Community-based coalitions are critical to improving care transitions. To this end, people working throughout the community, in a variety of settings, really need to work to get to know one another, understand each other’s systems, and develop solutions that will translate into effective services for the community. Dr. Joanne Lynn describes a few steps to take to launch such a coalition.
Key Words: care transitions, coalition building, Section 3026, Joanne Lynn
by Larry Beresford
The Hospital Association of Southern California, which convened a Palliative Care Committee to provide mutual support among its members working on palliative care initiatives, recently changed the committee’s name to the Care Transitions Committee, reflecting the affinities between these two major quality currents within America’s hospitals. But as the cover story in the most recent Quarterly newsletter of the American Association of Hospice and Palliative Medicine asks: “Where is Palliative Care in the Readmissions Boom?”
A growing body of research has documented palliative care’s ability to help seriously ill, hospitalized patients clarify their goals for treatment, manage their symptoms, and plan for the next stages of their care in alignment with their values, often at lower cost of hospital resources and higher patient satisfaction. Palliative care teams in the hospital often see the patients with the most serious illnesses, psycho-social complications and multiple chronic conditions, who are also at higher risk for readmission. Palliative care, in contrast to hospice, does not require a terminal diagnosis or time-limited prognosis. It can be offered from the point of diagnosis of a serious, chronic or incurable condition, in conjunction with any other treatment modality. Palliative care focuses on quality of life, relief of pain and suffering, and support for emotional and family concerns.
But palliative care is also serious and complex specialty care, with board certification offered in Hospice and Palliative Medicine, accredited medical fellowship opportunities, and advanced certification for hospital palliative care programs offered since September by the Joint Commission. A growing body of quality measures used in palliative care has been recognized by the National Quality Forum. Although it has been slower to develop outside the hospital’s four walls, the number of hospital-based palliative care services has steadily grown to 1,568, 63 percent of all hospitals with 50 or more beds. The same way that hospitals and hospital medicine groups are coming to recognize their responsibility for the outcomes of their discharge plans after the patient leaves the hospital, palliative care teams are now exploring their role post-discharge.
So why isn’t palliative care, with its specialty recognition and demonstrated positive outcomes, more front-and-center in current national efforts to improve care transitions across the health care system, thereby contributing to preventing unnecessary rehospitalizations? Some places, like the Hospital Association of Southern California, have acknowledged the connection. Others have given palliative care representatives a seat at the table when cross-setting teams meet to work on improving care transitions in their communities.
But Dr. Diane Meier, director of the Center to Advance Palliative Care, tells AAHPM’s Quarterly that the biggest barrier is the absence of research demonstrating the impact of palliative care consultations in the hospital on 30-day readmission rates — in contrast to data that convincingly demonstrates palliative care’s value equation within the hospital. “I think that is an urgent, high-priority research question for our field,” Dr. Meier says. “I am concerned that we are going to miss this window of opportunity, even though our patients are a big part of the readmission problem.” (For more information on palliative care, see the Center to Advance Palliative Care.)
Key words: palliative care, care transitions, discharge planning, readmissions
Dr. Joanne Lynn describes Project RED (Re-Engineered Discharge), a program developed by Dr. Brian Jack and his colleagues at Boston University. It is designed to help hospitals to re-engineer their discharge processes, and offers some free online materials and guidance, as well as IT-enabled patient transition aids. You can read more about the details of the program on its website at: http://www.bu.edu/fammed/projectred/
And you can listen to Dr. Lynn describe it below.
Key words: Care transitions, discharge planning, health information technology, Project RED
In a factsheet from AARP’s Public Policy Institute, Lynn Feinberg and Allison M. Reamy detail how provisions of the Affordable Care Act (ACA) will lead to better recognition of and support for family or informal caregivers. An estimated 40 million Americans are family caregivers, and provide everything from help with transportation to assistance with daily living. As boomers age, the need for caregivers will grow tremendously—but their numbers will note. It is essential that we have public policies that address the social, financial, and health care realities of people who are family caregivers. The ACA takes a step in that direction.
Noting that the ACA explicitly mentions the term “caregiver” 46 times, and “family caregiver” 11 times, the authors are hopeful in their analysis of how caregivers might benefit from programs and policies enacted under various sections of the Act. In particular, they note that progress will be made in four critical areas: engaging individuals and families in shared decision making and addressing family experience of care; recognizing caregivers as part of the care team in new models of care; improving education and training not only of the health care workforce, but of family caregivers; and improving support for services at home and in the community.
Of special note is the effect Section 3026, the Community-Based Care Transitions Program, will affect the lives of caregivers. Under that program, grantees will have to carry out at least one transitional care intervention, which could include any of several scenarios, with a focus on engaging beneficiaries and their caregivers. Topics might include discharge education, help to ensure timely follow-up appointments with post-hospital and outpatient providers, self-management education, and help with comprehensive medication review and management.
The entire factsheet is available free and online at: http://assets.aarp.org/rgcenter/ppi/ltc/fs239.pdf
Key Words: care transitions, Section 3026, public policy, health care reform, ACA, family caregivers
Advanced practice nurses can be very effective in helping to bridge transitions from hospital to home. Dr. Joanne Lynn describes the Transitional Care Model, developed and tested by Dr. Mary Naylor and her colleagues at the University of Pennsylvania. You can learn more about TCM from: https://www.nursing.upenn.edu/ncth/transitional-care-model/about-the-tcm/, and by watching the video below.
Keywords: Transitional Care Model, Care Transitions, Joanne Lynn, Advanced Practice Nurses
Patient activation—teaching patients to take charge of their care—is an essential element of improving care transitions. Patients need to know what to expect, how to recognize when things are going wrong, and what to do about it. Dr. Joanne Lynn talks about the Patient Activation Measure, one way to gauge patient engagement in their care, and the Care Transitions Intervention developed and tested by Dr. Eric Coleman at the University of Colorado.
In today’s installment of the video series on improving care transitions, Dr. Joanne Lynn describes three crticial elements for ensuring smoother transitions. These are standardizing the process (in part by mapping what you do now and understanding how the current system works–or does not); activating and mobilizing patients and caregivers to take charge of the transition, to know what is going on, what to expect and how to recognize when things are falling apart; and ensuring good information flow among all settings and with patients and caregivers.
Key Words: Care transitions, quality improvement, process standardization, patient activation, information flow
A three-part protocol, involving standardized assessment, palliative care consultations, and root cause analysis led to a 20% reduction in hospital readmissions for elderly skilled nursing facility residents, according to the AHRQ Health Care Innovations Exchange.
Led by Dr. Randi Berkowitz, a Practice Change Fellow, the initiative focused on reducing the risk of hospital readmissions at Hebrew SeniorLife, an integrated eight-site system of health care, housing, research, and teaching based in Boston. The Practice Change Fellows Program [now the Practice Change Leaders for Aging and Health Program] is a two-year award that enables clinicians to work on projects to improve care of older adults, supporting them as they develop leadership skills and content expertise.
According to AHRQ, Berkowitz developed a program that featured: standardized assessment at admission to identify patients with multiple prior hospitalizations, palliative care consults and care plans for those who had had three or more hospitalizations in the previous six months, and a multidisciplinary staff conference to examine the root causes of inpatient readmissions when they occurred. As a result, inpatient readmissions decreased by 20%, from 16.5% before implementation to 13.3% after it.
Developing the project required that Berkowitz obtain approval from Hebrew SeniorLife leaders, form and advisory committee, develop the standardized admissions template, and introduce program and multidisciplinary conferences. Learn more about the work at
http://www.ncbi.nlm.nih.gov/pubmed?term=Berkowitz%2C%20Randi%20American%20Geriatrics%20Society
Key Words: readmissions, palliative care consults, skilled nursing facility, care transitions
AHRQ Innovators Exchange features information and a video about a pilot study to improve care for low-income elderly patients with chronic illnesses.
https://innovations.ahrq.gov/videos
Conducted by Ohio-based Summa Care under the leadership of Practice Change Fellows and Advisory Board Member Kyle Allen, DO, AGSF, the project reports that 70% of participants reported improved health, and 93% rated their experience as good or excellent one year after participation. The program led to cost savings of approximately $600 to $1000 per patient per month as a result of decreased hospitalizations. Summa Health is now conducting a three-year randomized controlled trial to confirm these results.
Summa Health System developed a program called the Frail Elders Care Management Program. The project involved interdisciplinary teams that provide integrated medical and social care management to low-income elderly in-patients who have chronic illnesses. The program aimed to ease the transition from hospital to home, provide preventive care, identify new and emerging problems, reduce readmissions, and prevent functional decline. Most participants were over the age of 65, had several chronic conditions and impaired activities of daily living, and had one or more problems that required an intervention. For example, nearly 40% of patients took more than 10 prescriptions, and nearly 50% had experienced one or more falls.
The project featured an interdisciplinary team whose members included a geriatrician, an advanced practice nurse, a registered nurse care manager, a social worker, and a geriatric pharmacist. Other clinicians were called on as needed. Primary care physicians, who then received a one-time fee, participated in a consultation with the nurse care manager. Over the course of three years, the Frail Elders Care Management Program served 1,272 patients. Based on promising preliminary results, AHRQ funded a three-year randomized controlled trial.
Key Words: frail elders, care transitions, quality improvement, interdisciplinary teams
Fixing what’s wrong with care transitions will require changes in how systems work, both internally and with other systems. In this video, Dr. Joanne Lynn explains the importance of understanding your own health care system in order to fix problems in care transitions. Community and medical care providers need to work together to understand drivers in their own system before they can engineer effective solutions. You can also learn more about how to work locally by reading the Get Started guide, which you can find here:
https://medicaring.org/get-started/#why-local-reform
Key words: Care transitions, quality improvement, community-based organizations