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1Relative patient benefits of a hospital-PCMH collaboration within an ACO toimprove care transitionsAnuj K. Dalal, MD, FHM...
2Disclosures• None
About the Principal Investigator3Dr. Jeffrey L Schnipper
4Goals of this Talk• To describe the design of the newly funded PCORIstudy:– “Relative patient benefits of a hospital-PCMH...
Description of study design5
6Specific Aims• Aim 1: To develop, implement, and refine a multi-faceted,multi-disciplinary transitions intervention withc...
7Rationale• Partners is increasingly focused on improving value forpatients and is now a “Pioneer Accountable CareOrganiza...
8Conceptual Model: Ideal Transition in CareBurke, Kripilani, Vasilevskis, and Schnipper. JHM 2013.
Our PCORI Proposal9In the era of ACOs, can hospitals andPCMHs collaborate to fortify this bridge?
10InterventionBurke, Kripilani, Vasilevskis, and Schnipper. JHM 2013.DischargeplanofcareInptandouptpharmacistmedrecWeb-bas...
11Intervention: Main Components• Hospital– Inpatient medication safety interventions*– Inpatient “discharge advocate” (DA)...
12Methods• Patients– 1800 patients admitted to BWH or MGH– Affiliated with 50 Partners’ primary care practices “primed” to...
13Methods• Mixed Methods– Evaluate facilitators of and barriers to implementation viaprovider surveys and focus groups– It...
Stakeholder Engagement14Step in CER Process Purpose of Patient Engagement Method(s) of EngagementTopic Solicitation Is thi...
A detailed description of selectedintervention components15
16General Description• Goals:• Standardization of function– Each unit, service, hospital, and practice may do thingsdiffer...
17Inpatient Discharge Advocate• Goals:– Point person for patient, family, post-discharge providers– Coordinate discharge p...
18Responsible Outpatient Clinician (ROC)/Patient Coach• Goals:– Serve as a bridge between inpatient stay and outpatientcli...
19ROC/ Patient Coach Activities• While patient is still in the hospital:– Ask patient about most important goals for recov...
20ROC/ Patient Coach Activities (continued)• During post-discharge clinic visit:– Review patient’s goals for the recovery ...
21ROC/ Patient Coach Activities (continued)• Make 3 phone calls during the month after discharge– Perform coaching activit...
22Outpatient Pharmacist• Goals:– Ensure patient is discharged on the correct medicationregimen, understands that regimen, ...
Potential implications – what will we learn?23
24Early Experience with Study• ACO leadership is supportive– Believe it is the right thing to do– Believe it will require ...
25Early Experience with Study• Patient and caregiver engagement– Changes dynamic of steering committee meetings– What comp...
Discussion• Implications for communities– Should communities be embracing the move towardsconsolidation, ACOs, PCMHs?– Wha...
Thank You!• Questions? Comments?• Special thanks to our PCORI team:– Nyryan Nolido, MA– Gwen Crevensten, MD– Eric Weil, MD...
Additional Info• The remaining slides provide additional information about theintervention components and study design28
29Inpatient Medication Safety Intervention• Goals:– Ensure accurate medication reconciliation• In-depth med rec at admissi...
30Other Inpatient Care Providers• Goal: Standardize and distribute work• Primary nurse:– Talk with ROC, learn about patien...
31Partners Healthcare at Home (PHH)• Goals:– Assess patient’s home situation, current services, and levelof support– Ensur...
32Other Outpatient Providers: PCP• Goals:– Evaluate status of active medical problems compared withdischarge and post-disc...
33Interventions for High-Risk Patients• Home visits by patient coach• Telemedicine programs:– CHF: weights– Diabetes: POC ...
34Advance Care Planning• Automatic trigger tool for inpatient palliative careconsultation• Structured consultation regardi...
35Information Technology• Web-based discharge ordering module (BWH)• Automated system to alert providers of results of tes...
Analysis• Quantitative– Primary Outcome: Adverse events within 30 days of discharge• Logistic regression adjusted for stud...
Analysis• Qualitative– Grounded theory method• Analyze focus groups and interviews re: barriers andfacilitators of impleme...
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Weitzman 2013 Relative patient benefits of a hospital-PCMH collaboration within an ACO to improve care transitions.

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Anuj K Dalal presents information on a PCORI research grant: Relative patient benefits of a hospital-PCMH collaboration within an ACO to improve care transitions.

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  • Think of the 10 domains of an ideal transition as structural supports of the ‘‘bridge’’ patients must cross from one care environment to another during a care transition. Those domains that mainly take place prior to discharge are closer to the ‘‘hospital side’’ of the bridge, those that mainly take place after discharge are closer to the ‘‘community side’’ of the bridge, while those that take place both prior to and after discharge are in the middle. Lack of a domain makes the bridge weaker and more prone to gaps in care and poor outcomes. The more that is missing, the less safe the bridge is. In the worst case, the patient then falls off the bridge and must make it back either to the community or more realistically, the hospital -> readmissions.
  • Some intervention components are adequately resourced, just need standardization: VNA visit Inpatient DA Some components are in place but need a better payment mechanism: Telemedicine programs through Center for Connected Health Some components are being worked on through existing projects: Palliative Care IT: TPADs, video conferencing, mobile technologies Some components are frankly under-resourced, and we ’re using the grant as a way to get these resources: Inpatient pharmacists to do medication safety interventions Nurse ROC/Patient Coach Outpatient pharmacists
  • Communicate with patient/family re: discharge planning Confirm patient can get to follow-up appointments Give patient/family realistic expectations of date/time of discharge Coordinate communication among clinicians for timely decision-making and handoffs in care Fax discharge documents to relevant out of network specialists Inform inpatient pharmacists regarding patient ’ s needs, estimated discharge date Enter all providers into Partners Enterprise Patient List application, initiate group emails Identify, communicate, and make plans to resolve barriers to patients/caregivers being able to carry out the post-discharge plan Perform safety checklist Adequate post-discharge monitoring is in place Resident ’s discharge documentation is adequate Timing of follow-up is adequate Point person in case patient, family, or post-discharge providers have questions about the hospitalization
  • While patient is still in the hospital Ask patient about most important goals for recovery period Discuss reasons for and importance of keeping follow-up appointments Remind patient to bring discharge instructions, personal medical record, follow-up calendar, medication list, pill bottles Review use of personal medical record Discuss barriers to keeping post-discharge appointments and explore ways to overcome them Use teach-back to confirm understanding During post-discharge clinic visit Review patient ’s goals for the recovery period, discuss how best to meet them Review discharge summary, patient instructions, follow-up appointment calendar, patient ’s PMR, VNA notes Review test results finalized since discharge Begin patient coaching How to monitor medical conditions at home How to manage behavioral changes Danger signs to watch for How to use medical system How to keep a personal medical record
  • Confirm medication reconciliation done correctly in the hospital and at discharge, update EMR Identify and resolve discrepancies between discharge regimen and what patient thinks s/he should be taking Answer questions about medications Ensure patient has filled prescriptions and knows how to obtain refills Assess adherence with medications, address as needed Identify and manage possible medication side-effects Contact inpatient team as needed Communicate with PCP, make changes to medications as needed Provide patient coaching Work with patient/caregiver on strategies to maximize medication adherence, how to identify medication red flags, what to do if problems arise Document findings in the EMR
  • How does it feel? To be called “high risk” Too overwhelming Shameful Invasive (privacy) Or Empowering Like someone cares Easy to navigate User friendly
  • Activities tailored to patient ’s needs In-depth medication reconciliation at admission and discharge Patient/caregiver education re: medication changes, reasons for changes, potential side effects, etc. Communication with post-discharge providers by email re: discharge medication regimen, reasons for changes, establishing a point of contact
  • Evaluate ability of patient to function at home with current level of support and services Evaluate and address ability of patient/caregiver to perform necessary self-care activities Take medications Perform other treatments (e.g., wound care) Modify health-related behaviors (e.g., diet) Manage follow-up appointments Assist with above activities as needed Teach patients/caregivers to perform these activities until they are independent or the activities are no longer needed Document all findings in templated note in EMR Communicate with inpatient attendings by email (and cc PCP and NP) re: questions with discharge plan, status at time of discharge, etc. Communicate with outpatient providers (PCP, NP, specialists) regarding plan of care
  • Transcript of "Weitzman 2013 Relative patient benefits of a hospital-PCMH collaboration within an ACO to improve care transitions."

    1. 1. 1Relative patient benefits of a hospital-PCMH collaboration within an ACO toimprove care transitionsAnuj K. Dalal, MD, FHMAnuj K. Dalal, MD, FHMBWH Hospitalist ServiceBWH Hospitalist ServiceAssociate Physician, Division of General Medicine,Associate Physician, Division of General Medicine,Brigham and WomenBrigham and Women’s Hospital’s HospitalInstructor, Harvard Medical SchoolInstructor, Harvard Medical SchoolCo-InvestigatorCo-Investigator
    2. 2. 2Disclosures• None
    3. 3. About the Principal Investigator3Dr. Jeffrey L Schnipper
    4. 4. 4Goals of this Talk• To describe the design of the newly funded PCORIstudy:– “Relative patient benefits of a hospital-PCMHcollaboration within an ACO to improve caretransitions”• To review the several components of the intervention• To discuss early experience and potential implicationsfor communities
    5. 5. Description of study design5
    6. 6. 6Specific Aims• Aim 1: To develop, implement, and refine a multi-faceted,multi-disciplinary transitions intervention withcontributions from hospital and primary care personnelacross several PCMHs within the Partners HealthcarePioneer ACO.• Aim 2: To evaluate the effects of this intervention on post-discharge adverse events, functional status, patientsatisfaction, and emergency department and hospitalutilization within 30 days of discharge.• Aim 3: To understand barriers to and facilitators ofsuccessful implementation of this intervention acrosspractices
    7. 7. 7Rationale• Partners is increasingly focused on improving value forpatients and is now a “Pioneer Accountable CareOrganization (ACO)”– Partners hospitals have several financial incentives to reduce 30-dayreadmissions– As part of the ACO effort, most primary care practices will soonbecome Patient-Centered Medical Homes (PCMH)– In theory, both Partners hospitals and primary care practices willhave a vested interest in preventing readmissions• An ideal transition requires efforts of inpatient andoutpatient personnel– BUT, there are limits to how much can be provided by the hospitalsalone without participation and complete buy-in of primary carepractices
    8. 8. 8Conceptual Model: Ideal Transition in CareBurke, Kripilani, Vasilevskis, and Schnipper. JHM 2013.
    9. 9. Our PCORI Proposal9In the era of ACOs, can hospitals andPCMHs collaborate to fortify this bridge?
    10. 10. 10InterventionBurke, Kripilani, Vasilevskis, and Schnipper. JHM 2013.DischargeplanofcareInptandouptpharmacistmedrecWeb-baseddischargemoduleAutomatednotificationofTPADsFocusededucationandteachbackEngagecaregiversandcommunityservicesAutomatedtriggerofpalliativecareconsultEMR,careteamidentification,videoconfVNAassessment;disease-specificmonitorTimelypost-dischargef/u
    11. 11. 11Intervention: Main Components• Hospital– Inpatient medication safety interventions*– Inpatient “discharge advocate” (DA)• Primary Care Practices (PCMHs)– Nurse “Responsible Outpatient Clinician” (ROC)/Patient Coach*– Multi-disciplinary post-discharge clinic visit: ROC*/pharmacist*/PCP• Both Hospital and PCMH– Interventions for high-risk patients (e.g., telemedicine)†– Advance care planning‡– Information technology (e.g., video-conferencing, pending tests)‡• Other– Visiting nurse intervention†Available, but requires a better payment mechanism‡Being worked on as part of an existing project*Require additional personnel, currently under-resourced
    12. 12. 12Methods• Patients– 1800 patients admitted to BWH or MGH– Affiliated with 50 Partners’ primary care practices “primed” tobecome PCMHs• Study Design: “Stepped Wedge”– Randomize order in which each practice implements theintervention (once achieve “primed” status)• Outcomes Assessment: 30 days post-discharge by phoneinterview and medical record review:– Adverse events– Patient satisfaction and functional status– Health care utilization (e.g., ED visits, readmissions, etc.)– Preventability of readmission via 360-degree review(patient/family, inpatient attendings, PCP)
    13. 13. 13Methods• Mixed Methods– Evaluate facilitators of and barriers to implementation viaprovider surveys and focus groups– Iteratively refine intervention components• Subgroup Analyses– Who benefits the most? (e.g., elderly, low health literacy,etc.)• Engage Patient and Caregiver Stakeholders– Patient and family advisory council– Patient/family representation on study steering committee
    14. 14. Stakeholder Engagement14Step in CER Process Purpose of Patient Engagement Method(s) of EngagementTopic Solicitation Is this an important topic? • Patient and Family Advisory CouncilFraming the Question Is the specific research question important? • Patient and Family Advisory CouncilCreation of ConceptualFrameworkIs the proposed conceptual framework compatible withpatient/caregiver experience? Is there anythingmissing?• Patient/Caregiver representation on Steering CommitteeSelection of comparatorsand outcomesHow do we design this intervention such that it is truly"user-friendly" to patients and their caregivers?• Patient and Family Advisory Council Meetings, emails andconference calls as needed.• Patient/Caregiver representation on Steering CommitteeWhat post-discharge outcomes do you care about most? • Patient and Family Advisory Council Meetings, emails andconference calls as needed, with participation of researchstaff*• Patient/Caregiver representation on Steering CommitteeData Collection Is this survey process appropriate? Are the proposedquestions clear and meaningful?• Patient and Family Advisory Council Meetings, pilot testing ofresearch questions, emails and conference calls as needed, withparticipation of research staffAnalysis Plan Are we enrolling the correct patient population? Havewe identified appropriate patient subgroups?•Patient and Family Advisory Council Meetings, with participationof research staff•Patient/Caregiver representation on Steering CommitteeReviewing and interpretingresultsHow is the study progressing?Are the results of the study believable?• Patient/Caregiver representation on Steering CommitteeTranslation How do we best explain the results to other patientsand the public?• Patient and Family Advisory Council Meetings• Patient/Caregiver representation on Steering CommitteeDissemination How do we best engage other patients when wedisseminate the findings?• Patient and Family Advisory Council Meetings• Patient/Caregiver representation on Steering CommitteeMullins, C. D., et al. (2012). JAMA 307(15): 1587-1588
    15. 15. A detailed description of selectedintervention components15
    16. 16. 16General Description• Goals:• Standardization of function– Each unit, service, hospital, and practice may do thingsdifferently, and with different personnel– But hopefully, all achieving the same ends• Liberal use of checklists to ensure activities are completed• Reduction in redundancy in tasks, except where necessary• Process redesign and standardization may result in greaterefficiency, but additional personnel still needed– Some of these tasks have never been adequately resourced,rarely performed
    17. 17. 17Inpatient Discharge Advocate• Goals:– Point person for patient, family, post-discharge providers– Coordinate discharge plan with the patient, caregivers,hospital team, and outpatient team• Communicate and manage expectations with patient/family re:discharge plan, follow-up appointments• Coordinate communication among clinicians for timelydecision-making and handoffs in care (e.g., fax dischargedocuments, facilitate care team emails)– Educate and prepare patient and caregivers for discharge• Resolve barriers to executing post-discharge plan (e.g., fillingprescriptions, transportation)• Perform safety checklist (e.g., adequate monitoring, dischargedocumentation, follow-up)
    18. 18. 18Responsible Outpatient Clinician (ROC)/Patient Coach• Goals:– Serve as a bridge between inpatient stay and outpatientclinic– Modify post-discharge plan as needed– Coach patients and caregivers so that they are best ableto carry out the post-discharge plan
    19. 19. 19ROC/ Patient Coach Activities• While patient is still in the hospital:– Ask patient about most important goals for recovery period– Discuss reasons for and importance of keeping follow-upappointments– Remind patient to bring discharge instructions, personalmedical record, follow-up calendar, medication list, pillbottles– Review use of personal medical record– Discuss barriers to keeping post-discharge appointmentsand explore ways to overcome them– Use teach-back to confirm understanding
    20. 20. 20ROC/ Patient Coach Activities (continued)• During post-discharge clinic visit:– Review patient’s goals for the recovery period, discuss howbest to meet them– Review discharge summary, patient instructions, follow-upappointment calendar, patient’s PMR, VNA notes– Review test results finalized since discharge– Begin patient coaching• How to monitor medical conditions at home• How to manage behavioral changes• Danger signs to watch for• How to use medical devices (e.g., glucose monitor)• How to keep a personal medical record
    21. 21. 21ROC/ Patient Coach Activities (continued)• Make 3 phone calls during the month after discharge– Perform coaching activities as above• For high-risk patients, conduct home visits– Evaluate patient/caregiver’s ability to carry out plan at home– Perform coaching activities as above• For all activities– Use role-playing and teach-back as needed– Contact inpatient providers as needed– Identify barriers to self-management and explore ways toovercome barriers with patient, caregiver, and PCP– Communicate with PCP, makes plans/arrange follow-up asneeded– Document findings in the EMR
    22. 22. 22Outpatient Pharmacist• Goals:– Ensure patient is discharged on the correct medicationregimen, understands that regimen, and is adherent with thatregimen• Confirm med rec done correctly, update EMR• Identify and resolve discrepancies between discharge regimen andwhat patient thinks s/he should be taking– Screen for barriers to adherence, early side-effects, andaddress as needed– Coach patient/caregiver regarding issues of medicationsafety• Work on strategies to maximize med adherence• Identify medication red flags,• Provide contingencies when problems arise
    23. 23. Potential implications – what will we learn?23
    24. 24. 24Early Experience with Study• ACO leadership is supportive– Believe it is the right thing to do– Believe it will require additional resources– Willing to work together across traditional silos– Are they willing to open their pockets?• Everyone feels financially constrained• ROI is a leap of faith• Incentives are still not completely aligned
    25. 25. 25Early Experience with Study• Patient and caregiver engagement– Changes dynamic of steering committee meetings– What components of the intervention do they reallycare about?– How does it feel to receive this intervention?– What outcomes do they care about?– Does an adverse event mean to same thing to patientsas they do to clinicians?
    26. 26. Discussion• Implications for communities– Should communities be embracing the move towardsconsolidation, ACOs, PCMHs?– What are the cons?• Might mean less choice of providers, might feel more“corporate”, might mean less time with MDs and moretime with other providers, etc.– What are the pros?• Might mean better coordination of care, better access todata, different ways to provide care outside a visit, moreproactive care– Does the answer depend on who you are?26
    27. 27. Thank You!• Questions? Comments?• Special thanks to our PCORI team:– Nyryan Nolido, MA– Gwen Crevensten, MD– Eric Weil, MD– Cherlie Magny-Normilus, NP– Asaf Bitton, MD, MPH– Maureen Fagan, DNP, MHA– David Bates, MD, MSc– Lipika Samal, MD, MPH– Stephanie Labonville, Pharm D– Joe Frolkis, MD– Namita Mohta, MD– Jackie Somerville, RN, PhD27
    28. 28. Additional Info• The remaining slides provide additional information about theintervention components and study design28
    29. 29. 29Inpatient Medication Safety Intervention• Goals:– Ensure accurate medication reconciliation• In-depth med rec at admission and discharge• Communication with post-discharge providers re: dischargemedication regimen, reasons for changes, etc.– Educate patients/caregivers about the dischargemedication regimen• Help understand discharge regimen (indications, specialinstructions, how and why different from before)– Prepare patients/caregivers to take medications safelyand correctly after discharge• Minimize adverse drug events
    30. 30. 30Other Inpatient Care Providers• Goal: Standardize and distribute work• Primary nurse:– Talk with ROC, learn about patient, communicate– Document discharge patient instructions• Behavioral changes, final discharge plan, red flags, dischargestatus– Educate patient and family• Identify active learner, review instructions, use teach-back– Give patient personal medical record to use• Unit coordinator:– Schedule follow-up appointments based on time-frame,patient/caregiver and provider availability– Give patient calendar of follow-up appointments
    31. 31. 31Partners Healthcare at Home (PHH)• Goals:– Assess patient’s home situation, current services, and levelof support– Ensure ability of patients/caregivers to manage theirmedical conditions at home• Take medications, perform wound care, modify health-related behaviors (e.g., diet), manage follow-up appointments• Assist /teach patients/caregivers to perform these activitiesuntil independent or no longer needed– Communicate with members of the transition care team• Document findings in EMR, communicate with inpatient andoutpatient care team by group email re: discharge plan
    32. 32. 32Other Outpatient Providers: PCP• Goals:– Evaluate status of active medical problems compared withdischarge and post-discharge visits based on discharge summaryand VNA notes– Discuss advance directives as needed– Follow up on any other issues raised by discharging team, visitingnurse, ROC, outpatient pharmacist, and communicate with theseproviders as needed (i.e., outpatient specialists)– Arrange for additional follow-up as needed (e.g., closermonitoring of chronic conditions, social worker or psychiatricfollow-up, palliative care services)
    33. 33. 33Interventions for High-Risk Patients• Home visits by patient coach• Telemedicine programs:– CHF: weights– Diabetes: POC glucose testing– Hypertension: blood pressures
    34. 34. 34Advance Care Planning• Automatic trigger tool for inpatient palliative careconsultation• Structured consultation regarding goals of carediscussion with patients, caregivers, and providers• Communication with outpatient providers sodiscussion can be continued• Documentation in the EMR
    35. 35. 35Information Technology• Web-based discharge ordering module (BWH)• Automated system to alert providers of results of testspending at discharge• Group email capability linked to robust applicationthat identifies care team members (Partners EnterprisePatient Lists)
    36. 36. Analysis• Quantitative– Primary Outcome: Adverse events within 30 days of discharge• Logistic regression adjusted for study month, arm, and confounders• Clustered by nursing unit, practice, attending, and PCP– Secondary Outcomes:• Preventable adverse events• Duration of ameliorable adverse events• Patient satisfaction• ED and hospital readmission• Change in functional status– Subgroup analyses: elderly, low health literacy, high co-morbidity,high risk for readmission36
    37. 37. Analysis• Qualitative– Grounded theory method• Analyze focus groups and interviews re: barriers andfacilitators of implementation– Mixed methods• Are certain facets consistently implemented with high fidelityand associated with improved outcomes?• Where success is variable, can it be linked to choice ofimplementation components, low intervention fidelity?• Can low intervention fidelity be linked to certain contextualfactors?37
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