“COACHING THE FRAIL EDLER THROUGH CARE …€¢ Discern how coaching is different from discharge planning and case ... Four Pillars 1. Personal Health Record (PHR) 2. Medication
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2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
• Discern how coaching is different from discharge planning and case management in usual practice
• Describe and discuss the four pillars
DISCLOSURE Heidi M. Kramer, RN, CNS, ND does
not have a significant financial interest or other relationship with manufacturer(s) of
commercial product(s) and or provider(s) of commercial services discussed in the
presentation.
2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
The The ““SilentSilent”” Care CoordinatorsCare Coordinators
� By default, older patients and family caregivers
function as their own care coordinators
� First line of defense for transition related errors
� Model explicitly recognizes their role as
integral members of the interdisciplinary team
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Slide 5
Care Transitions Are CommonCare Transitions Are Common……
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Slide 6
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2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
Slide 7 The Care Transitions Intervention:The Care Transitions Intervention:
Designed to encourage older patients and
their caregivers to assert a more active
role during care transitions
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Slide 8
Key Elements of InterventionKey Elements of Intervention
� “Transition Coach” (Nurse or Nurse Practitioner)
– Prepares patient for what to expect and to speak up
– Provides tools (Personal Health Record)
� Follows patient to nursing facility or to the home
– Reconciles pre- and post-hospital medications
– Practices or “role-plays” next encounter or visit
� Phone calls 2, 7 and 14 days after discharge
– Single point of contact; reinforce, ensure follow up
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Slide 9 The Four PillarsThe Four Pillars
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2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
____________________________________________________________Remember to take this Record with youto all of your doctor visits
PersonalPersonal
HealthHealth
RecordRecordThe Personal Health Record of:
Josephine Patient
Personal Information:
Address:
Home Phone#:
Birth Date:
Patient ID#
PCP Name:
Advanced Directives?:
Hospitalization Information:
Admitted: _/_/_ Discharged: _/_/_
Reason for Hospitalization:
___________________________________________
Caregiver Information:
Name:
Phone #:
Relation to Patient:
Personal History
Please check any illnesses or health
problems listed below that you have
ever experienced.
� Arthritis
� Abnormal Heart Rhythm
� Cancer
� Diabetes
� Hardening of the Arteries
� Heart Disease
� Heart Failure
� High Blood Pressure
� Hip Fracture
� Lung Disease
� Medical/Surgical Back conditions
� Pneumonia
� Stroke
� Other: ____________________
After I leave the hospital…
1. I will write down questions I have about my condition.
2. I will take all bottles of medicine I
am using to each doctor visit.
3. I will call _________________
immediately at (XXX) XXX-XXX if I
experience any of the following:
• Temperature above 101°F
• Uncontrollable pain
• Increased confusion
• Increased redness or d
drainage around wound
• Questions about which
medications to take
Before I leave the hospital….
� I have the instructions I need to keep my health condition from becoming worse.
� I know what symptoms to watch out for.
� I know the name and phone number of who to call if I see any of these symptoms.
� My family or someone close to me knows what I will need once I leave the hospital.
� I know what medications to take, how to take them, and possible side effects.
� I will schedule a follow up appointment with my primary care doctor.
� I will have a clear and complete copy of my discharge instructions.
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Slide 11
Four PillarsFour Pillars
1. Personal Health Record (PHR)
2. Medication Management
3. Red Flags
4. Follow up
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Slide 12
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2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
Slide 23 Introducing the Medication Introducing the Medication
DiscrepancyDiscrepancy Tool (MDT)Tool (MDT)
� Patient-centered
� Applicable across a variety of health settings
� Identify patient- and system-level factors
� Items need to be actionable at point of care
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Slide 24
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2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
The lack of quality measures for The lack of quality measures for
care transitions remains a care transitions remains a
significant barrier to quality significant barrier to quality
improvementimprovement
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Slide 33 Brief History of the Brief History of the
Care Transitions Measure (CTM)Care Transitions Measure (CTM)
� Qualitative studies shaped items
� Transition-specific items => Common set of items
� Items discriminate among facilities
� CTM endorsed by NQF in May 2006
Supported by The National Institute on Aging
and The Commonwealth Fund
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2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
Slide 35 Relationship Between CTM scores Relationship Between CTM scores
and Return to the EDand Return to the ED
.0044.679CTM Score
.833.045Age
.2251.486Co-morbidity
Score (Deyo)
.685.166Intercept
.0133.040Model
SignificanceF statistic
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Slide 36
Demand for the CTMDemand for the CTM
� Over 1400 requests for permission to use
from 15 Countries
� Adopted by WHO multi-national (Europe)
hospital quality collaborative
� Highmark Blue Cross Blue Shield P4P
� Maine to vote on statewide public reporting
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2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
Key Elements of InterventionKey Elements of Intervention
� Conceptual Elements
– The 4 “Pillars” (conceptual domains)
� Instrumental Elements
– Transition Coach
– Personal Health Record (PHR)
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Slide 39
Four PillarsFour Pillars
�Medication self-management
�Patient-centered record (PHR)
�Follow-up with PCP/Specialist
�Knowledge of “Red Flags” or warning
signs/symptoms and how to respond
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2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
____________________________________________________________Remember to take this Record with youto all of your doctor visits
PersonalPersonal
HealthHealth
RecordRecordThe Personal Health Record of:
Josephine Patient
Personal Information:
Address:
Home Phone#:
Birth Date:
Patient ID#
PCP Name:
Advanced Directives?:
Hospitalization Information:
Admitted: _/_/_ Discharged: _/_/_
Reason for Hospitalization:
___________________________________________
Caregiver Information:
Name:
Phone #:
Relation to Patient:
Personal History
Please check any illnesses or health
problems listed below that you have
ever experienced.
� Arthritis
� Abnormal Heart Rhythm
� Cancer
� Diabetes
� Hardening of the Arteries
� Heart Disease
� Heart Failure
� High Blood Pressure
� Hip Fracture
� Lung Disease
� Medical/Surgical Back conditions
� Pneumonia
� Stroke
� Other: ____________________
After I leave the hospital…
1. I will write down questions I have about my condition.
2. I will take all bottles of medicine I
am using to each doctor visit.
3. I will call _________________
immediately at (XXX) XXX-XXX if I
experience any of the following:
• Temperature above 101°F
• Uncontrollable pain
• Increased confusion
• Increased redness or d
drainage around wound
• Questions about which
medications to take
Before I leave the hospital….
� I have the instructions I need to keep my health condition from becoming worse.
� I know what symptoms to watch out for.
� I know the name and phone number of who to call if I see any of these symptoms.
� My family or someone close to me knows what I will need once I leave the hospital.
� I know what medications to take, how to take them, and possible side effects.
� I will schedule a follow up appointment with my primary care doctor.
� I will have a clear and complete copy of my discharge instructions.
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
The Personal Health RecordThe Personal Health Record
� Record of patient’s medical history
� Red flags, or warning signs
� Medication list and allergies
� Advance Directives
� Structured Checklist of critical activities
(instructions, f/u appointments)
� Space for patient questions and concerns
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Slide 44
PHR: Key PrinciplesPHR: Key Principles
� Portable
� Readable
� Easy to Locate
� Easy to Update
� Patient-Centered
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Slide 45
Structure of the InterventionStructure of the Intervention
� Visits
– Hospital visit
– Home visit
– *SNF visit
� Calls
– 2-day
– 7-day
– 14-day
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2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
– Prepare for follow-up� Introduce notion that follow-up visits will need to be scheduled
after discharge
� Remind patient to call coach after discharge
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Slide 47 First Interaction First Interaction
(Hospital or Home Visit)(Hospital or Home Visit)
� Home Visit
– Introduce the Program
� Structure of the intervention: visits and calls
� Role and purpose of the coach
� Accessibility of the coach
– Introduce the Personal Health Record
� Patient and coach complete PHR together
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Slide 48
Home Visit, cont.Home Visit, cont.
– Reconcile pre- and post-hospital medications
� Patient updates medication list in PHR
� Patient is knowledgeable about medication purpose,
how to take medications, side effects, who to call if problems arise
– Prepare for follow-up
� Practice and “role-play” upcoming calls and visits
– Review red flags and assure patient can identify
and respond to warning signs
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2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
N.B.: The training team does not receive any royalties
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2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.
2008 Summer Nursing Conference Arizona Geriatrics Society
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society.