Patient Engagement for Safe Transitions of Care

Proposal to the Minnesota Hospital Association

Background:

In December of 2012 the Minnesota Alliance for Patient Safety (MAPS) Board of Directors selected three new strategic priority areas for MAPS to significantly impact in the next 3 to 5 years (Appendix A). Improving safety at transitions of care was one of these priority areas. MAPS began work on this priority by convening an exploratory work group comprised of local experts with knowledge of reducing harm at transitions of care. (Appendix B)

This work group concluded that much activity was already underway in the community aimed at addressing specific transitions and harm. The group also concluded that the best way for MAPS to compliment the existing work locally and nationally was to focus on improving the understanding patients, families and consumers have about their role and responsibility for safety at transitions of care. Under this proposal, MAPS would build on the work of its existing work group and use this workgroup as the initial advisory group for the project. MAPS will broaden representation as necessary.

Problem Summary:

One of the most potentially harmful legs of the health care journey remains care transitions – moving from one care setting to another. For example, more than 20% of patients experienced a preventable adverse event within three weeks after discharge from a hospital. (1) Additionally, nearly 20% of all Medicare patients experience a readmission within 30 days of discharge from a hospital, 75% of these are potentially avoidable. (2,13) Care coordination problems overall are estimated to cost $25-45 billion additional health care dollars, annually. (13) The Centers for Medicare and Medicaid Services are seeking to ameliorate this harm and associated costs with their Partnership for Patients initiative and expansion through the LEAPT program.

To understand how a patient engagement effort might reduce harm at transitions of care, the critical elements that lead to unsafe and costly care transitions need to be identified. There are many factors that contribute to potential harm at transitions, but recent literature points to a few particularly problematic and recurrent areas of focus:

Medication reconciliation : Medication changes and discrepancies account for a large portion of harm at transitions of care. Up to 67% of hospital admits experience medication discrepancies, with 33% of these likely to result in moderate harm and 6% likely to result in severe harm. (3,4)

Lack of patient education : Patients with the lowest “activation” scores (activation as defined here means a patient’s ability and willingness to manage his or her own health care) experience higher readmissions, hospital visits and 21% higher costs, according to one local study at Fairview Health Services. (5)

Incomplete communication about test results and follow-up care : Problems with information transfer from one care setting to another abound. Part of this problem is the high frequency of test results that are delivered after discharge – nearly 40%. (6) Additionally, availability of critical information at the time of the first follow-up visit is typically low (12-34%). (7) Discontinuity of care is significantly more likely to result in a readmission or medical error (8).

Certainly these focus areas must be addressed on a provider level, and require high levels of investment, customization and dedicated staff, such as a care transitions interventionists, pharmacists or hospitalists. Evidence indicates that the most

Note: for the purposes of this proposal, the term patient is meant to capture all consumers of health care services including, resident, consumer, family-member, etc.

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successful interventions are bundled approaches, such as Eric Coleman’s Care Transitions trial and Project RED, which are most effectively implemented at the provider/system level.

Because many provider-focused improvements are already underway at local provider organizations and with other local collaborative efforts (i.e. the RARE Campaign), MAPS chose to focus on the patient/consumer, an often-overlooked component in the patient safety problem. (9) Evidence shows that patients who are sufficiently engaged in their care experience better outcomes at lower costs. (5) MAPS holds a dual position in the community as an authority on patient safety and also a liaison to the consumer. This uniquely positions MAPS to implement a broad patient engagement strategy designed to increase activation and education, thereby decreasing readmissions and harm at transitions of care. Successful interventions center on patient maintenance of a simplified health record and discharge plan that routinely includes the following elements: (10,11)

1. Medication reconciliation,2. Communicating test results, 3. Understanding the warning signs that a medical condition is worsening, and4. Completing next steps or follow-up appointments

The work proposed here will focus on how to activate patients so that they can prevent harm at transitions based on these key pieces of information. Doing so would change the expectation of patients and health care organizations, making critical information communication and follow up the norm. Experts have grappled with this problem for years and while there is no silver bullet, MAPS feels strongly that critical components for patient activation have been missing from previous strategies. The research of experts such as Eric Coleman and the National Transitions of Care Collective has gifted the community with consensus around the content of information consumers must understand to minimize adverse events, readmissions, and other potential harm. Thus far, patients remain sporadically engaged and not adequately activated regarding the steps they must take at every transition of care to prevent harm at transitions. MAPS proposes to work with patients to identify a set of simple, universally applicable information to be utilized at every care transition and make the case for “why” patients need to engage for safer care.

Proposed Staff and Support:

MAPS will work with its member organizations, oversee the project and engage local sub contractors to accomplish the work proposed below. For added clarity, the proposed entity responsible for each component of the intervention, evaluation and measurement activities will be specified in brackets “[ ]” after each component.

Primary subcontractors include:

Joe Loveland, LOVELAND COMMUNICATIONS

Loveland Communications provides award-winning marketing, public relations, public affairs, and communications services to organizations intent on changing the world. Loveland communications specializes in strategic social marketing, planning and management, and public affairs oriented public relations. Over the past 25 years, Loveland Communications has helped develop integrated social marketing campaigns to promote nutrition, physical activity, tobacco cessation, child support collection, health insurance coverage, tobacco taxation, secondhand smoke protections, land conservation, savings, low-income tax credits and early education quality. Loveland Communications has served a wide variety of clients, including BlueCross BlueShield of Minnesota’s Center for Prevention, Allina Hospitals and Clinics, United Hospital, St. Paul Heart Clinic, Summit Orthopedics, Children’s Hospital, HealthPartners, Minnesota Council of Health Plans, Society for Cardiovascular Angiography and Interventions (SCAI), Institute for Clinical Systems Improvement (ICSI), Human Services Incorporated, Minneapolis Heart Institute, Hazelden, Clearway, the University of Minnesota School of Public Affairs’ Center for Excellence in Rural Safety, the Minnesota Department of Human Services, the Minnesota Department of Public Health, American Cancer Society, Bike Walk Twin Cities, the Trust for Public Land, eWorkPlace Minnesota, Minnesota Early Learning Foundation, and many others.

Prior to starting Loveland Communications, Joe served as Senior Vice President for Health Care of Weber Shandwick, Social Marketing Director the Minnesota Department of Health, Media Relations Director for Allina Hospitals and Clinics, Communications Director for former Minnesota Attorney General Hubert Humphrey, and Issues and Communications Director for former U.S. Senate Majority Leader Tom Daschle.

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Joe has led teams that have won a SABRE award for Best Social Marketing campaign, PRSA Silver Anvil for Best Integrated Marketing campaign, a Minnesota PRSA award for Best Media Relations and a Minnesota PRSA award for Best Crisis Communications.

A native of South Dakota, Joe earned his bachelor’s degree from South Dakota State University and his master’s degree (Public Affairs) from the University of Texas in Austin.

Cihan Behlivan, KAREOUTCOMES

KareOutcomes is a patient-centered care technology platform. KareOutcomes enables healthcare providers to measure clinical outcomes of treatments and their patients care experiences for better quality of care and transparency. They proactively collect data from patients through an intelligent and proprietary patient follow-up system. KareOutcomes combines different technology solutions to effectively collect data from patients and care staff, with data collection experience ranging from complex clinical outcome questionnaires, patient experience surveys, and AHRQ’s CAHPS surveys. The unique “minimal-burden” process design minimizes data collection/reporting stress on healthcare providers’ administrative and care personnel. KareOutcomes operates only in the healthcare industry. Accordingly, all of its system infrastructure and data collection, reporting and analysis protocols are designed for HIPAA compliance and high security.

Mr. Behlivan is the co-founder and Chief Experience Officer of KareOutcomes. KareOutcomes was founded in 2009 in order to measure, report and analyze clinical outcomes data for medical treatments. Before KareOutcomes; he was part of the founding team of an internet based healthcare IT company, where he served for 6 years. He managed the product development, marketing and customer support functions of the company. He also has three years of corporate finance experience as an investment banker. He led the first technology IPO of Turkey in 2000. He has a BA degree in Business Administration from Marmara University, Istanbul, and an MBA degree from Carlson School of Management, University of Minnesota.

Proposed Intervention:

Objective: The goal of this initiative is to identify effective ways to engage health care consumers in taking a more active and informed role in management of their health care transitions to reduce the potential of harm at care transitions.

Phase I – July 1, 2013 to 12-8-13

The MAPS Intervention will be a 2-phased solution. The first part will be the development of a content piece or tool that patients will use to guide a safe care transition. Current research shows that an average of 70 pages are produced during a single hospital discharge. (12) The tool developed here would be simple and universally applicable for all care transitions. Phase I of this project will consist of determining the ideal content and messaging for this tool, as well as ensuring it is accessible for people in several demographic segments. The purpose of this tool will not be to provide the patient with ALL necessary health care information, rather the critical information that, when unavailable, evidence shows is most likely to result in harm.

Phase I of the project would include the following major tasks aimed at creating effective communications tools for explaining to health care consumers their “to dos” when involved in medical transitions, such as a discharge from a hospital or a post acute setting. These tools will be shared with MHA and national Partnership for Patients Hospitals.

Best Practices Identification. This phase would begin by summarizing expert medical opinion about the most important patient “to-dos” when transitioning their care. Much of this work has already been done by MAPS (Appendix B) and others, but MAPS will hire a consultant to refine and summarize that work. In addition, MAPS will utilize existing patient advisory groups such as the MHA Patient and Family Advisory Group to obtain initial feedback regarding consumer messaging. [MAPS & Loveland Communications]

Key Message Development. A communications consultant will develop key messages around the patient to-dos for medical transitions. Key messages are the brief thoughts that most need to be stressed and repeated to the target audience in order for them to be persuaded to change their attitudes and behavior. In this case, the key

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messages would be the messages most likely to persuade patients to do the things necessary to stay safe during medical transitions. [Loveland Communications]

Consumer Education Tactic Development. A communications consultant would then partner with an ad copywriter and graphic designer to capture the patient to-do key messages in a few public relations tactics, such as 1) a “one pager,” 2) a patient wallet card; 3) a print advertisement; and 4) a radio script. These sample marketing tactics would be designed to persuade patients to do what is necessary to stay safe during medical transitions. [Loveland Communications]

Consumer Market Research Validation. These tactics would then be shown to five small groups of patients of various ages, races, ethnicities and backgrounds. We would partner with Loveland Communications and the market research firm Galligan & Associates and 20/20 Research. We will recruit a statewide panel of 100 respondents to participate in a 10-day session to gather input about how respondents think about medical transitions, their input on the materials we develop, and their input on revisions to the materials we make as a result of their input. We would work with our partners to recruit the respondents, plan and review a research, design the screening questionnaire and discussion guide, moderate four bulletin board communities (minimum of 4 hours/day), develop a topline summary for purposes of refining or eliminating concepts mid-project, and develop a final summary analysis. The goal of this qualitative research would be to determine whether patients a) understand the draft materials, b) find the materials persuasive and c) have any suggestions for improving the materials. [Loveland Communications]

Consumer Education Tactic Refinement. The draft tactics would then be refined based on the marketing research. [Loveland Communications]

Phase II – December 9, 2013 to December 8, 2014

The second part will be the relevancy campaign, where MAPS will seek to educate consumers on why it is important to play an active role in his or health care.

Phase II of the project would focus on piloting the use of the materials in Minnesota hospitals and measuring their effectiveness. Major tasks in Phase II would include the following:

Prioritize Tactics. Based on consumer feedback in Phase I, tactics would be prioritized according to likelihood of reaching and effectively educating consumers about their to-dos in medical transitions. [MAPS & Loveland Communications]

Develop Campaign Education Plan. Based on this prioritization, MAPS will develop a media education plan for delivering messages to consumers. In addition to materials provided directly to patients, the plan may also include print, radio, and Internet advertising [Loveland Communications]

Production of Materials. Materials developed in Phase I would be produced for use in Phase II. Both print and electronic tools will be produced. [Loveland Communications]

Electronic Communication Platform Setup [KareOutcomes]o Process Design Support

Patient Interactivity Design & Setup, including: Email – Text – Reminders Website for general information Patient Specific Web Access

Mass Distribution of Materials. The materials developed in Phase I would be distributed to Minnesota consumers, as identified in the aforementioned Campaign Education Plan. [Loveland Communications]

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Final Report. Qualitative and quantitative learnings from the campaign would be captured in a final report, to ensure that the learnings are available to state and national peer organizations who could benefit from them. [Loveland Communications]

Evaluation & Measurement:

MAPS will provide MHA a monthly summary of activity and monthly data once evaluations begin.

Phase I outcomes will be the development and completion of a consumer directed, and validated transitions communications tool as well as the evaluation setup, questionnaire development, and hospital recruitment.

In phase II MAPS will track distribution of the tool and, ideally, will evaluate the tool in 1-2 care settings for utilization and patient activation resulting from use of the transitions tool. Major tasks in Evaluation and Measurement include the following (& will take place in Phase II unless otherwise noted below):

Recruitment and pilot testing. For Phase II MAPS will recruit 1-2 care settings for testing the tool with patients in transitions of care. The testing will include patient surveys and care will be taken to minimize the burden on both the patients and care setting staff when collecting this information. The surveys will gauge changes in patient awareness, attitudes and behaviors related to their role in self-managing medical transitions. (Recruitment, Phase I [MAPS]) If care settings cannot be recruited, more robust distribution tracking will be implemented to understand utilization and use of the tool.

Utilization and Patient Reported Outcomes Measures [KareOutcomes] Measure Design & Selection (Phase I) Template Creation (Phase I) Setup data collection methods such as:

Email with Smart Links Paper by Mail Web Based Data Capture

Data Processing & Reporting [KareOutcomes] Data Processing Reporting Analysis & Distribution

Patient Help Line and Customer Support [KareOutcomes] Respond patient questions about safe transitions Modify communication tools among patients, care providers and family members based on

feedback received 24/7 Personalized Support for questions regarding surveys

Overall Project Management: MAPS would provide overall financial, logistical and administrative oversight and management of the project.

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Communications Leadership and Management. Campaign development project management, message development, market research management, campaign materials development management, campaign manager, final report writer. [Loveland Communications]

Market Research Design, Execution and Analysis [Loveland Communications]

Production of Electronic Platform: Web development - Initial Platform Design & Setup [KareOutcomes]

Evaluation: Data collection, reporting & support based on a 2 care setting pilot [KareOutcomes]

Public Awareness Campaign Production and Placement [Loveland Communications]

The awareness campaign will depend on the nature of consumer feedback we receive in Phase I. For instance, we may find in our research that patients need to repeatedly be exposed to compelling “why” messaging -- messages explaining why these to-dos are worth the extra effort – before they will be receptive to “what” messages – messages that explain specifically what steps patients need to take during medical transitions. In response to that consumer feedback, we may want an awareness plan that initially invests in repeatedly delivering such “why” messages in long-format media, such as targeted commercial radio ads or online ads driving consumers to a brief video heavily focused on “why” messages.

On the other hand, we may find in our qualitative research that most consumers already understand the “why” rationale for the medical transition to-dos, but primarily need “what” message reminders. In that case, it would make more strategic sense to invest in things like distribution of wallet cards, refrigerator magnets, provider and pharmacist flyers, postcard reminders, and/or targeted online ads giving to-do reminders.

Similarly, patients may tell us that they would be more likely to use Tactic X, Y and Z than Tactic A, B and C, so we would want the awareness campaign to reflect that feedback.

SOURCES

1) Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The Incidence and severity of adverse events affecting patients after discharge from hospital. Ann Intern Med. 2003.

2) Stephen F. Jencks, M.D., M.P.H., Mark V. Williams, M.D., Eric A. Coleman, M.D., M.P.H. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009;360:1418-28.

3) Cornish PL, Knowles SR, Marchesano R, Tam V, Shadowitz S, Juurlink DN, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165:424-9. [PMID: 15738372]

4) Wong JD, Bajcar JM, Wong GG, Alibhai SM, Huh JH, Cesta A, et al. Medication reconciliation at hospital discharge: evaluating discrepancies. Ann Pharmacother. 2008;42:1373-9. [PMID: 18780806]

5) Health Policy Brief Patient Engagement. HealthAffairs. February 14, 2013.

6) Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143:121-128. JAMA, February 28, 2007—Vol 297, No. 8

7) Sunil Kripalani, MD, MSc, Frank LeFevre, MD, Christopher O. Phillips, MD, MPH, Mark V. Williams, MD, Preetha Basaviah, MD, David W. Baker, MD, MPH. Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care.

8) Carlton Moore, MD, Juan Wisnivesky, MD, Stephen Williams, MD, and Thomas McGinn, MD. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003 August; 18(8): 646–651.

9) Maria Koutantji, Rachel Davis, Charles Vincent, and Angela Coulter. The patient's role in patient safety: engaging patients, their representatives, and health professionals Clinical Risk May 1, 2005 11: 99-104

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10) Rachel E. Davis MSc, Rosamond Jacklin MRCS, Nick Sevdalis PhD, Charles A. Vincent PhD . Patient involvement in patient safety: what factors influence patient participation and engagement? Health Expectations Volume 10, Issue 3, pages 259–267, September 2007.

11) Eric A. Coleman, MD, MPH, Jodi D. Smith, ND, GNP, Janet C. Frank, DrPH, Sung-Joon Min, AM, Carla Parry, PhD, MSW,and Andrew M. Kramer, MD. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. JAGS 52:1817–1825, 2004.

12) Hanson, Candy RN, Julie Jacobs MS, RN. StratisHealth HIT PAC (Health Information Technology – Post Acute Care) Environmental Scan. January 2013

13) Health Policy Brief: Reducing Waste in Health Care. Health Affairs. December 13, 2012.

*This proposal was more generally informed by the results of AHRQ Making Health Care Safer II and by Roni Caryn Rabin’s “Health Care’s Dirty Little Secret: No One May be Coordinating Care”

APPENDIX A: Contractor Information – MAPS

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Company Name: Minnesota Alliance for Patient Safety (MAPS)Company Website: www.mnpatientsafety.org

Minnesota Alliance for Patient Safety was established in 2000 by current strategic partners, Minnesota Department of Health, Minnesota Medical Association and Minnesota Hospital Association, as a response to the 1999 Institute of Medicine Report, "To Err is Human."

In an effort to achieve the "Safest Care Possible" MAPS engaged a broad-based stakeholder coalition including providers, associations, regulators, purchasers, consumers, academia, and insurers. Between 2000 and 2010 MAPS addressed safety concerns through multiple avenues and strategies; MAPS transformed the Informed Consent form to be more consumer-friendly and available in many languages. In 2001, MAPS met with legislators to advocate for changes in the Minnesota Peer Review Statute, which paved the way for the groundbreaking and first of its kind Minnesota Adverse Health Care Event Reporting Act. Medication Safety was another important focus for MAPS - in 2006, MAPS developed the My Medicine List, an easy-to-use medication reconciliation form for consumers. MAPS also led the industry in key patient safety topics, such as pressure ulcers, retained foreign objects, consumer literacy, safe surgery verification, falls prevention, infection reporting and rapid response efforts.

Finally, MAPS realized that for the important system-wide improvement efforts to be sustainable a complimentary culture of safety would need to be developed. MAPS realized the galvanizing force behind the success of all patient safety efforts is the simultaneous cultivation of a supporting cultural infrastructure. Accordingly, MAPS led the way in developing the framework for a "just" culture, whereby health care workers are both held accountable for errors, but also encouraged to report errors without fear of retribution. MAPS has since worked with many providers and facilities to implement this important work and in 2006 received the John M Eisenberg Patient Safety and Quality Award for Innovation. MAPS built upon this work with the creation of the Culture Road Map, a compendium of best practices that makes it possible for all organizations to access the tools that lead to a culture of safety.

In an effort to both continue its first decade efforts and also expand these efforts to all care settings, MAPS became an incorporated organization with a Board of Directors, five Strategic Partners and dedicated staff in 2012. In its second decade MAPS will refine previous efforts and embark on new initiatives to achieve "Safe Care Everywhere." In July 2012, MAPS Board of Directors developed a strategic plan to guide the focus and efforts and MAPS. In December 2012, 6 priority initiatives were chosen to advance the overall strategy. Both documents, MAPS Strategy Mountain and MAPS Priority Initiatives, are included below.

APPENDIX A: Contractor Information – MAPS

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APPENDIX B: Contractor (MAPS) Initial Work on Safe Transitions of Care

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Transitions of Care Exploratory Work Group Roster & Work Product (SAFE Transitions)

This group of experts convened 3 times in 2013 and produced a DRAFT patient engagement piece (on following page), which will be used to inform LEAPT work.

Patti Cullen President and CEO

Care Providers of MN

Susan FlanniganConsumer Member

Tania Daniels VP of Patient Safety

Minnesota Hospital Association

Kathy CummingsProject Manager

Institute for Clinical Systems Improvement

Steve Fredrickson Consumer Member

Jessica Flurry Patient Safety Analyst

Park Nicollet Health Services

Katie Bear-Pfaffendorf Patient Safety/Quality Specialist Minnesota Hospital Association

Dr. Paul Sanders Corporate Medical Director Benedictine Health Systems

Rachel Jokela Adverse Health Events Program

Director Minnesota Department of Health

Karen McDonald Board Chair

Minnesota Organization of Leaders in Nursing

Janelle ShearerProgram Manager

StratisHealth

APPENDIX B: Contractor (MAPS) Initial Work on Safe Transitions of Care

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SAFE ACTIONS FOR EVERY TRANSITION OF CARE*DRAFT

Sort through ALL medications. If you have been prescribed a new medication or a new dose of your old medicine make sure you know what it does and any possible side effects. Make sure there are no bad reactions with your existing medications

All test results have been communicated to you and to the doctors, nurses and others taking care of you. If you have had a procedure, an x-ray, or had samples analyzed by a laboratory, do not assume that “no news is good news” and the results have gotten to you others helping take care of you. Always check and ask if you have any questions. Take copies of the results with you to appointments.

Follow up with any appointments, prescriptions or tests that you have been told that you need. If you have any questions about whom, when or where you need to go next, make sure and ask. Know what the tests are and what the results mean.

Early warning signs are very important if something is going wrong. Make sure you know the possible side effects of any medicines, or any symptoms that may suggest you are getting worse from the condition that you have. Know what to do if you have any of these early warning signs.

Transitions include, but are not limited to:o Leaving the hospital and going home, or to a nursing home or getting home care,o Going from a nursing home or rehab center to home, with our without home care,o Going from a nursing home to the hospital o Any referral or change of care from one doctor to another o Going to the pharmacy to get a new or changed prescription

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