For the Healthcare Provider
TRANSITIONS OF CARE
ATRIAL FIBRILLATION
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TABLE OF CONTENTS
• What is Transitions of Care?
• Efficacy of Transitions of Care Approach
• Project Scope
• The Role of the Provider
• The Role of the Patient
• Resources
• Action Requested and Timeline
• Feedback Survey
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BACKGROUND AND CHALLENGES
• Most commonly diagnosed arrhythmia disorder
• 2.3 million people in U.S. living with AF
- 160,000 new cases annually
• Patients with multiple chronic conditions can visit ~16
physicians annually
• AF is responsible for 88,000 deaths per year
- $16 billion in healthcare costs
• Challenge of coordinating basic information (e.g., test results,
prescription medications, diagnosis)
• Poor coordination often leads to adverse clinical outcomes,
increased re-admissions, over-utilization of health care services, and
untimely follow-up
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TRANSITIONS OF CARE DEFINITION
• Transitions of Care refer to the movement of patients
between health care locations, providers, or different
levels of care within the same location as their conditions
and care needs change.
• Specifically, they can occur:
• Within settings
• Between settings
• Across health states
• Between providers
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CARE COORDINATION DEFINITION
• Care coordination is a function that helps ensure
the patient’s needs and preferences for health
services and information sharing across people,
functions, and sites are met over time. Coordination
maximizes the value of services delivered to
patients by facilitating beneficial, efficient, safe,
and high-quality patient experiences and improved
healthcare outcomes.
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PRINCIPLES
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Care coordination is important for everyone
Some populations are particularly vulnerable
Care coordination measures may be appropriate
at the clinician-level; others may be appropriate
at the group, practice or organizational-level
Patient/family surveys are essential to measure
care coordination; performed within close
proximity to the healthcare event
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ELEMENTS OF TRANSITIONS OF CARE
• Medication reconciliation
• Follow-up tests and services
• Changes in plan of care
• Involvement of team during hospitalization, discharge,
follow-up, etc.
• Communication
• Transfer of all information when site of care changes
• Education of the patient and family
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NATIONAL CARE COORDINATION GOALS
•Healthcare organizations and their staff will continually strive to
improve care by soliciting and carefully considering feedback
from all patients and their families regarding coordination of their
care during transitions.
•Medication information will be clearly communicated to
patients, family members, and the next healthcare professional
and/or organization of care, and medications will be
reconfirmed at each transition.
•All healthcare organizations and their staff will work
collaboratively with patients to reduce 30-day readmission rates.
•All healthcare organizations and their staff will work
collaboratively with patients to reduce preventable emergency
department visits.
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EFFICACY OF TRANSITIONS OF CARE
•Hospital to Home – ACC & IHI national quality
improvement initiative to reduce cardiovascularrelated hospital readmissions and improve the
transition from inpatient to outpatient status for
individuals hospitalized with cardiovascular disease
(e.g., heart failure)
• Medication management
• Follow-up
• Symptom management
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TRANSITIONS OF CARE AND PROVIDER PAYMENT
• Provider payments are shifting toward the key elements of
Care Quality and Care Coordination
• By 2015, providers will be required to document quality
improvement indicators or face decreases in reimbursement
• By 2017, Medicare reimbursement will be adjusted based on
documented quality outcomes for all physicians
• Capturing those indicator data will aid in either enhancing
existing care protocols or developing new ones
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AFIB TRANSITIONS OF CARE GOAL
Project Goal:
• To develop practical resources to encourage best
practices in clinical decision-making, patientprovider communication, and patient selfmanagement.
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ROLE OF THE CARE PROVIDER
• Engaging Mended Hearts Volunteers
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Making a referral to post-ablation patients
• Review Patient Care Pathway
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Patient Care Plan
Review Patient Discharge Checklist (provided in patient kits)
Review AF Educational Resources (provided in the patient kits)
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ROLE OF THE MENDED HEARTS VOLUNTEER
• Understand the Patient Care Pathway
Peer-to-peer patient support
Patient Care Plan (No interpretation of orders/prescriptions)
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Patient Discharge Checklist (General)
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And what is it and why is this important?
And what is it and why is this important?
Atrial Fibrillation Educational Resources
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ROLE OF THE PATIENT AND CAREGIVER
• Understand the Patient Care Pathway
Patient Care Plan
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Patient Discharge Checklist
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And what is it and why is this important?
And what is it and why is this important?
Atrial Fibrillation Educational Resources
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PROVIDER/PATIENT KIT RESOURCES
•Provider Resource Kit
• Best practices
• Patient care plan
elements
•Discharge checklist
•Transition record
checklist
•Mended Hearts Info
•Patient Resource Kit
•Elements of a care plan
•Patient discharge checklist
•Role of the caregiver
•Guide to AFib brochure
•AFib Patient DVD
•Mended Hearts Info
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FEEDBACK SURVEYS
• Healthcare Provider
• Web-based / monthly survey - 4 questions
• Mended Hearts Volunteer
• Telephone / Web-based surveys – Monthly/Quarterly
• Patients
• Postcard / Received during visit – 4 questions for 30 days
post event
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QUESTIONS?
Thank You!
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