1. 1 Engaging Patients and Families to Improve Care Transitions

2. Objective for the Session Discuss strategies for partnering with patients and families to improve their experience of discharge from the hospital and coordination of post-acute care.

3. Background: BIDMC’s Readmission Rates Publically Available Medicare Data:

4. 4 How has BIDMC involved patients and families? Patient and family involvement is vital to improving care transitions and, at BIDMC, the level of patient and family involvement has evolved overtime. 2010 2012 2011 Patients & Families as Advisors Patients & Families as Team Members Patient Family Advisory Council STAAR Cross- Continuum Team Patient Family Advisory Council STAAR Cross- Continuum Team Patient Family Advisory Council STAAR Cross- Continuum Team With Increased Advisors Patient Family Interviews My Care Conference Pilot DC Med List Focus Group HF Pt Pathway Focus Group HCA Care Transitions Pilot

5. How is BIDMC engaging patients and families in improving care transitions? Macro Level Involvement Mico Level Involvement Cross Continuum Team Patient Family Advisory Council Working at an individual level to enable real-time patient- and family- centered handoff communication

6. Case Example Case Example: Developing “My Care Conference” from concept to implementation Identified Need Established Vision Created Project Team Pilot Implementation Measured Progress Adapted Strategy

7. 7 Step 1: Identifying the Need Key Themes from Patients & Family Members in Interviews and Focus Groups Patients/families don’t feel like they can contribute to their plan; or when concerns are voiced may be ignored; afraid to push back and be labeled a “difficult” patient Discharge was too fast; no time to process what was happening & ask questions Discharge materials are an ineffective way to communicate PCP seemed unaware of hospitalizations Specialists appointments weren’t scheduled in a timely manner / not clear to pt why it was needed Too many silos for patients to manage/coordinate on their own (many want a “single point of contact”)

8. 8 Step 2: Establishing the Vision

9. My Care Conference Connecting Patients with Their BIDMC Team Our standard practice for ALL patients to: 1.Make a plan with them 2.Ask them what they think 3.Listen and answer their questions 4.Talk to each other 5.Coordinate their care “My Care Conference” = Transformative Change 9

10. My Care Conference Connecting Patients with Their BIDMC Team Slowing down to speed up… Applying this Lean principle by meeting with the patient/family members and developing a plan together, as a team, prior to discharge, will enable faster implementation and less confusion. Taking an extra 15 to 30 minutes upfront will help to align team, improve communication, and enhance the patient’s experience. Current StateDesired Future State 10

11. 11 Step 3: Building the Implementation Team Membership Scope of Work Timeline Patient Physician Leader Project Manager Nurse Manager Social Worker Patient Relations Define workflow for delivering care conference to patients Develop communication materials for patients & families Engage post-discharge providers Train floor based staff Create mechanisms for monitoring and review processes Jan 2011 Project team formed Mar 2011 Pilot Initiated 2-Months for Planning & Development

12. 12 Step 3: Building the Implementation Team Scope of Work Define workflow for delivering care conference to patients

13. My Care Conference Connecting Patients with Their BIDMC Team Making It Happen: Care Conference Facilitator A new role to help bring all the key participants together Checks in with newly admitted patients to introduce “My Care Conference” Identifies potential times for the conference, and coordinates with the patient, family members and BIDMC Team Helps patient prepare questions and identify objectives for the conference Facilitates the conference session to help patient achieve his/her objectives Care Conference Facilitator 13

14. My Care Conference Connecting Patients with Their BIDMC Team Key Participants Patient & Family Member(s) Nurse Care Conference Facilitator Physician Pharmacist (As Available) Case Manager (As Available) Interpreters will also be included, as needed Additional Perspectives As Needed / Available ConsultantsPCP or Primary NP Home Care Nurse LTAC or SNF 14 Conference Components: Care Team Members

15. My Care Conference Connecting Patients with Their BIDMC Team Conference Components: Environment of Care Location Ideally, the conference would occur outside the patient’s room in a dedicated family meeting space. To foster dignity and respect 15

16. My Care Conference Connecting Patients with Their BIDMC Team Conference Components: Post Meeting Follow-Up All participants will leave the conference with a copy of the plan Care Conference Facilitator will use a template to document the meeting and include a copy of the plan in OMR Develop a standard planning document for the Patient and the Care Team to complete during the conference 16

17. 17 Step 3: Building the Implementation Team Scope of Work Develop communication materials for patients and families

18. 18 Step 3: Building the Implementation Team

19. My Care Conference Connecting Patients with Their BIDMC Team Pilot: Outcome Measures to Monitor (Quarterly) Primary Metrics: Patient Satisfaction Scores: The hypothesis is that this drastically different intervention will enable us to better meet inpatients’ needs, and show a consistent improvement in H-CAHPS scores for the floor (when compared to Farr 2 or CC7). Secondary Metrics: Operational Efficiencies: Increased coordination will potentially decrease wasted or duplicated effort (measured through work sampling) Planning with the patient from the first day of their visit will help the Team better understand the goals of care and decrease length of stay or improve discharge times Ultimately, over the long term, this strategy may improve transitions in care and reduce readmissions. Staff Satisfaction: Although this intervention will require a time commitment from the Care Team, it will enable staff to more effectively connect with their patients, potentially increasing staff satisfaction. 19

20. 20 Step 4: Pilot Implementation & Learning / Adaptation Challenges Observed at 3-Months -Staff still perceive Care Conferences as only for the most complex patients -Because conferences have been held primarily for highly complex patients, they typically last longer than the estimated 20 minutes -Time staff is available doesn’t correlate with when family members can easily attend -Patients sometimes decline– they don’t want to disrupt their busy doctors

21. 21 Step 4: Pilot Implementation & Learning / Adaptation Questions Presented to PFAC 1) Timing: Based on your perspective, when during a patient’s stay would this type of conference be most beneficial? 2) Participation: Some patients have expressed a reluctance to participate in the conferences, how can we better present this option to them? 3) Triggers: Are there any factors that should automatically "trigger" a Care Conference?

22. 22 Step 5: Measuring Progress Care Conferences are currently being piloted on Farr 7, with an average of four to five conferences per week (max=8; min=0). Impact on 30-Day Readmissions (March – August 2011) Although the population may not be large enough to fully assess the impact, the changes on a case by case basis are staggering. For example, 8 patients who in total represented 34 admissions in the past 6 months were discharged without a 30-day readmission. Further analysis is underway to evaluate the impact of Care Conferences on H- CAHPS scores. Ave CMI = 1.8 Ave CMI = 1.2

23. 23 Step 5: Measuring Progress 56% of Farr 7’s Discharges Occur Before 4:00 PM Inpatient Discharges by Hour as a Percent of Total Discharges on General Medicine Floors Between March 1, 2011 and February 29, 2012 44% of Discharges Occur Before 4:00 PM on CC7 and Farr 2

24. 24 PFAC and STAAR Advisors Have Offered Valuable Insight to These Changes Hospital-Based Interventions Admission Checklist Teach Back Method for Patient Education Readmission Huddles Revised DC Instructions Condition-focused Inpatient Education Automated Fax to PCP (on admission & discharge) Care Connection Appointment Scheduling Service Pharmacist Assisted Medication Reconciliation Discharge Checklist Discharge Summary Curriculum Enhanced Sharing of Electronic Records Anticoagulation Mgmt Initiative Post-Hospital Interventions Post-discharge Telephone Outreach Transitions Coach Intervention (Home Visit) Transition Back to Primary Care Hospitalist-staffed Post- discharge Clinic Enhanced VNA-PCP Coordination Enhanced ECF-PCP Communication Contingency Management Cardiology “Heart Line” for patients after discharge Improved Access to Urgent Care Visits Outpatient Diuresis Clinic Preventing Unnecessary Hospitalization ED-based Cardiologist During Peak Admitting Hours Case Management “Leveling” Patients in the ED

25. Challenges to Date Our Main Challenges in Involving Patients and Families in this Work Time Commitment Sometimes hard to identify the “line” between engaging a patient or family member in a project and asking too much of a volunteer. The best times for patients and families to meet are not always the most convenient time for staff. Committee Readiness Newly developed committees / teams are often hesitant to involve patients and families until they feel the group is more organized. “Representative” Population The patient and family members who volunteer their time to these initiatives may not be fully representative of our entire hospital population.