Care Coordination
Damien Doyle
MD/CMD/FAAFP
Medical Director
Optum HealthCare of MidAtantic
Staff Physician
Charles E. Smith Life Communities
Damien_J_Doyle@Optum.com
“The single biggest problem with
communication is the illusion that it has
taken place”
George Bernard Shaw
System vs. Patient – An inherent
Conflict
• Care delivered by specialized practitioners
with narrow focus
• Organizations deliver care along product
lines and specialties and are site specific
• Patients are increasingly complex with a
greater variety of co-morbidities managed
in a growing variety of settings
Too many cooks….
• Typical Medicare beneficiary sees an
average of 2 PCPs and 5 specialists
annually
• Who coordinates this care?
Care Coordination Definition
• Many definitions exist and this is part of the
•
confusion
“The term ‘care coordination’ has no wellestablished definition. Rather, it is generally
understood to mean a process of improving
communication among the various medical
professionals with whom patients come in
contact and between these professionals and
the patients themselves (and their families).”
Brown 2004
Care Coordination Definition
• From the National Library of Medicine,
Closing the Quality Gap Vol. 7 “the
deliberate organization of patient care
activities between two or more
participants (including the patient)
involved in a patient's care to facilitate the
appropriate delivery of health care
services.”
Care Coordination Goals
• (1) identify the full range of medical, functional, social,
•
•
•
and emotional problems that increase patients' risk of
adverse health events
(2) address those needs through education in self-care,
optimization of medical treatment, and integration of
care fragmented by setting or provider
(3) monitor patients for progress and early signs of
problems
Such programs hold the promise of raising the quality of
health care, improving health outcomes, and reducing
the need for costly hospitalizations and medical care.”
• Chen 2000
Transition of Care Definition
• Movement of patients between health care
locations, providers or different levels as their
care needs change
– Within settings
• PCP to specialist
• ICU -> ward
– Between settings
• Hospital -> Subacute or Home
– Across health states
• Curative -> Palliative
AMDA Transitions of Care Practice Guideline 2010
Care Transitions:
Definition
• “Care Transitions” refers to the movement
patients make between health care practitioners
and settings as their conditions and care needs
change during the course of a chronic or acute
illness
9
Care Coordination and
Transition of Care are
critically and inherently
linked
Charles E. Smith Life Communities
OUR SPECTRUM OF SERVICES
Most Acute
Subacute
Subacute
Medical
Model
Nursing Home
Outpatient
Diagnostic &
Treatment
Least Acute
Least
Restrictive
Social
Model
Hebrew Home
Home Living
Support
Independent
Living
Assisted
Living
Hebrew Home
451 Beds
1969
Wasserman
Smith -Kogod 1981
Landow House 2005
60 Units
Hirsh Health Center 1991
Home Care Solutions, LLC
Joint Ownership Augustine Home Health
Ring 1989
Revitz 1978
70 Bed Unit
( 250 Apts.)
(250 Apts.)
2000
37 Total Acres21
CARE MANAGEMENT
Most Restrictive
Is This Really a Problem?
• ~ 10% of all NH residents had an ED visit in
•
past 90 days
Of these, 40% have a potentially preventable
cause
(Caffrey, US Dept HHS 2004)
• Of Patients who are hospitalized,
– 19% re-hospitalized within 30 days
– 42% re-hospitalized within 24 months
• Hard to define what is the appropriate/expected
number
What illustrates bad Care
Coordination
•
•
•
•
•
•
•
Medication Errors
Increased Health Care Utilization
Inefficient/Duplicative Care
Inadequate patient/caregiver preparation
Inadequate follow-up care
Dissatisfaction
Litigation/Bad publicity
•
•
Eric Coleman, MD/MPH
University of Colorado, Denver
High Risk for Transition Problems
•
•
•
•
•
•
•
•
•
Multiple Medical Problems
Dementia
Depression or other Mental Health issues
Isolated – lack of caregivers
Poverty
Non-English speaking
Minorities
Recent immigrants and refugees
IE, most of our patients!
What are the Common Factors?
• Most transitions are unplanned and due to
acute illness
• Patients are vulnerable – functional loss,
delirium, pain and anxiety are all common
• Only true common factor is the patient
themselves
What Can We Do?
• Move?
• Give up?
Safer Coordination
• Communication
• Medication Reconciliation
• Patient Centered Care
• End of Life Care – Patient driven plan of
care
Safer Coordination Communication
• Discharge Instructions – Expectations
– Shift the concept of “discharge” to “transfer
with continuous management”
– Begin transfer planning upon admission
– Incorporate patient/caregiver preferences
– Identify social support and function
– Collaborate with practitioners across the
spectrum
Safer Coordination –
Communication
• Expectations for the Transferring Team
– Patient is Stable
– Patient and caregiver understand the purpose of the
transfer
– Patient and caregiver understand their coverage
– Receiving institution is capable and prepared
– Care plan, orders, and clinical summary precede the
patient’s arrival
– Timely follow-up is arranged
Safer Coordination –
Communication
• Expectations for the Receiving Team
– Review the transfer forms, clinical summary
and orders
– Incorporate the patient/caregiver goals and
preferences
– Clarify any discrepancies regarding the care
plan, patient’s status or medications
Care Coordination
Models
• Key national models
– Care Transitions Program
– Transitional Care Model
– Transforming the Care at the Bedside
– Project RED (Re-Engineer Discharge)
– Project Better Outcomes for Older adults
through Safe Transitions (BOOST)
23
Care Transitions: Four
Pillars
Coleman, Univ. of Colorado
www.caretransitions.org
Celtic Healthcare
24
Transitional Care Model
Naylor, Univ. of Pennsylvania
Celtic Healthcare
25
Transforming The Care
at the Bedside Model
Institute of Healthcare Improvement
Celtic Healthcare
26
Project RED
Boston University
Celtic Healthcare
27
Home Healthcare Role
• Transition Coach” (Nurse or MSW)
– Prepares patient for what to expect and to speak up
– Educated on use of a Personal Health Record
– Educates the care team in home of patient’s needs
• Follows patient to the home
– Reconcile pre- and post-hospital medications
– Practice or “role-play” next encounter or visit
• Phone calls after discharge
– Single point of contact; reinforce, ensure follow up
• Does not replace hospital discharge planning!
Celtic Healthcare
Specialized Care Models
• ISNP (Institutional Special Needs
Population) – Medicare Advantage
Programs
• Home Care Management Programs
• NORC (Naturally Occurring Retirement
Communities)
http://www.aoa.gov/AoARoot/AoA_Programs/OAA/oaa_full.asp#_Toc15395
7728
Resources and
References
• Home Health Quality Improvement
Campaign
– Original Campaign Transitional Care Coordination Best Practice
Package and resources
• www.homehealthquality.org/hh/ed_resources/intervention
packages/tcc.aspx
– Current Campaign
• www.homehealthquality.org
– Care Transitions Program
• www.caretransitions.org
• Coleman, E., et. Al. (2006). ARCH INTERN
MED., Vol. 166.
30
Care Transition Tools
and Resources (cont.)
• Medication Management Tools
•
•
31
– Collaboration for Homecare Advances in Management and
Practice (CHAMP) Program
– www.champ-program.org
Barriers to Medication Adherence, Medication Management
Evidence Brief, Reducing Adverse Drug Events
Beers Criteria, ARMOR Polypharmacy Tool, How to Write a
Pill Card, Medication Reconciliation Process, Risk Assessment
for Non-adherence, Script for Adherence Counseling, Speak Up
Brochure – Help Avoid Mistakes with Your Medicines, Tips for
Preventing Problems When Taking Multiple Medications, Your
Medications – What to ask
• “There was an important job to be done
and Everybody was sure that
Somebody would do it. Anybody could
have done it, but Nobody did it…
Everybody blamed Somebody when
Nobody did what Anybody could have
done”
– Anonymous