Home -- Indiana Medicare -- Care Transition/Patient Pathways

Care Transition/Patient Pathways

The Care Transitions Program focuses on improving coordination across the continuum of care. In particular, promoting seamless transitions of care for Medicare beneficiaries from the hospital to home, skilled nursing care, or home health care.

Indiana Medicare Quality Improvement Organization (QIO) Activities
Health Care Excel was awarded a contract by the Centers for Medicare & Medicaid Services (CMS) to improve care transitions between health care settings for Medicare patients. Nationally, CMS chose only 14 communities for this exciting and innovating project to reduce the number of hospital re-admissions by coordinating care across health care settings. This project offers the Evansville Hospital Service Area (HSA), which includes Vincennes, Indiana, an opportunity to show its capability to work as a community to improve the quality of care for its residents. Health care providers, patients, caregivers, families, and the community are joining forces to improve coordination of care by promoting seamless transitions from the hospital to home, skilled nursing care, home health care, and other provider settings.

Program Goals

• Eliminate unnecessary hospital readmissions for Medicare patients in the Evansville HSA
• Connect Evansville HSA health care providers to improve communication and information exchange when a Medicare patient leaves the hospital
• Activate partnerships in the community that include senior service organizations, community and business leaders, and families to enable safer, more effective transitions for Medicare patients
• Engage patients, caregivers, and their families to actively participate in their health care, particularly when leaving the hospital

Program Strategies

• Introduce transition coaching to help Medicare patients to self-manage their health care
• Use patient coaching and systems interventions for Medicare patients at the highest risk for hospital re-admission
• Establish individualized plans of care for Medicare patients
• Improve medication reconciliation
• Educate family members, care givers, and business and community organizations about the importance of personal health records

For more information and resources about the 14 QIOs across the nation implementing Care Transitions projects in select communities, go to the Care Transitions Quality Improvement Organization Support Center.

How Can My Organization Participate?

If you are an Indiana health care provider or community support organization in the Evansville Hospital Service Area and are interested in participating, e-mail QIOCareTransition@inqio.sdps.org.

References

Eric Coleman’s Care Transition Intervention
Under the leadership of Dr. Eric Coleman, the Care Transition Intervention was designed in response to the need for a patient-centered, interdisciplinary intervention that addresses continuity of care across multiple settings and practitioners. The overriding goal of the intervention is to improve care transitions by providing patients with tools and support that promote knowledge and self-management of their condition as they move from hospital to home.

The Care Transition Intervention focuses on four conceptual areas, referred to as pillars:

• Medication self-management: Patient is knowledgeable about medications and has a medication management system.
• Use of a dynamic patient-centered record: Patient understands and utilizes the Personal Health Record (PHR) to facilitate communication and ensure continuity of care planning across providers and settings. The patient or informal caregiver manages the PHR.
• Primary Care and Specialist Follow-Up: Patient schedules and completes follow-up visit with the primary care physician or specialist physician and is empowered to be an active participant in these interactions.
• Knowledge of Red Flags: Patient is knowledgeable about indications that their condition is worsening and how to respond.

Project RED: Re-Engineering Discharge
Project Re-Engineered Discharge (RED) is a series of Randomized Controlled Trials at Boston University Medical Center. Each phase of Project RED is aimed at improving patient safety by recreating the process by which patients leave the hospital. Project RED intervention is founded on 11 discrete, mutually reinforcing components and offers a provider toolkit to help facilitate improvement of discharges processes.

Project BOOST: Better Outcomes for Older Adults through Safe Transitions The Society of Hospital Medicine launched Project BOOST to improve care of older patients as they transition from the hospital to home or another care facility. The project uses a team approach to assess patients’ risk for re-hospitalization and plan and execute risk-specific discharge planning activities. This site offers a comprehensive resource room, covering planning, best practices, education resources and clinical tools.

• Literature Review
  Topics covered include patient and caregiver involvement, concerns following discharge, medication reconciliation, handoff communication, re-admission and preparing patients for discharge.
• Process Flow Mapping
  Achieving your quality improvement goals likely require that substantial changes be made to whichever process you target. Although you may assume you understand the gaps between your current process and best practices, formally mapping the process will almost certainly reveal gaps that would otherwise be overlooked. Mapping also will provide your team with a better understanding of the process in general.
• Society of Hospital Medicine Care Transitions Implementation Guide
  This 69-page guide can serve as your workbook to facilitate implementing interventions in your facility. All interventions are adaptable to fit conditions unique to your facility.

The Institute for Healthcare Improvement (IHI)
IHI is an independent not-for-profit organization helping to lead the improvement of health care throughout the world. IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action.

• How-to Guide: Creating the Ideal Transition Home for Patients with Heart Failure
  This How-to Guide builds upon relevant research and published literature, and integrates what Transforming Care at the Bedside (TCAB) hospitals have learned as they strive to improve the quality of care for patients discharged from the hospital to home or to another health care facility.

National Transitions of Care Coalition (NTCC)
The National Transitions of Care Coalition (NTOCC) was formed in 2006 bringing together thought leaders, patient advocates, and health care providers from various care settings dedicated to  improving the quality of care coordination and communication when patients are transferred from one level of care to another.  This site offers information and resources for patients, health care professionals and policy makers.

Heart Failure Society of America
Guidelines for treatment of acute heart failure.

Ask Me 3-National Patient Safety Foundation
Ask Me 3 is an educational program provided by the Partnership for Clear Health Communication at the National Patient Safety Foundation, a coalition of national organizations that are working together to promote awareness and solutions around the issue of low health literacy and its effect on safe care and health outcomes

MedQIC
This Web site supports QIOs and providers in finding, using, and sharing quality improvement resources.