1. Transitions of Care
Project 2C

2. The Problem
Modern health care is siloed and safe transitions require that information move from an active care delivery team to a prepared receptive team. Mind the gap.
Hospital to-
SNF
ALF
Home
SNF to
Hospital
Additional high-risk transfers include leaving incarceration, SUD treatment

3. The Project 2C Description
Transitions are high-risk events because care crosses a boundary which can silo information and be a barrier to communication. We understand that different communities have different needs and resources and therefore will need to implement different but aligned evidence-based approaches. The project will improve support for at-risk enrollees at care transitions by strengthening and broadening existing person/family-centered interdisciplinary/interagency (ID/IA) collaborative initiatives across the region and implementing proven tools to support management of acute changes in condition without transport to hospital. These include person/family-centered assessment and service (eg- ConsistentCare), collaborative community paramedicine efforts, and the INTERACT tool sets. Further, there may be benefit to expanding the scope of Health Homes by extending eligibility to enrollees at high risk for readmission as identified by tools such as BOOST. This has the advantage of building on existing relationships and networks. These efforts do not have uniform penetration across the ACH and would have to be spread, which will require time, resources, and in some areas institution of novel systems or networks. We further note the nascent state-wide efforts by WSMA and WSHA to increase advance care plans (ACP) through Honoring Choices PNW ( and note the possibility for synergy without needing to be explicitly included in this project.

4. The Project 2C report revisited
Evidence-based interventions called out by HCA
INTERACT
TCM
CTI
CTIMH
Evidence-based approaches not called out by HCA for care transitions
Hospice referral/Honoring Choices
RAP
Community-based paramedicine
Local network hybrids
Metrics
The crucial metrics are Potentially Avoidable ED Visits for the target population and Plan All-Cause Readmission Rate

5. INTERACT
“Interventions to Reduce Acute Care Transfers, INTERACT™4.0, - a quality improvement program that focuses on the management of acute change in resident condition.“

6. INTERACT
Grew out of work by Dr. Joseph Ouslander at Florida Atlantic University
Development was CMS backed
Was implemented in 19 Pierce County SNFs using a collaborative learning model in 2011, resulting in reduction of 30 day readmission rate from 16% to 11%.
In 2012 was integrated into PointClickCare, the industry-leading EHR for SNF/LTC

7. INTERACT
Role – Assisting in changes in condition in residential settings
Offers consulting and tool sets
Tools are free, as is online training
Foundation is already deployed in many buildings in GCACH

8. INTERACT – Tool Types Quality improvement tools Communication tools
Decision support tools
Advance Care Planning tools

9. INTERACT

10. Transitional Care Model
“Transitional Care Model (TCM), - a nurse led model of transitional care for high-risk older adults that provides comprehensive in- hospital planning and home follow-up.”
care-model

11. TCM
Grew out of research by Mary Naylor, PhD, FAAN, RN, at University of Pennsylvania starting in 1989.
Emphasis on nursing-led teams, with care coordinated and delivered by a master’s level advanced practice RN.
Currently lives at the NewCourtland Centers for Transitions and Health at Penn Nursing.

12. Transitional Care Model

13. Transitional Care Model
“Transitional Care Model (TCM), - a nurse led model of transitional care for high-risk older adults that provides comprehensive in- hospital planning and home follow-up.”
care-model

14. Transitional Care Model
Training is seminar and consultant-based.
Care is directed and delivered by nurse practitioners.
Involves the family, caregivers, and primary care team.

15. Care Transitions Interventions
“The Care Transitions Intervention® (CTI®), - a multi-disciplinary approach toward system redesign incorporating physical, behavioral, and social health needs and perspectives. Note: The Care Transitions Intervention® is also known as the Skill Transfer Model™, the Coleman Transitions Intervention Model®, and the Coleman Model®.”

16. Care Transitions Interventions
Coaches patients and caregivers.
Promises 20-50% reduction in readmission.
Coaches are trained in the program and deployed.

17. Evidence-based approaches not called out by HCA for care transitions
Hospice referral/Honoring Choices
RAP
Community-based paramedicine
Local network hybrids