Northwest Denver Care Transitions Improvement Project

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Northwest Denver Care Transitions Improvement
Project

• Risa Hayes, CPC
• CFMC
• CCMU Annual Conference Oct 2, 2009

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Aim

• measurably improve the quality of care
  transitions in the Northwest Metro Area through a
  comprehensive community effort

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Many Care Transitions
Hospital
Skilled Nursing Facility
Home
Ambulatory Care Clinic
Rehabilitation Facility
Hospice
Dr. Eric Colemans slide, printed here with
permission.
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And others
Skilled Nursing Facility
Hospital
Home Health
Specialists
Home
Ambulatory Care Clinic
Pharmacists
Rehabilitation Facility
Hospice
Payers
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Why Improve Transitions?
Skilled Nursing Facility
Hospital
Home Health
Specialists
Home
Ambulatory Care Clinic
Pharmacists
Rehabilitation Facility
Hospice
Payers
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Opportunities

• High dissatisfaction with discharge processes
• 76 of 30day readmissions preventable
• 64 received no post-acute care between discharge
  and readmission
• Readmission 2x more likely with just 1 medication
  discrepancy
• Patients trained to be passive receivers and we
  cant keep up

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How are we being Measured?

• Higher patient satisfaction with hospital DC
  process (HCAHPS)
• Medication education
• Symptom awareness and expectations
• Improved post-hospital follow-up care
• Reduced community rehospitalization rate

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National Overview

• CMS funded QI effort
• 14 communities
• Competitive award
• Expansion of TOC Pilot in Denver

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Our Approach

• QIO facilitated community effort
• Community led Steering Committee
• Action Teams
• Specific focus areas
• Standardized transfer processes
• Greater support for families/Care Givers
• Culture change around end-of-life quality
• Patient activation/self-management

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Coaching to Self-Management

• Dr. Eric Colemans Care Transitions Intervention
  (CTI) model (www.caretransitions.org)
• Short-term intervention (30 days)
• 5 coach - patient encounters
• Structured coaching
• Medication management
• Red Flag/Symptom knowledge
• Follow-up care
• PHR

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NW Community Coaching

• Several CTI trained coaches
• Coaching pool
• Jane Barnes (SAC) ReConnect Leaders program
• SW Interns
• 1 hospital visit
• 1 home visit
• 3 follow-up calls
• Patient Activation Measure (PAM) pre/post

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Keys to Activation

• Belief that actions make a difference
• Skills and knowledge
• Confidence

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Some of our Stories

• During home visit, patient stated that she cant
  afford to buy her medications as prescribed, so
  she takes ½ or less coach and patient explored
  options for assistance with her medications.
• At hospital visit, coach learned patient was
  homeless went over meds, red flags in the
  hospital. The patient was almost in tears when
  asked about his goal, and was immediately
  engaged. Coach was able to do 3 follow-up
  calls. Patient continued to take meds, use PHR,
  and had follow-up MD appt he said his doctor
  loved the PHR and the med list especially.
  Patient said, he is thankful to be in the
  program.

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Pilot Results Readmission Rates

• 14d 30d 60d
• Non-coached 17 20 29
• Coached 8 13 15
• Number needed to coach
• To prevent 1 MC readm 40 60 7
• To prevent 1 FFS readm 8 9 7

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Pilot Results
(N276, 274, 270)?
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Future Directions

• More Community Coaches
• Expanding to other populations/communities
• Continue to improve/standardize transfer
  processes
• Other opportunities for patient engagement and
  activation
• 10 SOW
• Building Health Communities

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Lessons Learned

• Community building takes longer than you think,
  but is critical
• Competitors are willing to partner for good of
  patients
• Hospitals do want to reduce readmission rate
• Lay coaches are excellent at meeting the patient
  where they are, not lecturing
• To be determined how many non-full time coaches
  for a community?

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Contact Information

• Risa Hayes, CPCProject Manager, NW Denver
  Project
• Quality Improvement Coach, National Support
  ContractCFMCrisah_at_cfmc.org
• http//www.cfmc.org/providers/providers_pcc.htm