SPECIFIC AIMS

The Same Page Transitional Care Always Event aimed to establish a sustainable patient-centered pro-

cess whereby patients would have the opportunity to utilize an electronic personal health record that: (1) ad-

dresses what matters to the patient, (2) provides actionable information to support health and well-being,

and (3) can be shared across care settings to ensure patients, their family caregivers, and healthcare pro-

viders all are on the same page with regard to the patients’ health and healthcare needs.

Same Page Transitional Care

Creating a Template for Optimal Transitions

Age Group # Patients with Care Partners Utilizing HYH

65-74 72

75-84 76

85+ 45

<65 8

Age unknown 18

Total 219

PHASE 2 FUNDING

Improved Medication Reconciliation and Self Management Support for Diabetic Patients throughout the Discharge Transition (Sanofi)

Utilizing HYH [including new SNF/Outpatient version] with focus on improving health confidence and reducing readmissions among patients with diabetes

PROCESSES FOR VOLUNTEER ENGAGEMENT IN SAME PAGE TRANSITIONAL CARE

Volunteers recruited from community health education groups, targeting retired healthcare professionals

Volunteers attend hospital volunteer orientation and Same Page training with master coach RN

Volunteers bring iPad to patient room, meet patient, and facilitate completion of on-line HYH survey

Post-discharge volunteers do one or more home visits, three or more follow-up phone calls, plus other transitional care strategies

Volunteers meet every Tuesday at hospital to share experiences and address questions or concerns

KEY LESSONS LEARNED

Health Information Technologies (HIT) may require setting-specific design

Introducing new HIT (e.g., HYH, iPads) to older adults is feasible with personnel support

HIT can garner volunteer interest among college-aged/-educated adults, retired health pros

Care Partner programs may be implemented with a focus on caregivers identified by patients

(e.g., family, friends) or with a focus on volunteers

EXTENT OF IMPLEMENTATION 219 patients utilized How’s Your Health 142 patients surveyed while in the care settings and ~3 days after discharge

Key Findings Hospital results are favorable: Patients are more confident (13/13 PAM items) SNF results are mixed: Patients are less confident (5/13 PAM items) Patients who are more confident in being able to manage their health have bet-ter quality of life

SUSTAINABILITY

Implementation of the Same Page Transitional Care process varied across the five sites of care according to local re-

sources and needs. Variations showed that a key attribute for sustainable implementation is the engagement of volun-

teers. Additional funding has been garnered to support Phase 2 of work.

Tools and Resources available at :

www.planetree.org > Resources & Tools

Planetree partnered with colleagues from Dartmouth College, the Case Management Society of America, Longmont United Hospital and

Transitional Care Unit, Wesley Village, Bethel Health Care, and Griffin Hospital on the Same Page initiative

Key Components of Patient-Centered Care

Text and Video Resources to Support Care Partner Programs and use of How’s Your Health

Process

Resources

Individuals

Patient Activation Measure results

Intervention Difference (ID) -Control Difference (CD)

Hospital SNF

Positive ID-CD 13 5

Neutral ID-CD 0 3

Negative ID-CD 0 5

142 Participants 87 Hospital

55 SNF

Average Age 76.9