Transitions of Care A Team Based ApproachCare Transformation Collaborative of R.I.DONNA SOARES RN, CDE, CDOE, CVDOENURSE CARE MANAGERUNIVERSITY FAMILY MEDICINE

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Definition of Transitions of Care

•Patient movement from one facility to another•Hospital to home, SNF to home, Hospital to rehab etc.

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Currently in Rhode Island• Realization of high re-admission rates in our state• Many missing pieces in TOC process•eg. Don’t always receive reports from hospitals re: patient updates etc.

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Before we Started•Where do we begin?•What do we want to accomplish?• Assess entire process – admission, pre-

discharge, discharge, accessing medical records• Assess current internal TOC process flow, then

turn to external areas

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What We Did:• Analyzed existing TOC process via process

mapping sessions• Involved entire team in workflow

development and implementation•Made NCM aware of all inpatient admissions• Attempt to streamline TOC reports from

multiple payers and CurrentCare (Direct Alerts)

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What We Did:• Review payer reports – not always reliable• Fine tuned entire process through messaging in

the EHR• Analyzed communication process amongst

team (Secretaries and Medical Assistants) for TOC • Identified and implemented opportunities via

process mapping

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Things to Consider • Patient discharge needs

• Available resources• Health care resources• Community resources• Continuity of care needs• Behavioral health

• All these are handled by hospital d/c planner prior to hospital d/c.

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Patient Example• 41 y/o male with muscular dystrophy fell at home on

3/24/2015. Went to KCMH ER. DX – distal clavicle fracture.

• 83 y/o grandmother is patient’s caretaker. She called our office on 3/25/2015 to schedule follow-up for him here. She was given an appointment for him for 3/30/2015.

• With our process, I was notified of the upcoming appointment before I had notification of ER visit. I contacted patient’s grandmother and was able to facilitate an appointment with orthopedic for 3/27/2015.

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Results:• NCM is not a solo sport• Team involvement is key with the TOC process • PCP needs to be coordinator for TOC• Developed at a glance identification of high risk

patients in EHR • Eliminated much of paper trail

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Results:•Dynamic and fluid process•Smoother TOC for our patients•Efficiencies gained with workflow redesign•Re-evaluate our re-admission rates

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Moving Forward • Seamless TOC for the patient, for practice staff• Improved communication with all players in the state• Foster partnerships with hospital discharge planning staff and NCM • Involve specialists• Ongoing meetings with Healthcentric Advisors – involving representation from all healthcare

arenas (hospitals, SNF’s, home care)• Improved data from payors (timely and actionable)

• Triple Aim • lower healthcare costs, • improved satisfaction / experience of care, • improved care across the population)

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Questions? Thank you!

Resources: http://www.dea.ri.gov/Pocket%20Manual/2014%20Pocket%20Manual-November%205,%202014.pdf

http://www.pcpci.org/

http://www.safetynetmedicalhome.org