The document summarizes a webinar presentation on discharge follow-up appointments and care transitions. It provides an overview of the Office of the National Coordinator's i2 program which aims to spur innovation and highlight excellence. It then discusses the problem of care transitions and the opportunity to improve follow-up appointments. The document outlines elements of high-quality transitions and impacts on patients. It introduces the Critical Transitions Challenge to create a tool to improve post-discharge scheduling. It provides details on the challenge including desired tool components, pilot planning advice, and judging criteria.

1. Discharge Follow-Up Appointment
Challenge
Webinar Presentation
Wednesday, March 7th

2. On o a’s a
tdy cl l
:
Janhavi Marybeth Amy
Wil Yu JL Neptune
Kirtane Sharpe Berman
Special Assistant Senior Program
Senior Vice Director of Program
of Innovations Officer
President Clinical Director
and Research
Transformation
Gordon and John A.
ONC Hartford
Health 2.0 ONC Betty Moore
Foundation Foundation

3. A ed f T dy Me g
gnao o a’s et
r in
ON ad h I e in innoa n i2
C n ten s g I vt ( )
vt n io
Porm
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A I rdc n o a Tasio s
nn o ut t C r rnit n
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A Ovr w f e
n ev o t Discharge
ie h Follow-Up
Appointment C aeg
hlne
l
Q& A o th C a ne
A b u te hl g
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e

4. ON ad
C n i2

5. i2 – Investing in Innovations
Wil Yu
Wil.Yu@HHS.gov
Adam Wong
Office of the National Coordinator
5

6. i2 Goals
• Better Health, Better Care, Better Value through Quality Improvement
– Further the mission of the Department of Health and Human Services
– Highlight programs, activities, and issues of concern
• Spur Innovation and Highlight Excellence
– Motivate, inspire, and lead
• Community building – Development of ecosystem
• Stimulate private sector investment
6

7. Care Transitions
Definition: movement between health care practitioners and settings of care
as condition and needs change
Often dangerous:
- especially for frail, older patients and
- those with multiple chronic conditions

8. Care Transitions: Key Opportunity
Hospital readmissions frequent, and…
─ 19.6% of Medicare patients (65 years and older) readmitted to
the hospital within 30 days of discharge; 34% within 90 days
Costly, but…
─ At least $17B in Medicare spending; estimated $25B across
all insurance companies annually
Avoidable
– Variation between hospitals
– Heart Failure, Pneumonia, Coronary Obstructive Pulmonary
Disease, Heart Attack leading conditions
– Proven interventions

9. Some Elements of a High-Quality Transition
• Patient and family education on diagnosis and care during
hospital stay.
• Schedule post-discharge appointments.
• Organize post-discharge services.
• Reconcile medications and confirm medication plan.
• Expedite discharge summary to outpatient providers.
• Teach-back with patients and family.
• Discharge plan to patient.
• Confirmed hand-off to outpatient physicians and
others.
• (Telephone call 2-3 days after discharge)

10. Impact on Patients
The Critical Transitions Challenge Issue
– 50% of readmitted patients haven’t had primary care f/u
Problems
– Primary care provider may not know individual has been discharged
– Individual may not have primary care provider
– May not set appointment in right time frame
– Even with appointment set, problem may arise
– ex. Mary and her medications

11. Impact on Patients

12. T e hlne
h C a g:
l
e
“Create an easy-to-use web-based tool that
will make post-discharge follow-up
appointment scheduling a more effective and
shared process for care providers, patients
and caregivers.”
•In addition, developers will need to articulate a plan for broader adoption at the
community level.
•Submissions can be existing applications, or applications developed specifically for
this challenge.
•The technology developed will remain proprietary to the developer and will not
become open source.

13. Pr1T oD vl mn
a : o l ee p et
t o
The Ideal application for will include the following components:
4. Easy to navigate user interface
5. Easy to navigate process for downstream accepting providers
6. Information for patient and caregiver convenience and preference
7. Critical background information for downstream provider
8. Messaging capabilities to minimize no-shows and cancellations
9. EHR interface capabilities where applicable

14. Pr2P no s lad d p n
a : l f ce n ao t
t a ra io
To assist with pilot plan development, applicants are advised to
consider the following examples as potential audiences for the
challenge:
•Hospital(s) with a selection of owned or affiliated physician practices
•Community collaboratives or payment pilots focused on care
transitions improvement, which could include hospitals, physician
practices, community-based organizations, skilled nursing homes, etc
•Local payers focused on improving transitions at the community
level.
•Partnership for Patients Hospital Engagement Networks

15. Pr2P no s lad d p n
a : l f ce n ao t
t a ra io
To anticipate the needs of a test bed organization or community,
successful applicants will also need to submit a brief pilot
implementation proposal (250-500 words) that addresses factors
including
•timeline,
description of pilot environment needs (e.g., types of technical
capabilities,
•types and number of patients and providers included), and
•additional resource needs (e.g., staffing and technical
resources).

16. J g g re
u in Cit ia
d r
1. Effectively integrate inpatient data and provide structured
support for self-care
2. Integrate design and usability concepts to drive patient and
provider adoption and engagement
3. Demonstrate creative and innovative uses of mobile
technologies
4. Demonstrate potential to improve health status for individuals
and the community
5. Leverage NwHIN standards including transport, content, and
vocabularies
6. Demonstrate ability to implement the intervention in a pilot
setting, and ultimately to scale in a community

17. T ee
iml
in
Submission Period Ends
4-30-12
Winner Notified
05-23-12

18. Fr oen r a n
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C natenLc etn:
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