Adam Thompson Regional Partner Director NortheastCaribbean AIDS Education and Training Center South Jersey Regional Partner 1 aidsetcorg Overview Introduction Transitions of Care ID: 691884
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Slide1
Transitional Care: Minding the Gap
Adam Thompson, Regional Partner DirectorNortheast/Caribbean AIDS Education and Training Center – South Jersey Regional Partner
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aidsetc.orgSlide2
Overview
IntroductionTransitions of Care (ToC)Transitions in HIV CareQuestions and Comments
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aidsetc.orgSlide3
Northeast/Caribbean AIDS Education and Training Centers
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The AETC Program
The AIDS Education and Training Center (AETC) Program, a national program of leading HIV experts,
provides
locally based, tailored education and technical assistance to healthcare teams and systems to integrate comprehensive care for those living with or affected by HIV.
The AETC Program
transforms
HIV care by building the capacity to provide accessible, high-quality treatment and services throughout the United States
and its territories.
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aidsetc.orgSlide5
Requisite Steps to Optimal Outcomes
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Mugavero
MJ, Norton WE, Saag
MS. Health care system and policy factors influencing engagement in HIV medical care: piecing together the fragments of a fractured health care delivery system.
Clin
Infect Dis. 2011;52:S238-S246Slide6
HIV Care Continuum
6Centers for Disease Control and Prevention National HIV Surveillance System and Medical Monitoring Project, 2011Slide7
Integration
We can each say, I have done my job well … but collectively we are not doing our job well.
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aidsetc.orgSlide8
Transitions of care:
Hospitals tackle readmissions8
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Hospitals and Transitions
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Transitions and Error
Half of patients experience a medical error after discharge, usually one related to medication continuity, follow-up of test results, or completion of diagnostic work-ups.Approximately 20% of patients suffer an adverse event within 3 weeks of discharge.
Studies have suggested that most errors and adverse events could be prevented or ameliorated through better communication and coordination of care.
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Accessed From:
https
://
psnet.ahrq.gov/perspectives/perspective/52
on May 16, 2017Slide11
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Transitions of Care
Transitions of Care are a range of time limited services and environments that complement primary care and are designed to ensure health care continuity and avoid preventable poor outcomes among at risk populations as they move from one level of care to another, among multiple providers and across settings.
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Dr. Kathleen McCauley, PhD, RN, ACNS-BC, FAAN, FAHA @ NACNS 3.8.12, Chicago, IL Slide13
Transitions of Care
Transitions of Care occur:Within SettingsBetween Settings
Across Health States
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Transitional Care
Transitional Care is a set of actions designed to ensure the coordination and continuity of health care as patients transfer
between different locations or different levels of care within the same location.
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Coleman, E. A. and Boult, C. (2003), Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society, 51: 556–557.Slide15
Complex Health Systems
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Root Causes of Ineffective Transitions
Communication BreakdownsPatient Education BreakdownsAccountability Breakdowns16
The Joint Commission. Transitions of Care: The need for a more effective approach to continuing patient care. Hot Topic in Health Care June 27, 2012 Accessed from: https://www.jointcommission.org/hot_topics_toc/ on May 3, 2017Slide17
Factors that affect readmission
Diagnoses associated with high readmissionsCo-morbiditiesPolypharmacyA history of readmissionsPsychosocial and emotional factors
The lack of a family member, friend or other caregiver who could provide support or assist with care
Older ageFinancial distressDeficient living environment
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The Joint Commission. Transitions of Care: The need for collaboration across entire care continuum. Hot Topic in Health Care, Issue 2; February 19, 2013 Accessed from:
https://www.jointcommission.org/toc.aspx
on May 3, 2017Slide18
Positive Effect on Transitions
Strong leadership support for new transitions processesPositive relationships between the sending and receiving providersInterdisciplinary team involvementHandoffs that involve interpersonal communication (instead of only written or electronic communication)
Medication reconciliation, with the involvement of pharmacists
Two-way patient and family educationElectronic health records (EHRs), as long as they were not relied upon as a sole method of communication.
Assigned accountability for transitions-related tasks and outcomes
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The Joint Commission. Transitions of Care: The need for collaboration across entire care continuum. Hot Topic in Health Care, Issue 2; February 19, 2013 Accessed from:
https://www.jointcommission.org/toc.aspx
on May 3, 2017Slide19
Transitions Best Practices
Screening Process in place to identify patients at higher risk for health care problems that could possibly lead to a readmission after dischargeThe process commonly involves an interdisciplinary team, including a physician (or in some cases, a nurse practitioner), working together to determine what the patient will likely need after he or she leaves the setting.
Formal Assessment to identify the factors for readmission after dischargecase managers and/or discharge planners (who are often registered nurses or social workers) work with physicians and other team members to plan and coordinate the transition to the next setting.
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The Joint Commission. Transitions of Care: The need for collaboration across entire care continuum. Hot Topic in Health Care, Issue 2; February 19, 2013 Accessed from:
https://www.jointcommission.org/toc.aspx
on May 3, 2017Slide20
Key Components of Effective Care Transitions
Perform an initial risk stratification to identify patients at moderate or high risk of readmissionConduct an in-depth patient assessment for the highest-risk patients
Determine the next site of care and assign clear points of contactEngage the right participants, leveraging warm handoffs before discharge
Tailor post-discharge support to patient needs and site of discharge
Connect the patient to the primary care team, ideally via warm handoff
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Tyrell, R. Care Transformation Center Blog. The 6 key components of an effective care transition process. September 7, 2016 Accessed from:
https://www.advisory.com/research/care-transformation-center/care-transformation-center-blog/2016/09/care-transitions-process
on May 3, 2017Slide21
Transitions of care in HIV
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Youth to Adult Transitions
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Corrections to Community
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Linkage Collaboratives
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Transitions for HIV-infected Patients
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Transitions
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How to ensure successful transitions?
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Care Coordination
Care Coordination is the deliberate organization of patient care activities between two or more participants
involved in a patient’s care to facilitate the appropriate delivery of health care services.
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McDonald KM,
Sundaram
V,
Bravata
DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 7—Care Coordination. Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services; June 2007Slide29
Care Coordination
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Reducing Care Fragmentation: A Toolkit for Coordinating
Care
accessed from
http://
improvingchroniccare.org/index.php?p=Care_Coordination&s=326
on May 16, 2017Slide30
Challenges (or Strengths?)
Accountability for the process is shared, which contributes to ambiguity as to who is responsible for
making it work well.Many PCPs no longer have the personal relationships
with consultants and hospitals that make communication easier.
The
added time and effort required to
achieve an
effective referral/consultation or transition
is generally
not reimbursed.
Most
primary care practices do not have
the dedicated
personnel or information
infrastructure to
coordinate care effectively.
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Reducing Care Fragmentation: A Toolkit for Coordinating
Care
accessed from
http://
improvingchroniccare.org/index.php?p=Care_Coordination&s=326
on May 16, 2017Slide31
Defragmenting through Coordination
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Develop a tracking system
Organize a practice team to support patients and families
Identify, develop, and maintain relationships with key stakeholders
Develop formal agreements with key stakeholders
Develop and implement an information transfer system
Decide as a primary care clinic to do care coordination
Reducing Care Fragmentation: A Toolkit for Coordinating
Care
accessed from
http://
improvingchroniccare.org/index.php?p=Care_Coordination&s=326
on May 16, 2017Slide32
Framing Questions
How do we strengthen our medical neighborhoods?What are the factors that can predict poor linkages and how can we identify them before a patient experiences a gap or is lost to care?What balancing measures can we put in place to strengthen
linkages?Who are the stakeholders not in the room?
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