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Hamster Healthcare
Rates of Rehospitalization within 30 Days after Hospital Discharge
Jencks SF et al. N Engl J Med 2009;360:1418-1428
Chronic Illness Epidemic
Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update
Transitional Care (TC) Defined
Transitional care – range of time limited services and environments 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/or across settings.
The Billion Dollar U-Turn
Quality is Awful!
“The transitional period between sites of care is an especially vulnerable time for
patients, often characterized by conflicting medical advice, medication errors, and a lack of additional treatments that might have been avoided. Care transitions
interventions are designed to target these problems and ease the transition between
sites.”
Dr. Eric Coleman, MD
Transitional Care Programs
Dangers of Discharge
• ¼ of hospitalized patients need further work up
• >1/3 are not done• Missing discharge summary• Family not ready to take patient• Lack of understanding• Hazards in the home• Info transfer is missing
Transitions are Dangerous…
• To…
• From…
• Within…
"If you think that you can run an organization in the next 10 years as
you've run it in the past 10 years you're out of your mind."
CEO, Coca Cola
. . . That Culminated in Complex Legislation March 30,
2010Public Law No. 111-148: Patient Protection and Affordable Care Act: March 23, 2010
Public Law No. 111-152: Health Care and Education Reconciliation Act of 2010: March 30, 2010
REFORM
11
Began Jan. 11, 2010 …. 5 years
Tuscaloosa HRR
Metro Atlanta East
Harlingen HRR
NW Denver
Whatcom County
Evansville
Omaha
Greater Lansing Area
Western PA
SW NJ
Upper Capital Region
Providence RI
Baton Rouge
Miami
14 QIOs with 14 Target Communities
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The Four Pillars of Care Transitions• Medication management• Patient-centered record
(PHR)• Follow-up with
PCP/Specialist• Knowledge of “Red Flags”
or warning signs/symptoms and how to respond – Stoplight Tools
Dr. Eric Coleman
http://www.caretransitions.org/
Transition Coaches
• The ability to shift from doing things for a given patient to encouraging them to do as much as possible for themselves
• Competence in medication review and reconciliation, and
• Experience in activating patients to communicate their needs to a variety of health care professionals.
Acute Care Hospitalization
and ED:The Number
One Target in Healthcare Reform !
The Beers List
Care Transitions Tools: Medication Discrepancy
My Medications are:Medication Dose______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________Allergies: _____________________
Reason Side Effects______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
____________________________________________________________Remember to take this Record with youto all of your doctor visits
PersonalPersonalHealthHealthRecordRecord
The Personal Health Record of:
Josephine Patient
Personal Information:
Address:
Home Phone#:
Birth Date:
Patient ID#
PCP Name:
Advanced Directives?:
Hospitalization Information:
Admitted: _/_/_ Discharged: _/_/_
Reason for Hospitalization:
___________________________________________
Caregiver Information:
Name:
Phone #:
Relation to Patient:
Personal History
Please check any illnesses or health
problems listed below that you have
ever experienced.
Arthritis
Abnormal Heart Rhythm
Cancer
Diabetes
Hardening of the Arteries
Heart Disease
Heart Failure
High Blood Pressure
Hip Fracture
Lung Disease
Medical/Surgical Back conditions
Pneumonia
Stroke
Other: ____________________
After I leave the hospital…
1. I will write down questions I have about my condition.
2. I will take all bottles of medicine I am using to each doctor visit.
3. I will call _________________
immediately at (XXX) XXX-XXX if I experience any of the following:
• Temperature above 101° F
• Uncontrollable pain
• Increased confusion
• Increased redness or d
drainage around wound
• Questions about which
medications to take
Before I leave the hospital…. I have the instructions I need to
keep my health condition from becoming worse.
I know what symptoms to watch out for.
I know the name and phone number of who to call if I see any of these symptoms.
My family or someone close to me knows what I will need once I leave the hospital.
I know what medications to take, how to take them, and possible side effects.
I will schedule a follow up appointment with my primary care doctor.
I will have a clear and complete copy of my discharge instructions.