Care Beyond Walls
June 15, 2009
MN Critical Access Hospital
and Rural Health Conference
Michele Davis, RN, BSN
Kerry Johnson, RN
Heather Severson-Tañez, RN, BSN
Proprietary and Confidential
Objectives
• Increase knowledge of strategies to help people
navigate healthcare and transitions.
• Discuss health coaching techniques that
optimize the management of chronic diseases.
• Review the care manager’s role in assisting
discharge planners when transitioning patients
home or other settings.
United States Hospital Discharge
Statistics
• 34.9 million people are discharged from
hospitals every year
• For every 10,000 individuals, 1170 need
discharge planning
• Average length of stay in hospital = 4.8
days
• 46 million procedures performed in 2006
Source: 2006 National Hospital discharge survey tables 1,4, and 8
An Older Population
• Of the 34.9 million discharged patients,
38% are age 65 and older.
• The age group 75+ represent 24% of all
inpatient admissions
• These elderly, often very frail patients
have been hospitalized at a faster rate
than their younger counterparts.
Age and Chronic Disease
• 48% of Medicare participants aged 65+ have 3
or more chronic conditions
• 89% of the Medicare budge is used for 65+
• Care is often provided from multiple sources
• Communication to both the patient/caregiver and
across providers is often needed
• Current health care focus on acute/urgent care
Communication/Transition
Issues
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Inadequate patient/caregiver preparation
Conflicting advice for illness management
Inconsistent follow-up care
Greater use of hospital and emergency room
Increased readmission rates
The result is fragmentation, system
misalignment, financial hardship for the health
care “system” and emotional burdens to
individuals
Medication Errors
• In 46% of hospitalized patients, 1+
previously taken medications are
discontinued without explanation
• During transfers from care center to
hospital, on average, there are 3
medication changes
• 20% lead to adverse drug events
• Medication errors due to multiple
prescribers
Boockvar Arch Int Med 2004 (164) 545-50
Impact to Health Care
• Inefficiencies/duplication of services
• Greater hospital and ED use and
readmission
• Litigation/negative press
• Ultimately, higher health care costs to all
of us
So, How Can We Improve
Things?
• Teamwork and Communication
• Health Coaching/Care Transitions
Intervention
• Care Management of Chronic Disease
Teamwork and Communication
• Teaching patients about their chronic
disease
• Perceived decrease in burden as all team
members work together to support the
patient
• Coordinated care across health care
continuum
The Care Transitions Intervention
• Designed to encourage older patients and
their caregivers to assert a more active
role during care transitions
• Includes both onsite visits and follow up
phone calls
Care Transitions Intervention
• “Transition Coach” (Nurse or Nurse Practitioner)
– Prepares patient for what to expect and how to speak
up
– Provides tools (Personal Health Record)
• Follows patient to nursing facility or to their
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 follow up of care
Management of Chronic Disease
Focus on Key Components
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Contain the disease
Slow its progression- especially the associated disability
Manage its symptoms- paramount being pain and discomfort
Adhere to treatment regimen - involves self-care on the part of
the patient
Recognize subtle decline - implement management and
contingency plans
Acknowledge the trajectory – inform the patient and
caregivers/family
Develop an advance plan for care - include key goals
Assist the individual and key relatives/caregivers with coping
skills
Recognize social, economic, spiritual, and cultural
implications and integrate into plan of care
Common signs of decline in
chronic illnesses
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Decline in function- ADL’s
Decline in cognition
More frequent exacerbations
More complications from acute infections
– Pneumonias, UTI’s, viral diseases.
• Increasing withdrawal, anxiety, and
depression
Integrated Chronic Disease
Management Program
• Care Coordination
• Identification and education of illness trajectory
• Identification of baseline and signs/triggers of
decline
• Formulation of plan of care to address decline
• Focus on function
• Shared decision-making
• Assistance with transitions across health care
continuum
• Communication with all key persons
Who Can Help?
• Evercare is a geriatric care management
company founded in Minnesota in 1987
• Nurse Practitioner and Care Management
models throughout Minnesota
• Bring health care to long term care facilities,
assisted living, community, congregate housing
and metro/rural communities
• Experience and programs that have been
validated throughout MN and in over 35 states
Care Beyond Walls: Evercare
• Optimize the health and well-being of
people who have long term or advanced
illness, are older or have disabilities
• Leading provider of geriatric care
management
Partnership with Geriatric Primary
Care or Care Management
• The American Geriatrics Society describes
comprehensive geriatric care as inclusive
of traditional medical care as well as
attention to the individual’s psychological,
social and functional needs.
Role of the Geriatric Care
Manager
• Provides an assessment of patient’s current health
status and environment, identify potential needs, and
develop a plan of care with the patient, family and
caregivers
• Serves as a coordinator and central point of contact for
patient’s health care issues
• Facilitates the provision of preventive care and chronic
health care management
• Assists the patient in getting the most out of their health
care benefits
• Assist to monitor and maintain treatment plans
• Provide communication, education for patient and
caregivers and support to manage their disease
processes- serving as a “health coach”
Additional value for facilities
• Ability to encourage and access needed services
through the facilities home care, therapy departments, or
other providers
• Facilitate communication and coordination to medical
providers including specialists
• Assure preventive health care measures are followed
• Provide a contact for facility billing issues or questions
• Provide routine family education and communicationcoordinated with facility
• Attend care planning conferences as needed
• Transition assistance across the health care continuum
What seniors tell us….
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I don’t get enough time with my doctor
The insurance paperwork is confusing
I hate going to the hospital
I have many doctors and they are telling me different
things
My doctor doesn’t seem to want to hear about my
concerns
I don’t want to burden my family
I want to know what to expect of my health in the future
I want to stay as independent as possible
My family lives far away and they worry about me
I need better information to make health care decisions
Chronic Illness Special Needs
Plan
• This plan addresses the needs of the
chronically ill over 65 Medicare population
in Minnesota
• This plan is a Medicare Advantage plan
being offered by Medica
• Plan will focus on providing benefits and
services relating to individuals with specific
diseases
Evercare Programs
• Our clinical models are available through
the following health plan product options:
– Minnesota Senior Health Options (MSHO)
– Chronic Special Needs plans
• Addresses needs of the chronically ill 65+
• Is a Medicare Advantage plan through Medica
• Provides benefits/services to individuals with
specific chronic conditions
Case Study
• 76 year old widowed male
• Hospitalized with COPD exacerbation
• Transferred to Skilled Nursing facility for
nursing care and rehab services
• Transitioned back to community
Case Study
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68 year old female
CHF, Diabetes, Chronic Kidney Disease
Living in community setting
Hospitalized for CHF exacerbation
Transitioned to TCU/Rehab facility and
then back to community setting
Positive Outcomes of Chronic
Disease Management Program
• Informed, engaged patients
• Productive interactions with their MD
• Understanding of their chronic disease
and their place in the trajectory of illness
Positive Outcomes of Chronic
Disease Management Program
• Understanding their early warning signs
for their condition worsening
• Adverse event avoidance
• Smooth transitions across the health care
continuum
Care Beyond Walls
Any questions??