1. MA STAAR Fall Learning Session Ensuring Post-Hospital Care Follow-up 2:45-4:00PM Breakout St. Anne’s Hospital, MetroWest Medical Center Peg Bradke and Kate Bones

2. I.Perform Enhanced Admission Assessment of Post-Hospital Needs II. Provide Effective Teaching and Facilitate Enhanced Learning III. Ensure Post-Hospital Care Follow-Up A.Reassess the patient’s medical and social risk for readmission. B.Prior to discharge: Schedule timely follow-up care and Initiate clinical and social services summarized from the assessment of post-hospital needs. IV.Provide Real-Time Handover Communication A.Give patient and family members a patient-friendly post-hospital care plan which includes a clear medication list. B.Provide customized, real-time critical information to next clinical care provider(s). C.For high-risk patients, a clinician calls the individual(s) listed as the patient’s next clinical care provider(s) to discuss the patient’s status and plan of care. Creating an Ideal Transition Home

3. How do we effectively and efficiently act on our assessment of post-discharge needs and collaborate with patients, their families, and the community (healthcare and support systems) to transition.

4. Hospitals Perform an enhanced assessment of post-hospital needs Provide effective teaching and facilitate enhanced learning Ensure post- hospital care follow- up Provide real-time handover communications Office Practices Provide timely access to care following a hospitalization Prior to the visit: prepare patient and clinical team During the visit: assess patient and initiate new care plan or revise existing plan At the conclusion of the visit: communicate and coordinate ongoing care plan Home Care Meet the patient, family caregiver(s), and inpatient caregiver(s) in the hospital and review transition home plan Assess the patient, initiate plan of care, and reinforce patient self- management at first post-discharge home care visit Engage, coordinate, and communicate with the entire clinical team Skilled Nursing Facilities Ensure that SNF staff are ready and capable to care for the resident patient’s needs Reconcile the Treatment Plan and Medication List Engage the resident and their family or caregiver in a partnership to create an overall place of care Obtain a timely consultation when the resident’s condition changes

5. Transition from Hospital to Home Enhanced Assessment Teaching and Learning Real-time Handover Communications Follow-up Care Arranged Post-Acute Care Activated MD Follow-up Visit Home Health Care (as needed) Social Services (as needed) Skilled Nursing Facility Services Hospice/Palliative Care Supplemental Care for High-Risk Patients * Transitional Care Models Intensive Care Management (e.g. Patient-Centered Medical Homes, HF Clinics, Evercare) or IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations * Additional Costs for these Services Improved Transitions and Coordination of Care Reduction in Avoidable Rehospitalizations Patient and Family Engagement Cross-Continuum Team Collaboration Evidence-based Care in All Clinical Settings Health Information Exchange and Shared Care Plans

6. Requested Coordinating Activities and Communications What information does the receiver need from hospitals… What information the community providers can provide to the hospitals…

7. Potential Next Steps Practice(s) and/or their representatives become part of the hospital’s STAAR CCT. Hospital STAAR CCT chair appoint a contact who will work with the practices or community provider and report back to the CCT regularly. At a CCT meeting (including the practices and/or their representatives) the CCT reviews a patient case where lack of coordination between the hospital and practice had an impact on patient care. Based on the patient case, the practice(s) and/or their representatives and the hospital CCT select 2-3 areas to begin testing how to best coordinate activities and communications. Community providers and the hospital contact develop a work plan for learning from testing and addressing all the agreed upon change areas.

8. Discussion Who is working with practices and clinics now? How are you cooperating to reduce risk for readmission?

9. Social Risk Assessment Besides Meals on Wheels, what other social service and community resources do you refer your patients to? Does anyone have a useful check list for identifying social risks (lives alone, little involvement of others in care, anxiety and/or depression, quality of life, and functional status, along with socioeconomic status)?

10. Social Support Social support is broadly defined as the existence or availability of people on whom one can rely; people who let one know that they are cared about, valued, and loved. Lack of social support is associated with increased morbidity and mortality in patients with ischemic heart disease." (Vaglio, Conrad, et al Testing the performance of the ENRICHD Social Support Instrument. Health Qual Life Outcomes. 2004; 2: 24.)

11. ENRICHD Social Support Instrument "The results also provide conceptual insight into the nature of social support. The majority of questions on the ESSI consider general feelings about being loved and valued rather than instrumental types of support. This supports the theory that social support is not a tally of actual supportive "services" rendered, but rather a patient's belief that others care about them and are available if needed."

12. Health Literacy, Medication Adherence and Social Support "having a trusted confidant was the only type of social support associated with better medication adherence for limited-literacy patients” (Johnson, Jacobson et al. Does social support help limited-literacy patients with medication adherence?: A mixed methods study of patients in the Pharmacy Intervention for Limited Literacy (PILL) Study.)

13. Discussion How might we expand social support beyond the technical to include assessing for someone who cares about me? How might this help us? Help patients?

14. What is one new thing you learned today that you would like to test?