Transition of Care Program: Connecting the Dots
Transition of Care Program: Connecting the Dots
June 26, 2010
David Kelley, M.D.
Chief Medical Officer
Pennsylvania Department of Public Welfare
Office of Medical Assistance Programs
Bureau of Fee-For-Service Programs
c-dakelley@state.pa.us
Transition of Care Program: Connecting the Dots
Key Facts and Timeline
• September-October 2009
Initiated and completed program
planning and design, including
identification of preferred pilot site
ERIE
WARREN
McKEAN
SUSQUEHANNA
BRADFORD
TIOGA
POTTER
WAYNE
CRAWFORD
FOREST
• November–December 2009
Initial meetings with Williamsport
Regional Medical Center
WYOMING
ELK
VENANGO
CAMERON
CLINTON
LUZERNE
COLUMBIA
JEFFERSON
CLARION
LAWRENCE
MONROE
MONTOUR
CLEARFIELD
BUTLER
UNION
CENTRE
CARBON
ARMSTRONG
SNYDER
NORTHUMBERLAND
NORTHAMPTON
BEAVER
INDIANA
MIFFLIN
JUNIATA
CAMBRIA
SCHUYLKILL
BLAIR
LEHIGH
BERKS
PERRY
WESTMORELAND
DAUPHIN
BUCKS
LEBANON
HUNTINGDON
MONTGOMERY
WASHINGTON
CUMBERLAND
LANCASTER
SOMERSET
GREENE
– Hired and trained nurse manager
– Completed arrangements with
hospital
PIKE
LYCOMING
MERCER
ALLEGHENY
• January-March 2010
LACKAWANNA
SULLIVAN
FAYETTE
CHESTER
BEDFORD
FULTON
PHILADELPHIA
YORK
FRANKLIN
ADAMS
DELAWARE
ACCESS Plus and Voluntary Managed Care
ACCESS Plus only
Health Choices Region
• March 29, 2010
Launched pilot program
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Transition of Care Program: Connecting the Dots
Why Transition of Care (ToC)?
• Patients transitioning from one setting of care to another
are at risk of poorer outcomes due to:
–Miscommunication between multiple providers, patients,
family and caregivers
–Medication changes
–Lack of understanding of discharge instructions
• Dedicated resources focused on the immediate transition
period have demonstrated improved patient outcomes
–Coleman Care Transitions Intervention
–Naylor Transitional Care Model
–Boston Medical Center Re-engineered Discharge Project
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Transition of Care Program: Connecting the Dots
ToC Program Goal and Focus
Manage patient transitions from acute care through community-based care to improve
quality of care and, ultimately, the patient’s experience and health status, thereby reducing
days in post-acute care, hospital readmissions and emergency department visits.
1 – 6 weeks post‐discharge
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Transition of Care Program: Connecting the Dots
ToC Program Scope and Role
• Population
– ACCESS Plus (Enhanced Primary Care Case Management program) enrollees
admitted to Williamsport Regional Medical Center
– Excludes maternity and newborns (other programs serve these patients)
• Transition of Care Manager Role
– Improve coordination among key stakeholders prior to, during, and
immediately after transitions from one care setting to another
– Key stakeholders include:
• Patient/family/caregivers
• Primary care physician and other treating physicians
• Hospital and post-acute care facilities
• ACCESS Plus disease management
• Pharmacy services (internal and external)
• Intense medical case management unit (IMCM)
• Medical assistance transportation program (STEP)
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Transition of Care Program: Connecting the Dots
Process Overview
End
NO
Admission notification via daily census report
Meets program eligibility criteria?
Discharge to PCP
Refer to IMCM or Disease Management (if appropriate)
YES
Evaluate medical record and condition
Will patient benefit from ToC
program?
Conduct post‐
discharge home visit(s) and phone calls
Follow patient in hospital and other post‐
acute setting
Meet with patient* and describe ToC
program
YES
Agreement to participate?
NO
End
* Patient may mean patient or family/caregiver
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Transition of Care Program: Connecting the Dots
Benefits of ToC Program
• Medical Assistance Program and Consumers
– Fill unmet need(s) for ACCESS Plus consumers
– Focus on improving quality of care and health outcomes
– Strengthen partnership between the Department and the Hospital
• Hospital
– Reduce readmissions
– Single point of contact for hospitalized consumers
– Onsite Medical Assistance resource
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Transition of Care Program: Connecting the Dots
ToC Program Measurement
• Efficiency/Cost/Utilization
– Hospital Readmission Rates
– Emergency Room Visits
– Post Acute Facility Days/ Services
– Expected vs Actual Spending
– PMPM Rates
– Post-acute Service Utilization
• Program Utilization
– Program Volume
– Opt Out Rate
• Quality
– Consumer Satisfaction Survey
– Medication Reconciliation
– Adverse Events
– Mortality
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Transition of Care Program: Connecting the Dots
Results to Date
• ToC Program went live Monday 3/29/10
– Through 6/4/10 (10 weeks of operation), ToC Manager has:
– Screened 49 consumers
– Offered ToC services to 46 consumers
– Enrolled 46 consumers
– Discharged 21 consumers
• All enrolled consumers have received post-discharge follow up,
including health education/wellness promotion, diet,
medications, reminders about follow up appointments, etc.
• Nine consumers received counseling and/or assistance regarding
smoking cessation (e.g., Chantix, nicotine replacement)
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Transition of Care Program: Connecting the Dots
Results to Date (continued)
Percentage of Enrollees by Type of Assistance
Other healthcare services
Supplies and equipment
Assistance with medication
Diagnostic testing
Assistance with PCP
Transportation assistance
Social/non‐health assistance
0%
5%
10%
15%
20%
25%
30%
35%
40%
n = 33 ToC enrolled consumers
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Transition of Care Program: Connecting the Dots
Results to Date (continued)
• Sample vignettes include:
– Diabetic with high blood pressure was instructed at discharge to check
blood sugars twice a day, but not given prescription for glucometer.
ToC Manager obtained glucometer from Diabetes Educator, took it to
him and instructed him on proper use. Also followed him to make sure
he kept all his doctor appointments, went to the lab for his blood work,
and had transportation there. He had a cold and was taking an OTC
cold medicine that was affecting his blood sugars and blood pressure.
ToC Manager instructed him on recommended cold medications.
– Consumer admitted with CHF exacerbation was discharged with
Altace, a medication not on formulary and pharmacy did not fill it or
call the doctor. When ToC Manager called the day after discharge she
had no heart medication. ToC Manager called the pharmacy to get a 5
day supply of Altace, then contacted the physician who ordered a
comparable (formulary) medication.
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Transition of Care Program: Connecting the Dots
Results to Date (continued)
• Sample vignettes include:
– Consumer with liver failure was discharged and informed that he
needed to see a liver specialist at a nearby larger medical center.
Consumer’s father handles his affairs, and the father kept waiting for
the specialist to call him. The consumer needed immediate medical
care, so ToC Manager instructed them to go to the ER at the medical
center. Consumer’s father was told at the medical center that if
treatment was not provided that day, the consumer may have died.
– Diabetic with cardiac complications was discharged with a list of
medications from the hospital that was different from his previous
regimen. When ToC Manager called him and reviewed medications, he
was doubling up on some medications that were prescribed with
different doses and was taking the new dose along with the old dose.
He also required encouragement to follow up with his PCP. ToC
Manager also reviewed low cholesterol, low sodium, diabetic diet.
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Transition of Care Program: Connecting the Dots
Results to Date (continued)
• Sample vignettes include:
– Consumer was obese individual admitted for total knee replacement
and discharged with home PT. ToC Manager coordinated with
physician and home health agency to have PT and blood work at home
until she was able to get out of her house safely. After 3 days, home
health agency did not start therapy, so ToC Manager contacted agency
and they initiated services that evening. Consumer also needed raised
toilet seat and bars for the bathroom which ToC Manager assisted with.
– Consumer admitted with pneumonia and severe COPD with
malnutrition. He needed dental care which was affecting his eating.
ToC Manager set up dental appointment. He also had several doctors to
follow up with and did not know the address or phone number of one
physician. ToC Manager obtained physician’s contact information for
the family, and also addressed many questions about medications.
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Transition of Care Program: Connecting the Dots
Results to Date (continued)
• Sample vignettes include:
– Consumer admitted with respiratory failure and needed new BiPAP at
home. ToC Manager coordinated with the physician and DME company
about which equipment would be best because she now required BiPAP
during the day. Consumer also wanted a living will, which ToC Manager
assisted with completing, made copies for her and dropped one off at her
physician’s office. Consumer would benefit from having a power scooter,
so ToC Manager obtained prescription and coordinated with DME vendor.
Also set her up for STEP transportation and assisted in obtaining a bedside
commode and shower chair.
– Consumer has new diagnosis of lupus and requires frequent monitoring of
bleeding times. She sees a cardiologist at a nearby medical center and they
can do finger sticks there, but the local lab could only do venipuncture.
ToC manager worked with the Coumadin clinic to obtain home finger stick
equipment that she will enable consumer to check her own PT/INR and call
in results to cardiologist, saving both time and energy.
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Transition of Care Program: Connecting the Dots
Key Program Design Considerations
• Selection of hospital partner
– Sufficient patient census to support activity of one ToC Manager (Williamsport
has approximately 500 non-obstetric or newborn discharges annually)
– “Solo” provider for service area
– 90+ percent of consumers live within 30 miles of hospital
– Interested/excited about program potential
• Selection of ToC Manager
– Previous discharge planning and/or home care experience (case management
experience preferred)
– Excellent communication and problem-solving skills
– Ability to work autonomously
– Knowledgeable about local area and resources
• Allow sufficient time for discussions and preparations with hospital
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Transition of Care Program: Connecting the Dots
Questions and Answers
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