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Transitions of Care

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Kate Flynn

on 11 March 2014

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Transcript of Transitions of Care

Improving Transitions of Care
in Southeastern Pennsylvania

SE PA Care Transitions:
Unique Challenges
Health information exchange facilitating transitions of care
Collaborative initiative to reduce
hospital readmissions
About HCIF
Mission: To lead healthcare improvement initiatives by engaging multi-stakeholder resources to implement solutions that no market participant could achieve individually

Vision: Through an engaged, collaborative community, the SE PA region benefits from a high-performing healthcare system demonstrating enhanced measures of safety, quality and effectiveness
Unique role as regional non-profit organization dedicated to quality and safety

Neutral, expert resource trusted by hospitals and health plans

Leadership stature to engage multiple stakeholders
HCIF as Convenor

(c) Eric A. Coleman, MD, MPH

The movement of patients from one health care practitioner or setting to another as their condition and care needs change

What is “Transition of Care”?

Transitions occur at multiple levels
Within Settings
Primary care > Specialty care
ICU > Med/surg unit
Between Settings
Hospital > Sub-acute facility
Ambulatory clinic > Senior center
Hospital > Home
Across health states
Curative care > Hospice
Personal residence > Assisted living

Hospital sends inpatient and
ED discharge information

Use Case #1
Direct Messaging: Discharge Information

HealthShare Exchange of Southeastern
Pennsylvania supports direct routing
and directory requests via the web
as well as automated web services

Health Plan IDs PCP/Care Team,
Routes to Care Manager

Use Case #2 Routing Claims History via Payers

Provider receives data via
EHR or secure email in
support of medication
reconciliation and treatment

Health Plan
Claims Data

Provider requests eligibility and
clinical history from Health Plan

Patient visits Provider
(hospital or practice)

Information returned via PDF or CCD
which can be consumed by EHR
Eligibility Request triggers plan
to request medication history
and claims data

Compact geography and density of hospitals
& physicians – many choices and tertiary referrals

ER as major access point -
9-1-1- calls go to nearest
(not always primary) hospital

Up to 50% of readmitted patients
return to a different facility

Provider (eg PCPs, specialists,
home health) receives info via EHR, email or via health
plan portal

Southeastern Pennsylvania (SEPA)
Regional Enhancements Addressing Disconnects (READS)
in Cardiovascular Health Communication

Preventive Health and Health Services Block Grant through PA Department of Health

October 2010 – June 2015

Partnership with
Forum for multi-organizational collaborative innovation and experimentation
Each group charged to develop at least one strategy or deliverable with potential for significant regional impact
Improving transitions between ED and SNFs
Standardization of ED discharge processes
Early, reliable follow up from ED visit
Addressing needs of frequent ED users
Project Overview
Identify and share best practices for transitions of care to and from EDs
Develop standardized regional approaches and tools to facilitate ED transition processes
Design and Timeline
Increase implementation of best practices across collaborative members
Engage providers and healthcare professionals across the continuum of care, as well as patients and their families, in the transition improvement process
Diverse partners across 5-county Southeastern PA invited to join:
Hospitals and Health Systems
Skilled Nursing Facilities, Long Term Care
Physician’s Offices
Other Community Providers
Newest Partnership for Patient Care initiative
18-month collaborative
Aim to improve care transitions both to and from EDs in the region, with focus on transitions between EDs and community settings (e.g., home, skilled nursing facilities)
Opportunity to develop regional approach to quality in the ED, with impact on safety and efficiency
Towards Safe, High Quality Emergency Department Care Transitions in Southeastern PA
Health care consumer training and
education on Ask Me 3 using a
peer educator model

Outreach and Training
of peer
educators at each participating
senior-serving organization

Consumer education sessions
led by
peer educators for members of their communities

peer educators trained
peers educated
Positive evaluations of sessions

Transforming our Transitions
Transforming our Transitions
JHS = 19%

JHS combined = 19%

Southeastern Pennsylvania’s 580,000
Inpatient Admissions by Healthsystem

What a patient hears . . . .
HCIF Collaborative Project Model

Provider Training
3 train-the-trainer, interactive modules:

Module 1:
Health literacy overview and effective oral communication, including teach-back, plain language

Module 2:
Written material development

Module 3:
Website development and additional topics as requested by partners (e.g., informed consent and wayfinding)
250 health care professionals trained
Positive evaluations of trainings
Increased knowledge and intentions to
change practices as result of training
Session Objectives
To describe the issues related to poorly coordinated care transitions in SE PA
To share innovative collaborative programs and models that have been formed to address care transitions
To discuss the progress of health information exchange in the region
Full transcript