adapting transitional care programs with person-centered interventions to impact readmission rates...
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ADAPTING TRANSITIONAL CARE PROGRAMS WITH PERSON-CENTERED INTERVENTIONS TO IMPACT READMISSION RATES
June Simmons, MSWPresident and CEO, Partners in Care Foundation
Partners in Care Foundation
Who do we serve?
• Partners serves older adults, adults with disabilities, and medically fragile adults who require in-home supports after hospital discharge or ongoing supports to avoid institutionalization
• We offer tailored, person-centered services to patients with diverse health and psycho-social needs in English, Spanish, and Armenian across the state of California
• Most patients receive managed Medicare
Evidence-Based Transitional Care Services
Partners offers all three interventions at our CCTP* communities.
Care Transitions
Bridge Model
CTI(Coleman Care
Transitions Intervention)
HomeMeds
• In-hospital visit and post-discharge phone calls
• 30 day duration
• In-hospital and in-home visits
• 4 week duration• In-Home
Medication Review & pharmacist intervention
• One-time
*CCTP: CMS-funded Community-based Care Transitions Program
Person-Centered Care
• Partners’ staff consider which of the 3 care transitions interventions, or combination of interventions, is best suited to decreasing the likelihood of readmission for each individual patient.
When selecting an intervention with the patient, we consider the patient’s:• Personal goals• Level of health risk• Social support needs• Cognitive status• Availability of family/caregivers• Neighborhood & local resources• Personal comfort and preferences• Cultural and linguistic characteristics
InterventionsUnique to Bridge
Set up services prior to discharge
Provide discharge preparation information sheet prior to discharge
Call patient within 48 hours of discharge
Make additional calls or schedule visits to resolve identified problems
Use health record to relay information to other providers
Track patients progress and address emerging needs at 30-days post
discharge
Bridge & CTI
Pre-discharge hospital visit
Assess for and address emerging needs post-discharge
Telephone follow-up to ensure adherence to plans
Coordinate with other providers and agencies
Interventions Unique to CTI
Use Personal Health Record (PHR) tool
Conduct one home visit 24-72 hours post-discharge
Actively engage patient in medication reconciliation
Use role-playing and other tools to transfer skills
Perform 3 follow-up phone calls to reinforce coaching , self-
management, sharing PHR
Bridging the Gap
Providing flexible, tailored programming for each patient’s needs means reducing readmission risk
The Bridge Model allows us to serve patients who:• Refuse home visits due to cultural reasons or personal discomfort; • Are cognitively impaired and difficult to coach• Are still too ill to take responsibility for behavior change• Lack caregiver or are otherwise in need of social supports and incapable of making
own arrangements • Are geographically beyond our reach
Across Partners’ 3 CCTP communities, over 9,096 patients were enrolled in the Bridge Model as of 9/30/15.
Increasing Bridge Interventions12/13-9/15
Number of Bridge Cases vs CTI Cases
A UCLA Study on Partners’ Bridge Patients7/14-12/14
9.78% Readmission Rate
For further information contact:• June Simmons, CEO at jsimmons@picf.org• Or check our website: picf.org
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