CommunityBased Transitions of Care

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Community-BasedTransitions of Care

• Marsha Thorson, MSPH
• Jane Brock, MD, MSPH
• Colorado Foundation for Medical Care
• QualityNET Conference Baltimore, MD
• October 25, 2007

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What well cover

• Background
• Care Transitions Intervention (CTI)
• Framework
• Models we are testing
• Data
• Measurement strategy
• Summary

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Background

• 18-month special study
• Initial design was to work with two communities
  to implement the CTI and decrease 14- and 30-day
  hospital readmission rates
• Because of VALUE special study, now working with
  3rd community
• Framework developed to describe how QIOs can work
  with communities to implement the CTI and support
  decreased hospital readmission rates

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Fundamental Disconnect
Hospital
Skilled Nursing Facility
Home
Ambulatory Care Clinic
Rehabilitation Facility
Hospice
Dr. Eric Colemans slide, printed here with
permission.
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Care Transitions Intervention

• Dr. Eric Coleman, University of Colorado
• Well proven
• Increase quality of care
• Cost-effective
• 4 pillars
• medication management patient-centered record
  follow-up red flags
• 5 encounters
• Hospital/SNF Visit Home Visit 3 Follow-Up Calls
• Care Transitions Measure (CTM)
• http//www.caretransitions.org

• Patient Centered
• Coaching

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CTM-3 Items

• The hospital staff took my preferences and those
  of my family or caregiver into account in
  deciding what my health care needs would be when
  I left the hospital.
• When I left the hospital, I had a good
  understanding of the things I was responsible for
  in managing my health.
• When I left the hospital, I clearly understood
  the purpose for taking each of my medications.

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Framework

• Background on care coordination and the CTI
• Test models for implementation
• Describe a measurement strategy
• Implications for future work
• Methods
• Workflow and process observation by CFMC staff
• Site exchange visitation among involved staff
  from different settings
• CTI Training
• Group structuring of improved transitional care
• Provision of readmission rate data feedback to
  the hospital
• http//www.medqic.org

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Dr. Eric Colemans slide, printed here with
permission.
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(No Transcript)
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Models we are testing

• Community 1
• Implemented modification of the CTI
• Community 2
• Implemented CTI in true form
• Community 3
• ??

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Data

• Community 1
• Quantitative qualitative
• Community 2
• Quantitative qualitative
• Community 3
• Qualitative, AI interviews

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Community 1Hospital Discharge
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Community 1SNF Discharge Flowchart
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Community 1Home Health Intake
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Community 1 Outpatient Intake
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Community 2Hospital Discharge
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Community 2SNF Admission
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Community 2 Home Health Start of Care
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Community 2Physician Office Patient Tracking
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Community 3Hospital Discharge
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Community 3SNF Admission
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Community 3Home Health Start of Care Visit
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Community 3Physician Office Intake

• To be observed.

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Measurement strategy
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Measurement strategy
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(No Transcript)
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Summary

• Transitional care and coordination of care
• Providers are ready
• Issues
• Patient centric
• Self management
• Patient activation
• Provider centric
• Information transfer
• Handover management

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Summary

• PCP capture
• Community building
• Commitment

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Call to action

• QIOs working on transitional care and
  coordination of care studies
• Discussion
• Wikipedia
• Invite providers to be involved
• QIO panel presentation/discussion

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Acknowledgements

• University of Colorado
• Eric Coleman, MD, MPH
• Carly Parry, PhD
• Sandy Chalmers, MPH
• Amita Chugh, BA
• Heidi Kramer, RN, ND

• CFMC
• Jane Brock, MD, MSPH
• Marsha Thorson, MSPH
• Risa Hayes, CPC
• Alicia Goroski, MPH
• Jason Mitchell, BS
• Christina Underwood, MPH

• Participants in each community
• Other QIOs

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Resources

• http//www.cfmc.org/value/
• http//www.caretransitions.org
• http//www.cfmc.org/providers/providers_pcc.htm
• http//en.wikipedia.org/wiki/Transitional_care
• http//www.ntocc.org/
• And many others!

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More information

• Marsha Thorson, MSPH
• Project Manager, Transitions of Care Program
• mthorson_at_cfmc.org
• 303.668.4690
• Jane Brock, MD, MSPH
• Medical Officer
• Clinical Lead, Transitions of Care Program and
  VALUE
• jbrock_at_cfmc.org
• 303.695.3300 ext. 3050

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• Disclaimer This material was prepared by CFMC
  (PM-415-146 CO 2007), the Medicare Quality
  Improvement Organization for Colorado, under
  contract with the Centers for Medicare Medicaid
  Services (CMS), an agency of the U.S. Department
  of Health and Human Services. The contents
  presented do not necessarily reflect CMS policy.