Preparing Patients and Preparing Patients and Caregivers to Caregivers to Participate in Care Delivered Participate in Care Delivered Across Settings: Across Settings: The Care Transitions The Care Transitions Intervention Intervention Monique Parrish, Dr.PH, MPH, LCSW
Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention. Monique Parrish, Dr.PH, MPH, LCSW. Background: Coleman Care Transitions Model. Qualitative Studies Inadequately prepared for next setting - PowerPoint PPT Presentation
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Preparing Patients and Caregivers to Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: Participate in Care Delivered Across Settings:
The Care Transitions Intervention The Care Transitions Intervention
Monique Parrish, Dr.PH, MPH, LCSW
Background: Coleman Care Transitions Background: Coleman Care Transitions ModelModel
Qualitative Studies– Inadequately prepared for next setting– Conflicting advice for illness management– Inability to reach the right practitioner– Repeatedly completing tasks left undone
The “Silent” Care CoordinatorsThe “Silent” Care Coordinators
By default, older patients and family caregivers function as their own care coordinators
First line of defense for transition related errorsModel explicitly recognizes their role as
“Care Transitions” refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.
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
The Four PillarsThe Four Pillars
Four PillarsFour Pillars
Medication Self-Management Patient Centered Health Record (PHR)
Focus: reinforcing the importance of knowing each medication – when, why, and how to take what is prescribed, and developing an effective medication management system
Pillar #2:Pillar #2: Personal Health Record (PHR)Personal Health Record (PHR)
Focus: providing a health care management guide for patients; the PHR is introduced during the hospital visit and used throughout the program
Key Elements of the Personal Health Key Elements of the Personal Health RecordRecord
Record of patient’s medical historyRed flags, or warning signsMedication list and allergies Advance DirectivesStructured Checklist of critical activities
(instructions, f/u appointments)Space for patient questions and concerns
My Medications are:Medication Dose______________________________
Patients with no identified med discrepancies 6.1%
P=0.041
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
Brief History of the Brief History of the Care Transitions Measure (CTM)Care Transitions Measure (CTM)
Qualitative studies shaped itemsTransition-specific items => Common set of itemsItems discriminate among facilitiesCTM endorsed by NQF in May 2006
Supported by The National Institute on Aging and The Commonwealth Fund
CTM ItemsCTM Items
The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital
When I left the hospital, I had a good understanding of the things I was responsible for in managing my health
When I left the hospital, I clearly understood the purpose for taking each of my medications
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 P4PMaine to vote on statewide public reporting
Qualitative EvaluationQualitative Evaluation
To evaluate the efficacy of the intervention
To augment the quantitative findings
Conclusion: Qualitative DataConclusion: Qualitative Data
Patients appreciated the follow-up, expertise, support and accessibility of the Transition Coach.
Reception of the PHR was mixed, with ½ using it, and ½ not at 30+ days post-intervention.
Barriers to successful implementation of intervention
Transition CoachTransition Coach
Competence– “She was always able to answer my questions”
Accessibility– “There was somebody I could go to if I needed, if I had
any questions, I knew I had somebody I could call.” Security
– “I was pretty skeptical about it. But it turned out to be a real beneficial thing…the program gives you a real inner comfort—when you’ve confirmed that you’re doing it right and you know what to expect.”