Transition Programs Pre-discharge: »Medication reconciliation »Structured discharge communication »Patient education Post-discharge: Less Clear »Multidisciplinary team approach »Patient-centered discharge plans »Medication reconciliation »Coordination of services (Care Managers) – facilitated communication (PCP) »Education and support – facilitate patient self care methods »Emerging: patient risk stratification 6

7. CRC (Complex Return Continuity) Visit Hospital follow-up appointment linked through GE scheduling system »Includes visit with Clinical Pharmacist followed by »Primary Care Provider visit and, if needed, »Care Manager Goals of implementation »Address common principles of care transitions Multidisciplinary team, coordination of care, medication reconciliation »Model and teach physician-led team based care »Improve patient centered outcomes, utilization and clinical outcomes 7

8. UNC Family Medicine Center 16,500 patients 64 PCP’s 50,000 visits 2010-2011 PCMH level 3 (2011 standards) 2100 Inpatient admissions/year

9. Evolution of the Complex Return Continuity (CRC) Process Phase 1: »Sequential PDSA (plan, do, study, act) cycles testing implementation Phase 2: »Comparison to usual care »Short term process metrics Phase 3: »Long term metrics Clinical quality Patient Experience Utilization and cost 9

10. 10 Trick to obscu re : What are we trying to do here? A week from now how will we be able to tell if this change is better? What changes can we test to make things better? You learn more from 4-5 quick cycles than one slow cycle

11. 11 Use of 1 room or 2 ? Communication – EHR or Verbal Group documentation: failed Patient notification of appt (canceled appointments) Coordinate with inpatient pharmacist Standing orders – support staff: failed Link appointments in GE (test) Communication with care manager Expand CRC appt template Involve department scheduler Anchor provider Begin with 1 faculty clinician Expand to R3’s  faculty  Side 2 Coordinate with Inpatient Team and Inpatient Scheduler Weekly meetings with clinical pharmacists Weekly PACE meetings (Pt exp, Access, Continuity, Efficiency) Operational structure and PDSA cycles Phase 1: Implementation

12. CRC visit progression 12 Expand to Team 4 residents Link appt in GE, test Phase 1: Implementation

13. 13 Q+A: Discussion of PDSA Process?

14. CRC Appointment Use Efficiency Total CRC scheduled36 % Discharges as CRC12.5% No show rate22.2% Re-admission rate25.0% Readmission rate of attended16.7% Re-admission rate of no-show27.3% 14 Phase 2: Process Measures

15. CRC cycle time 15 Patient Perception of Appointment Duration Patient Tracker Data Average Cycle Time FMC66.96 min Average Cycle Time CRC90.08 min Phase 2: Process Measures

16. Provider and Patient Survey 16 Provider perception of patient’s understanding of medications Patient’s perception of understanding medications Phase 2: Process Measures

17. Provider Satisfaction: Comments …[patient] was very happy with her visit with Gretchen (pharmacist). She found the medicine chart Gretchen made for her very helpful. Sometimes in a busy clinic it can be challenging for Zack (pharmacist) and/or Amy (care manager) to find me or vice versa to pass along pertinent info point-of- care. However, it is a huge improvement. 17 Phase 2: Process Measures

18. Role of Care Management 18 Story of Mr. R: » 42 year old presents to clinic for CRC appointment. While meeting with the Pharmacist, Mr. R mentions he is interested in returning to work. The Pharmacist contacts Care Manager to meet with Mr. R to discuss options. 3:40pm: Appointment with Pharmacist 4:15pm: Appointment with PCP Care Management interventions: » Introduced role of Care Management to Mr. R and his mother » Facilitated Medicaid application » Identified barriers to returning to work including uncontrolled bipolar disease and back pain » Facilitated short-term goal: volunteering and enrolling in vocational rehabilitation » Congratulated patient on sobriety x 4 years Since the intervention: » Enrolled in local vocational rehabilitation program » Attends Psychotherapy and routinely follows up with his PCP, specialists and PT »NO readmissions or ED utilization since 8/2011 (2 hospitalizations and 3 ED visits in previous 18 months) Care manager meets with Mr. R Phase 2: Process Measures

19. Utilization of Care Management Frequency of involvement – comparison data Assessment of barriers to care Referral for behavioral health Referral to community resources Medication Reconciliation Patient self confidence measures And ultimately: Clinical outcome metrics of chronic disease ED utilization Hospital re-admission 19 Phase 3: Outcome Measures

20. Unexpected Outcomes Realized we had no formal mechanism to track hospital follow-up visits or utilization Uncovered very complex and ineffective hospital system for scheduling follow-up appointments Resident buy-in and requests to expand to routine complex patients Opportunity to use common risk stratification system with inpatient Transitions Program 20

21. Barriers to Implementation Availability of Pharmacist »specific appointment templates Availability of Care Manager »Who can play this role? SW, RN, CMA? Patient involvement in scheduling »communicate role of “Outpatient Team” Communication between providers/systems »Inpatient  outpatient »Outpatient team Availability of data 21

22. Discussion How can our Patient Centered Medical Homes bridge that gap between inpatient Transitions Programs and outpatient practices? What barriers to quality improvement project implementation exist in your program ? What barriers exist in your program for developing an interdisciplinary outpatient based transitions program? 22

23. OUTPATIENT- BASED TRANSITIONS OF CARE WORKSHEET Process of Quality Improvement 1)Aim Statement: what do you want to change ? 2)Measure: How will you measure Process and Outcomes? 3)Changes: What changes can you implement and test using PDSA cycles this week? -- Develop an infrastructure (team) to implement quality improvement Barriers to Transitions Coordination and communication between inpatient team and primary care Pharmacy and Care Management Patient self-management skills Medication Reconciliation Health literacy and impaired cognition 23 What 2 barriers to implementing systematic quality improvement exist in your practice that you would like to address when you return? 1)_____________________________ 2)_____________________________ What barriers to accepting discharged patients exist in your practice that you would like to change? 1)_____________________________ 2)_____________________________ UNC Department of Family Medicine mark_gwynne@med.unc.edu sam_weir@med.unc.edu