Care Transition Opportunities for
LTC
Naomi Hauser , RN, MPA
Director Care Transitions
Quality Insights of Pennsylvania
August 14, 2013
Care Transitions
 A continuous process in which a patient’s care shifts
from being provided in one setting of care to another
Affordable Care Act
 New care transition/30-day readmission reduction
programs
 Increase incentives to improve coordination between
settings and providers that help reduce health care
costs through prevented readmissions
 Supporting individuals and caregivers who experience
a transition in their care setting
Financial Incentives/Penalties
 Medicare began financial incentives to reduce
potentially avoidable hospital transfers through payfor-performance initiatives, bundled payments and
other strategies
 October 2013
Facts
 Avoidable rehospitalizations drivers
– A failure in hospital discharge processes
– Patients’ ability to manage self-care
– Quality of care in the next community settings (skilled
nursing facilities, home health care agencies, and office
practices)
Facts
 IHI faculty discovered that the failures in care
coordination between the hospital and SNF that led
to rehospitalization within 30 days after discharge fell
into two main categories:
– Those related to care provided within the skilled nursing
facility
– Those related to care provided during the transition from
the hospital to the skilled nursing facility
Facts
 Nursing home residents transferred to hospitals for
acute change in their clinical condition
 1 of 4 Medicare patients admitted to SNF from
hospitals
– Readmitted within 30 days
– 2/3 potentially avoidable
Opportunities
 Identify improvement opportunities/RCA
 Use Interact tools
 Start the conversations with partners/ER
 Collaborate
 Transparency
 Establish goals/measures/collect data/trends
 Spread/sustainability interventions
Changing Image of LTC
 Important to understand consumers’ emerging and
changing needs, wants and expectations, especially
concerning
– Quality of their experience with providers position as
• Trusted advocates in helping consumers access services and
supports
• While assisting consumers and their families
– In navigating complex aging challenges
Action Steps
 Identify and implement effective programs and
practices
 Promote safe, effective care transitions while
decreasing potentially avoidable 30-day readmissions
 Get started now!
Interventions
 Hickory House
COACHING
C.O.A.C.H.
Customer Service and Education Based
Elaine Doyle, BSN BA RAC- CT
Mary Zebert, SW
What does C.O.A.C.H. mean?
 Communicate Expectations
 Organize Goals
 Assign Coach
 Continued Review
 Handoff Homework
Team Roster
 Case Manager
 Coach
 Rehab
 Social Services
 Clinical Services
 Registered Dietician
72-Hour Meeting
 Introductions
 Prior level of functioning
 Our goals
 Patient’s goals
72-Hour Meeting
 Goal is to shift the patient’s “time oriented” focus to a
“goal oriented” focus
 Rehab initiates the checklist and hands it off to the CM
before the meeting – CM adds the nursing goals
 Determine patient’s education needs and place patient on
“alert charting”
 Incorporate the patient’s expectations into your goal
sheet then review it with patient and family
 Introduce the COACH
Continued Communications
 Update the goal sheet at the weekly rehab meeting;
discuss possible need for a home assessment
 Share the changes with the patient
 If the patient is off track, their coach meets with the CM,
CM determines if an extra meeting is needed
 Nursing will monitor patient for early warning signs of
change in condition using the INTERACT tools to enable
early treatment of illness and avoid unnecessary hospital
readmission
Discharge Meeting

72 hours before discharge date

Case Manager approaches the patient regarding their safe transition home, reviews their
progress and offers a general overview of what to expect as they transition from SNF to home

The Case Manager and Social Worker coordinate the logistics of the discharge; DME and
transitional services are arranged

Verify that transport to home has been secured, confirm date and time of transition home

CM issues the Patient Education Handbook to the patient and explains how it will benefit the
patient

CM issues printed handouts related to patient’s needs

CM instructs patient that an appointment with his PCP needs to be made in a one week
Day of Transition
 Each team member will meet with the patient to
review the Patient Education Handbook in relation to
their corresponding area of expertise. Instructional
notes will be made in the book
 CM will review the safe transition instructions with
the patient
Transition Follow-Up
 SS places a call on day 2 or 3 to inquire about PCP
appointments
 SS places a second call on day 7 to 10 to find out if the
appointment was made
 SS places a third call on day 21 to 24 days to find out if
the appointment was kept
 SS places a fourth call on day 31 to find out if the
patient was readmitted to the hospital
Results
 The two months of data showed:
 22 patients had a Post-Discharge Follow-up phone call
on day 2 or 3
 20 patients were connected on day 2 or 3 with a
follow-up phone call
 16 patients reported appointment made on day 2 or 3
phone call.
Results
 The two months of data showed:
– 18 patients reported keeping appointment on day 7 followup phone call
– 17 patients were not readmitted within 30 days of hospital
discharge
Facts
 Research highlights that
– Nearly one-fourth of Medicare beneficiaries discharged
from the hospital to a SNF
– Are readmitted to the hospital within 30 days
– Cost Medicare $4.34 billion in 2006
QUESTIONS
This material was prepared by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization for
Pennsylvania, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of
Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 10SOW-PA-ICPCKD-080513. App. 8/13.