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Support for patients transitioning from hospital to home
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The transition from hospital to home
◦ High risk for patients
 Not feeling 100% yet
 Information overload at discharge
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Medications
Follow-up care
Diet
Exercise
Special instructions
Specialist care
Possible pending test results
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◦ Knowledge needs
 Who is in charge – who is the primary provider? I
have LOTS of doctors…
 Who should I call? My primary doctor? The doctor
who took care of me in the hospital? The name on
this paperwork? When should I call?
 Is this really a health problem or am I just having a
bad day?
 Am I having medication side effects? How do I know?
 Who should I tell?
 How do I know if my medicine is working?
 Do I know why I am taking all these medicines?
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Patients looking for guidance about how to
engage with their providers
Common patient beliefs
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Doctors and nurses are busy
I should not question their authority
If it is important, my doctor would have talked about it
If I ask questions, my doctor might think I am being
disrespectful
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Patients in need
◦ Outpacing number of available providers
◦ Patients have more complex illness
 Multiple chronic conditions
 Multiple complex medications
 Multiple providers
 Multiple settings
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Healthcare costs are rising at a faster pace
than inflation!
 Human costs
 Decreased quality of life
 Decreased community tenure
 Stress and worry
 Confusion
 Financial burdens
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Issues driving healthcare costs ↑
Chronic conditions
 Cardiovascular disease
 Highest costs
 > $40 Billion, 2010
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Chronic obstructive pulmonary disease (COPD)
Kidney disease
Pneumonia
Diabetes
Obesity
Asthma
Pain management…
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Economic strain on Healthcare System
◦ Rehospitalizations
◦ Emergency department visits
 US Hospital 30-day readmission rates of 20%
 Annual cost to Medicare fee for service > $17 Billion
 Readmission rates for chronic illness with respiratory
implications
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CHF: 27%
COPD 23%
90% of these readmissions unplanned
40% – 75% preventable if existing standards of care were
in place (Jencks, 2009)
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among
patients in the Medicare fee-for-service program. N Engl J Med.
2009;360:1418-28
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Why is chronic illness so costly?
Difficult to diagnose
Often occurs with other conditions
Symptoms overlap
Affects older population disproportionately
 Develops over time
 Cumulative effects of multiple issues
◦ Requires ongoing management – not curative
 Frequent doctor visits
 Ongoing changes in complex medication regimes
 Potential for adverse events always looming…
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Limited access to care
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Geographic boundaries
Cost barriers
Insufficient preventive care services
Gaps in provider-patient communication
Insurance barriers
Barriers in referral process
Long waiting lists for an appointment
Transportation barriers
Mobility barriers…
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Part of the Affordable Care Act of 2010
Public Law 111-148 and Public Law 111-152
Purpose:
◦ Reduce costs
 Reduce preventable rehospitalizations
 Reduce preventable ED visits
◦ Improve communication across care settings
◦ Improve quality of care
◦ Improve safety for patients
◦ Incentivize providers to “engage” in coordinated care
activities within and between care settings
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Agency for Healthcare Research and Quality
(AHRQ)
Bundled Payment:
“a method in which payments to health care providers
are related to predetermined expected costs of a
grouping or ‘bundle’ of related health care services”
(AHRQ, Publication No. 12-E007-EF, August 2012).
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How does Bundled Payment work?
◦ Intended to hold providers and healthcare
organizations “accountable”
 Type of services provided
 Number of services provided
 QUALITY of services provided
◦ Financial penalties
 Gaps in care
 Preventable rehospitalizations
 Preventable ED visits
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Improve the process of Care Transitions
Include ALL the stakeholders
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Patients & Families
Providers
Hospitals
Clinics
Private Practices
Payers/Insurors
Specialists
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The effective solution must be:
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Affordable
Simple
Effective & Useful
Meaningful
Available to all
Evidence-based
Clinically Relevant
Sustainable
Scalable
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Support for patients transitioning from hospital to home
Heather J. Sobko, PhD, RN
Mark Glenny, BA, MS, RN
Charles W. Callans, III, MPH
Douglas Mitchell, BS
Octavio E. Pajaro, MD, PhD
K. Randall Young, MD
Monika Safford, MD
Benjamin B. Taylor, MD, MSPH
Andrew Tyson, BS
Edward M. Sobko, BSME
Donald Schnader, MS, MSHI
Rob Rader
Shelli Andros
Kevin Leon, MD
Niveditha Thota, MSHI
Dan Piper, MS
Jody Fann
Steven Schnader, MS
Paul Crigler, ABPMP, CBPP
Gary West, MS, MBA
Susan Andreae, BS, BFA, MPH
Derek Mathews, BS, MS
Barbara A. Sobko, MS
Brian Gugerty, DNS, RN
Gregory L. Rohde, BS, ME
F. Don Siegal, Esquire
Scott J. McKay, MSE
James W. Conrad, III, CPA, CFP
Joshua S. Richman, MD, PhD
Zack Schaper
Joseph Fisher
Nachiketa Mishra, MSHI
Kenneth M. Bush, Esquire
Donald Schnader, MSHI
Cindy Boggs, MS
Robert Gilbert, BS
Thomas G. Spurlock, MD, DC
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Provide affordable, meaningful, technological
tools to extend healthcare support for patients
making the transition from the hospital to
home so that the transition is successful and
potential complications or problems are
minimized
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Reduce burden on human resources
 Increase efficiency and effectiveness of clinician time
 Reduce preventable Rehospitalizations
 Reduce preventable ED visits
 Provide meaningful relevant data
 ongoing monitoring of patients
 reporting outcomes
 improving processes
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 Improve provider-patient communication
 Increase and enhance provider communication across
settings of care
 Integrate relevant clinical data into existing workflows
 Focus on inclusion of all stakeholders:
 Patients & families
 Providers
 Hospitals
 Clinics
 Payers/insurers
 Private practices
 Specialists
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 Increasing patient engagement in managing chronic
health needs
 Create a comprehensive system that patients actually
enjoy and use because they like it and it is easy to use
 Allow choices for patients and families wherever
possible
 Keep it simple and make it affordable
 Design a scalable model so that it can meet the
growing needs of all the stakeholders WITHOUT
increasing costs!
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An Interactive Voice Response System designed
to provide support for patients during care
transitions
A comprehensive, self-contained system
◦ Calls out to patients electronically
◦ Evidence-based queries about specific health needs
(very focused)
◦ Calls scheduled to meet patient preferences
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Patients respond to queries using their
telephone keypad
Information is securely transmitted to a
clinician for review via a computer “dashboard”
System has a built-in triage system to support
clinical personnel in identifying patients in need
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Patients whose survey responses indicate a
need for some guidance, information or
support receive a personal phone call from a
Care Transition nurse
◦ The system database gathers information and can
create aggregate data in the form of reports to support
quality improvement and process improvement efforts
◦ Data can be used to support research efforts aimed at
resolving challenges associated with care transitions
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We have an affordable solution for the growing
costs of healthcare and the critical need to
support patients who are transitioning across
care settings
Additional information on our website:
www.CareTransitionSystems.com
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Support for patients transitioning from hospital to home