8/31/2012

BRIDGING TRANSITIONS OF CARE:

USING TECHNOLOGY TO LEVERAGE HEALTH
INFORMATION FOR A CLINICAL DECISION
SUPPORT SYSTEM

2012NAHCAnnualConference
Session604

Welcome
PamelaHall,RN,BSEd,MBA
ExecutiveDirector
Executive Director
AthensRegionalHomeHealthServices
Athens,Georgia

PattyF.Steele,MSN,RN,MBAHCM
SolutionManager,InformaticsNurse
Solution Manager Informatics Nurse
CernerExtendedCare
KansasCity,Missouri

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OverviewandObjectives
Describebestpracticeguidelinesforcare
planning
l i
Describetheprocessfordevelopingclinical
assessmenttoolsforpreventionandrisk
reduction

PatientsHealthcareExperience

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African Proverb:

When spider webs

unite, they can tie a
lion.

OrganizationofHealthCare
(Whatitis)

Carenotbasedonevidence,butexperienceand
t i i
training
Seldomateamapproachcaremainlydrivenbythe
physicianalone
Paternalistic&directiveapproach,littleattentionto
patientsbehavioralneeds
Limitedaccesstospecialistsorreluctanceof
primarycarereferral
i f l
Insurerlimitations
Fragmentedaccess
Informationsystemsinadequatetosupportclinical
decisionmaking

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FocusofCare&Incentives
Example:Diabetes
Now IllnessMindset:
Complicationsinevitable
C li ti i it bl
Worldclassfootamputations

TheFuture Preventive/SelfManagementSupport:
Potentialdiabetics diseaseprevention
p
Patientsw/diabetes
preventcomplicationsorevenreverseeffects
patientactivation

OrganizationofHealthCare
(Whatitshouldbe)

Evidencebasedpractice(EBP)
Teambasedapproach
Patientfocused
Accesstoclinicalexpertise&specialists
Supportive information systems
Supportiveinformationsystems

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SupportiveInformationSystems
Decisionsguidedatpointofcare
Integratecarewithothersettings
Integrate care with other settings
Abilitytotrackresultsrealtimetoproducemid
coursecorrections
Abilitytoconnectwithpatients
Predictivemodelingandpreventivecare
Rapidadoptionofnewknowledgethroughclinical
decision support tools
decisionsupporttools
Linkagebetweenclinical,financialandsatisfaction
outcomes
Patientregistries

WagnersChronicCareModel

Community Health Systems

Resources and Policies Organization of Health Care
Self Delivery
System Decision Clinical
Management Support Information
Support Design
System

Productive
Informed, Prepared,
Activated Interactions Proactive
Patient Practice
T
Team

Improved Outcomes
Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effect Clin
Pract.1998;1:2-4.

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MelnyksParadigm
EBPOrganizationalCulture
Context of Caring*

Research evidence
and evidence-based
theories

Clinical expertise (for example, High-quality

evidence from patient assessment Clinical decision patient
as well as use of health care making outcomes
resources)

Patient * The Context of

preferences Caring allows for
and values individualization of
the patient-provider
relationship.

Melnyk & Fineout-Overholt, 2003, 2010

EvolvingProviderBusinessModels
Wellness/Prevention Acute Care Chronic Care

Wellness centers
Retail clinics
Complimentary medicine
Concierge medicine
Medical home
Telehealth, telemedicine, e-visits
Medical tourism
Ambulatory surgery centers
Centers of excellence
Specialty hospitals
Mobile and home care

Source: IBM Global Business Services & IBM Institute for Business Value

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IncreasingValueRequires
IncreasingInformationIntensity
Good
Personalized
(based on people like me)
Access to
relevant Evidence-based
patient (based on population)
information
Evidenced-
based Clinician consensus
Trial & One size fits all
error
Individual clinician knowledge &
experience

Poor Good
Access to clinical knowledge
e.g. diagnostic tools, comparative effectiveness
Source: IBM Global Business Services & IBM Institute for Business Value

Definition:
ClinicalPracticeGuidelines
"Clinical
Clinicalpracticeguidelinesaresystematically
practice guidelines are systematically
developedstatementstoassistpractitionerand
patientdecisionsaboutappropriatehealthcarefor
specificclinicalcircumstances"(Instituteof
Medicine,1990).
Theydefinetheroleofspecificdiagnosticand
treatment modalities in the diagnosis and
treatmentmodalitiesinthediagnosisand
managementofpatients.Thestatementscontain
recommendationsthatarebasedonevidencefrom
arigoroussystematicreviewandsynthesisofthe
publishedmedicalliterature.

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LevelsofEvidence

ClinicalPracticeGuidelines
Basedonresearchofwhatworksbest
evidencebased
evidence based
Spansthecontinuumofcare
Driveshighqualitycarethroughtoolsthat
recommendevidencebasedcare
resolvepatientproblems
integratemedicalevidence
reduce unnecessary care
reduceunnecessarycare
Atthepointofcare,helpsclinicianmakedecisionaboutcare
Patientreceivesexcellentcare
Managementprovidedwithrealtimeactionabledata

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ExamplesofClinicalPractice
Guidelines
NationalGuidelineClearinghouse
http://guideline.gov/
http://guideline gov/
NationalHeartLungandBloodInstitute
http://www.nhlbi.nih.gov/guidelines/index.htm
AmericanDiabetesAssociation
http://care.diabetesjournals.org/content/35/Supplement_1
OmahaSystem
Omaha System
http://omahasystemmn.org/KBS_care_plans.php
MillimanCareGuidelines notpublic

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OverviewandObjectives
DefineClinicalDecisionSupport
Describehowitworks
Describehowweuseit?
Clinicalassessments&RiskAnalysis
Discussuseofclinicalassessmenttools
Describehowtoincorporateriskassessmenttools
Fallrisk/prevention
Readmissionrisk/prevention
Pressureulcerrisk/prevention
Identify
Identifykeyprinciplesinusingclinicaldecision
key principles in using clinical decision
supporttechnologytodriveoptimaloutcomes
Describetransitionsofcaremodels

BuzzwordBingo

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Clinical Decision Support (CDS)

Definition:HITfunctionalitythatbuildsuponthe
foundation of an EHR to provide persons involved in
foundationofanEHRtoprovidepersonsinvolvedin
careprocesseswithgeneralandpersonspecific
information,intelligentlyfilteredandorganized,at
appropriatetimes,toenhancehealthandhealth
care.CMSMeaningfulUseCoreMeasures,Measure11,Stage1cms.gov/Regulationsand
Guidance/11_Clinical_Decision_Support_Rule.pdf

Providingcliniciansorpatientswithclinical
knowledgeandpatientrelatedinformation,
intelligentlyfilteredorpresentedatappropriate
times,toenhancepatientcare.Osteroff etal,2006

Clinical Healthy
Decision Support

Provide
Providetherightinformation,totherightperson,in
the right information to the right person in
therightformat,throughtherightchannel,attheright
pointinthehealthcarecontinuumtoinfluencethe
healthydecisionsofindividualsandimprovetheoverall
healthofcommunities.me

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Clinical Decision Support

ExamplesofInterventionsinclude:
Alerts&Reminders
Alerts & Reminders
ClinicalGuidelines
OrderSets
PatientDataReports&Dashboards
DocumentationTemplates
DiagnosticSupport
g pp
ReferenceInformationDelivered
ToolstoSupportDecisionsthroughouttheClinical
Workflow

Clinical Decision Support

CDSInterventionscan:
Detect
Detectpotentialsafety&qualityproblems&helpprevent
potential safety & quality problems & help prevent
them
Detectinappropriateutilizationofservices,medications,&
supplies
Fosterthegreateruseofevidencebasedprinciples&
guidelines
Organize,optimizeandhelpoperationalizethedetailsofa
i i i dh l i li h d il f
planofcare
Helpgatherandpresentdataneededtoexecutetheplan
Ensurethatbestclinicalknowledge&recommendations
areutilizedtoimprovehealthmanagementdecisions

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Clinical Decision Support Rule

Exclusions Healt
Evidence
hy
Triggered
action
Trigger Evaluation response
of
conditional
conditional
DataInput limits

Attributes of the EHR

DataStorage
Enormouscapabilities
Smallspace
Accessibilityviasecureservers
Fromremotesites
Multiple,authorizedusersatsametime
Informationretrieval
Almost
Almostinstantaneous
instantaneous
RealtimeorJustinTime
TimedDeliveryofReports

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Attributes of the EHR

Linksthecliniciantoprotocols
Offerscustomizedviews
Improvesriskmanagement
Providesoutcomesassessment
Results in more accurate capture of
Resultsinmoreaccuratecaptureof
financialchargesandbillingefficiency
Increasespatientsatisfaction
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RiskofCHFrelatedreadmissioncanbeassessed

28

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Using the Readmission Risk Calculator

CHC 2011
2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 29

Readmission Preventionist Reviews the Trends

CHC 2011
2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 30

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ExamplesofClinicalDashboards

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ExamplesofPatientDashboards

PhysicianReviewsCompletedeVisit

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PhysicianReviewsRichardsQualityCard

PhysicianReviewsRecommendsontheQualityCard

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PhysicianAdjustMedicationDosage

RichardandProvidersareNotifiedoftheDoseChange

Readmission Preventionist Home Health Nurse

Richard

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ChartSearch

QualityMeasures

Predictive
BigData OASISC Modeling

Rules Clinical
Research Intelligence
Risk

44

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Move Toward the Electronic Health Record

EMR

EHR
PHR

45

TraditionalRiskAssessmentTools
Focusedon
Falls
F ll
CHF
Readmission
PressureUlcerPrevention
SmokingCessation
Pneumonia
InfectionSurveillance
DiabeticManagement

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IsFocusonReadmissionsJustified?
Medicare spends $17.4 billion annually on
unplanned readmissions that occur within 30
days
y of the p
patient being g 1.
g discharged

Up to 76% of readmissions may be

preventable2

CMS targeting 20% reduction in hospital

readmissions, which could result in:
Eliminating 1.6 million unnecessary re-
hospitalizations

Savings of $10 billion for Medicare over

three years

Total savings of $35 billion across our

health care system over three years
2009, New England Journal of Medicine analysis of 2005 discharge claims by the Centers 1for
Medicare & Medicaid Services2

1 of every 4 patients diagnosed with CHF is

readmitted within 30 days of initial discharge

About 5 million people in the U.S. have Congestive Heart

Failure (CHF)
The most costly diagnosis in the Medicare population
The most common cause for hospitalization in patients over the
age of 65 years.
Causes about 300,000 deaths in the United States each year

and treating CHF is costly and inconsistent

Annual cost may exceed $40 billion in the United States
Cost of treating CHF varies widely from hospital to hospital.
Researchers found a range from about $1500 to about $18,0001
Readmission cost varied from same as original to $31,643
Average 30 day Risk-Adjusted Readmission rates of 24.7%2

1 Hospital Cost of Care, Quality of Care, and Readmission Rates: Penny-Wise and Pound-Foolish
2 Averages for 30-day Risk-Adjusted Readmissions were calculated for the period July 1, 2006 - June 30, 2009 CHC 2011
2011 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. 48

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30DayReadmissionChartReview

HospitalReadmissionReview

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HospitalReadmissionReviewHomeHealth

HealthcareProviderswillshare
thefinancialrisk
PercentMedicarerevenueatriskbyyear
8.00%

7.00%

6.00%

5.00%
Upto3%of
4.00% Medicarerevenue
atriskin2017
3.00%

2.00%

1.00%

0.00%
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Medicare30DayReadmissions
ValueBasedPurchasing(PayforPerformance)
RHQDAPU(PayforReporting)

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HowDoWeTransitionThis?

HistoryofTransitionsofCare

Condition
Managementor
ChronicCondition
Management

DischargePlanners CareCoordinationTeam TransitionalCareTeam

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1ofevery4patientsdiagnosed
ReadmissionPrevention withCHFisreadmittedwithin30
daysofinitialdischarge

Transitions of Care

Short Term Inpatient Outpatient Rehab Home Health

Acute LTAC Rehab SNF Care

Higher Intensity of Service Lower

Patients first site of discharge

after short-term acute care
hospital stay

2% 10% 41% 9% 37%

Patients use of site during an

episode of care 2% 11% 52% 21% 61%

Data Source: RTI, 2009: Examining Post Acute Care Relationships in an Integrated Hospital System

Complex problems are rarely remedied

by simple solutions. Eric A. Coleman, MD, MPH 2011
"care transitions" refers to the movement
patients
ti t make k between
b t health
h lth care
practitioners and settings as their condition
and care needs change during the course
of a chronic or acute illness.

The Intervention Focuses on Four Conceptual Domains Referred to as

the Four Pillars:
1. Medication self-management
2 Use of a dynamic patient
2. patient-centered
centered record
record, the Personal Health
Record
3. Timely primary care/specialty care follow up
4. Knowledge of red flags that indicate a worsening in their condition
and how to respond

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TheCareTransitionsIntervention
FundingfromTheJohnA.HartfordFoundationand
TheRobertWoodJohnsonFoundation
Designedinresponsetotheneedforapatient
centered,interdisciplinaryinterventionthataddresses
continuityofcareacrossmultiplesettingsand
practitioners.
Overridinggoaloftheintervention
Toimprovecaretransitionsbyprovidingpatientswith
tools
tools
Providingsupportthatpromoteknowledgeandself
managementoftheirconditionastheymovefrom
hospitaltohome

TheCareTransitionsIntervention
Model
Themodeliscomposedofthefollowingcomponents:
Apatientcenteredrecordthatconsistsoftheessentialcare
elements for facilitating productive interdisciplinary communication
elementsforfacilitatingproductiveinterdisciplinarycommunication
duringthecaretransition(referredtoasthePersonalHealthRecord,
orPHR).
Astructuredchecklist(DischargePreparationChecklist)ofcritical
activitiesdesignedtoempowerpatientsbeforedischargefromthe
hospitalornursingfacility.
ApatientselfactivationandmanagementsessionwithaTransitions
Coach inthehospitaldesignedtohelppatientsandtheircaregivers
understandandapplythefirsttwoelementsandasserttheirrolein
managingtransitions.
i t iti
TransitionsCoach followupvisitsintheSkilledNursingFacility(SNF)
and/orinthehomeandaccompanyingphonecallsdesignedto
sustainthefirstthreecomponentsandprovidecontinuityacrossthe
transition.

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NationalTransitionsofCareCoalition
CaseManagementSocietyofAmerica(CMSA)convenes
theNationalTransitionsofCareCoalition(NTOCC)
Distinctionbetweentransitionalcareandtransitionsof
care
Twokeyterms:
CareCoordinationisthedeliberateorganizationofpatientcare
activitiesamongtwoormoreparticipants(includingthe
patientand/orthefamily)tofacilitatetheappropriatedelivery
ofhealthcareservices.
TransitionsofCarerefertothemovementofpatientsbetween
T iti fC f t th t f ti t b t
healthcarelocations,providers,ordifferentlevelsofcare
withinthesamelocationastheirconditionsandcareneeds
change.

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NationalTransitionsofCareCoalition
Transitionsofcarecanoccur:
Withinsettings;e.g.,primarycaretospecialtycare,or
g ; g,p y p y ,
intensivecareunit(ICU)toward
Betweensettings;e.g.,hospitaltosubacutecare,or
ambulatoryclinictoseniorcenter
Acrosshealthstates;e.g.,curativecaretopalliativecare
orhospice,orpersonalresidencetoassistedliving.
Betweenproviders;e.g.,generalisttoaspecialist
p
practitioner,oracutecareprovidertoapalliativecare
, p p
specialist.
Transitionsofcareareasetofactionsdesignedto
ensurecoordinationandcontinuity.

ConceptualModelforTransitionsofCare

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Theconstantsinallmodels

WiththePersonatthecenter

ManagingHealthandpreventingillness
Patients Home Page

Self-Care e-Pillbox Activities & Challenges

e-Visits

Family
Access Personal Health Record

By2013,25%ofpatientencountersin
NorthAmerica,WesternEuropeand
Asia/Pacificwillbeconductedvirtually.
GartnerPredicts2009

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InSummary
Thesecretofgettingaheadisgettingstarted.
Th
Thesecretofgettingstartedisbreakingyour
t f tti t t d i b ki
complex,overwhelmingtasksintosmall
manageabletasks,andthenstartingonthe
firstone.
MarkTwain

1887NursingJobDescription
Dailysweepandmopthefloorsofyourward,dustthepatientsfurnitureandwindowsills
Maintainaneventemperatureinyourwardbybringinginascuttleofcoalforthedays
business.
Lightisimportanttoobservethepatientscondition.Therefore,eachdayfillkerosene
lamps,cleanchimneysandtrimwicks
Thenursesnotesareimportantinaidingyourphysicianswork.Makeyourpenscarefully;
youmaywhittlenibstoyourindividualtaste.
Eachnurseondaydutywillreporteverydayat7a.m.andleaveat8p.m.,exceptonthe
Sabbath,onwhichdayshewillbeofffrom12noonto2p.m.
Graduatenursesingoodstandingwithdirectorofnurseswillbegivenaneveningoffeach
weekforcourtingpurposes,ortwoeveningasweekifyougoregularlytochurch.
Each nurse should lay aside from each payday a goodly sum of her earnings for her benefits
Eachnurseshouldlayasidefromeachpaydayagoodlysumofherearningsforherbenefits
duringherdecliningyears,sothatshewillnotbecomeaburden.Forexample,ifyouearn
$30amonth,youshouldsetaside$15.
Anynursewhosmokes,usesliquorinanyform,getsherhairdoneatabeautyshopor
frequentsdancehallswillgivethedirectorofnursesgoodreasontosuspectherworth,
intentionsandintegrity.
Thenursewhoperformsherlabors[and]servesherpatientsanddoctorsfaithfullyand
withoutfaultforaperiodoffiveyearswillbegivenanincreasebythehospital
administrationoffivecentsperday.

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Any Questions?

References
AmatayakulMK.Electronichealthrecords:Apracticalguideforprofessionalsandorganizations.Chicago(IL):AHIMA;
2009.
CITL.Thevalueofpersonalhealthrecords.CenterforHealthcareTechnologyLeadership,2008.Availablefrom:
http://tigerphr.pbworks.com/f/CITL_PHR_Report.pdf
GaretsD,DavisM.Electronicmedicalrecordsvs.electronichealthrecords:yes,thereisadifference.Chicago(IL):HIMSS
Analytics,2006,p.2.Availablefrom:http://www.himssanalytics.org/docs/WP_EMR_EHR.pdf
OfficeforCivilRights.HIPAAAdministrativeSimplification;RegulationText.US Department of Health and Human
Services,. 2006 Feb 16. Available from:
http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/adminsimpregtext.pdf
Markle.ConnectingforHealth. Apublicprivatecollaborative. Thepersonalhealthworkinggroup. Finalreport;2003Jul1;
NewYork:MarkleFoundation.p.3.
NationalTransitionsofCareCoalitionwww.ntocc.org
OfficeforCivilRights.ThePatientSafetyRule.USDepartmentofHealthandHumanServices.2008Nov21.Available
from:http://www.hhs.gov/ocr/privacy/psa/regulation/rule/index.html
OfficeoftheNationalCoordinatorforHealthIT.HealthITterms.[Internet]Availablefrom:
http://healthit.hhs.gov/portal/server.pt/community/health_it_hhs_gov__glossary/1256
ONC Acronyms Available from:
ONC.Acronyms.Availablefrom:
http://healthit.hhs.gov/portal/server.pt/community/health_it_hhs_gov__acronyms/1217
RoadmaptoBetterCareTransitions.CMS;http://www.healthcare.gov/compare/partnershipfor
patients/safety/transitions.html
TheCareTransitionsProgramwww.caretransitions.org
RobertWoodJohnsonFoundationwww.rwjf.org

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