Destination Safe Care Transitions

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• Destination Safe Care Transitions Staying on
  Track

Elizabeth Ingram BSClinical Application
AnalystUHCare Ambulatory EMR
Hiloni Bhavsar, MDAssistant Professor, General
Internal MedicineUH Quality Institute
LiaisonPhysician Informaticist, UHCare
Jonathan S. Lever, MPH, NREMT-PSenior Clinical
Data AnalystInstitute for Healthcare Quality
InnovationUniversity Hospitals Case Medical
Center
Chrissie Blackburn, MHAPrincipal Advisor,
Patient and Family EngagementUniversity
Hospitals UHCMCInstitute for Healthcare
Quality and Innovation
Edmundo Mandac, MDDepartment of Emergency
MedicineInterim Chair - UHCMC
Nancy DeSantisManager, Patient Access Services
Khaliah Fisher-Grace, MSN, RN, CPHQ, PCCNSenior
Quality Improvement NurseInstitute for
Healthcare Quality InnovationUniversity
Hospitals Case Medical Center
Lee Manning Schoeppler, RN, MSN, MBA, NEA-BC
Agency Administrator, Director of Clinical
Integration University Hospitals Home Care
Hospice
George V. Topalsky MD, F.A.C.P. UH Internal
Medicine Center Co medical director Southwest
Region Site director UH Independance health center
Mary Ann Gravenstein, MD
Stefan Gravenstein, MD, MPHProfessor of
MedicineInterim Chief, Division of Geriatrics
and Palliative CareCenter for Geriatrics and
Palliative CareCase Medical Center
Laura Wilson, BSN, RNClinical System Liaison,
Electronic Medical Records (EMR)/ UHCareUH
Conneaut Medical Center
Corinne Hurley, RN, MSNDirector, Institute for
HealthCare Quality and InnovationPhysician
Office Based Care
Cynthia B.R.Zelis, MD, MBAVice President
Clinical IntegrationUniversity Hospitals
Cleveland
Faisal A. Khan, Esq.Assistant General Counsel
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Disclosures

• Speakers in this presentation have no disclosures.

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Objectives

• Identify and describe national and local best
  practices in transitions of care through experts
  and patient perspective
• Understand the resources available within the UH
  system today
• Understand the implications of poor transitions
  of care on patient experience, readmissions, and
  reimbursement
• Attendees will write an I will statement at
  the end of the presentation to apply one
  transition of care best practice to their current
  workflow

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Overview

• Background information on transitions of care
• Best practices
• Case Dr. Mary Ann Gravenstein
• Workshop
• Large group discussion

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Clinical Integration

• The Key to Health Care Reform
• -American Hospital Association, Feb 2010
• Clinical Integration is the extent to which
  patient care services are coordinated across
  people, functions, activities, and sites over
  time so as to maximize the value of services
  delivered to the patient.
• S Shortell, R Gilles, D. Anderson
• Remaking Health Care in America, 2000

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Clinical Integration is a TEAM Effort

• WHY CLINICAL INTEGRATION?
• Quality
• Communication
• Patient Experience
• Work Flow Efficiency
• Lower Litigation Risk
• Cost Reduction
• System Revenue

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Transitions of Care Potential Consequences

• Readmission
• Prolonged Length of Stay
• Duplication of tests
• Inaccurate treatment
• Poor Patient Satisfaction
• Decreased patient loyalty
• Increased work for staff
• Incomplete documentation
• Risk of Joint Defense

• Quality
• Communication
• Patient Experience
• Work Flow Efficiency
• Litigation Risk

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ED/Urgent Care Best Practices RECIPROCITY
Communication of Key Info (Based on Evidence and
local input)
Community Physicians Office
ED/UC/ SNF/Hospital
Visit Timeline ED/UC/SNF/Hospital Best Practice Community Physician
At intake Notify PCP about hospital utilization Provide clinical info when referring patients for ED/UC evaluation
During visit Invite PCP to participate in EOL discussions Provide patient with effective education Provide patient with written d/c instructions Provide patient with f/u phone Perform medication reconciliation Schedule outpatient f/u appointment Provide ED/UC/Hospital with phone access to outpatient staff who can answer clinical questions Provide ED/hospital with access to outpatient clinical info
At discharge Provide PCP with hospital contact info Provide PCP with summary clinical info Confirm receipt of hospital d/c info
After discharge F/U with high risk pts via phone Conduct outpatient f/u Perform outpatient med reconciliation
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48-Hour Readmission Review Pilot (UH Case)

• 136 patient readmitted within 48 hours, November
  2014 March 2015
• 39 reviews completed

Measure Yes
All-or-none and standard of care met 2.6
Notify community MD office about observation/admission 74.6
Provide receiving MDs with hospital clinicians contact info 58.5
Patient education prior to discharge 92.4
Written discharge instructions prior to discharge 87.9
Follow-up phone number prior to discharge 72.3
Medication reconciliation 95.4
Schedule follow-up appt 87.7
Provide PCP office with patient summary 75.4
PCP participated EOL discussions during visit 96.8
EOLend of life

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Practices and Policy
Best Practice UH Policy
Notify community physician office about hospital admission N/A
Provide receiving clinicians with hospital clinicians contact information prior to discharge GM-68
Provide patient with effective education prior to discharge CP 24, G 846 (Nursing Practice Manual)
Provide patient with written discharge instructions prior to discharge CP 24, GM 68, G 846 (Nursing Practice Manual)
Provide patient with follow up phone number prior to discharge G 846 (Nursing Practice Manual)
Perform medication reconciliation prior to discharge CP 24, CP 112
Schedule outpatient follow up appointment prior to discharge G 846 (Nursing Practice Manual)
Provide community physician office with summary clinical information at discharge N/A
Invite primary care physician to participate in end-of-life discussions during hospital visit N/A
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Best Practices

• In an ideal world.
• Presenting diads
• Think about the practices during the case
  presented
• Use the practices at your table to apply them to
  the case

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THEME then best practices by setting
1 Notify of PCP of encounter and disposition
Hospital to PCP Notify community MD office about outpatient observation and hospital admission
Hospital to SNF Notify community MD office about encounter and disposition
SNF to ED/Hospital Notify community MD office about encounter and disposition
PCP to ED/Hospital N/A
ED/UC to PCP Notify community MD office about encounter and disposition
ED/UC to Hospital Notify community MD office about encounter and disposition
Coaching Patient/caregiver write contact information in PHR of each provider through care transitions
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Introduction
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Case Presentation
X-ray shows comminuted fx
Ortho MD attempts closed reduction without pain
meds
Patient falls at home
Arrives in ED
Admitted inpatient
Discharged to acute rehab
Pain control inadequate
Patient gets long-leg cast
Admit med rec is not correct
Discharged to home with home health
Scheduling amb cant go to PCP office
No appt. no opiates or INR management
Home health monitors INRs
PCP appt. made
Rehab doc fills opiates
Follow up with ortho
Eventually gets PCP follow up
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Workshop
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Group Discussion