ADAPTING TRANSITIONAL CARE PROGRAMS WITH PERSONCENTERED INTERVENTIONS TO

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ADAPTING TRANSITIONAL CARE PROGRAMS WITH PERSON-CENTERED INTERVENTIONS TO IMPACT READMISSION RATES June Simmons, MSW

ADAPTING TRANSITIONAL CARE PROGRAMS WITH PERSON-CENTERED INTERVENTIONS TO IMPACT READMISSION RATES June Simmons, MSW President and CEO, Partners in Care Foundation

Partners in Care Foundation

Partners in Care Foundation

Who do we serve? • Partners serves older adults, adults with disabilities, and medically

Who do we serve? • Partners serves older adults, adults with disabilities, and medically fragile adults who require in-home supports after hospital discharge or ongoing supports to avoid institutionalization • We offer tailored, person-centered services to patients with diverse health and psycho-social needs in English, Spanish, and Armenian across the state of California • Most patients receive managed Medicare

Evidence-Based Transitional Care Services • Bridge Model • • In-Home Medication Review & pharmacist

Evidence-Based Transitional Care Services • Bridge Model • • In-Home Medication Review & pharmacist intervention One-time Home. Meds • In-hospital visit and postdischarge phone calls 30 day duration Care Transitions • • CTI (Coleman Care Transitions Intervention) Partners offers all three interventions at our CCTP* communities. *CCTP: CMS-funded Community-based Care Transitions Program In-hospital and in-home visits 4 week duration

Person-Centered Care • Partners’ staff consider which of the 3 care transitions interventions, or

Person-Centered Care • Partners’ staff consider which of the 3 care transitions interventions, or combination of interventions, is best suited to decreasing the likelihood of readmission for each individual patient. When selecting an intervention with the patient, we consider the patient’s: • Personal goals • Level of health risk • Social support needs • Cognitive status • Availability of family/caregivers • Neighborhood & local resources • Personal comfort and preferences • Cultural and linguistic characteristics

Interventions Unique to Bridge & CTI Set up services prior to discharge Pre-discharge hospital

Interventions Unique to Bridge & CTI Set up services prior to discharge Pre-discharge hospital visit Use Personal Health Record (PHR) tool Assess for and address emerging needs post-discharge Conduct one home visit 24 -72 hours post-discharge Provide discharge preparation information sheet prior to discharge Call patient within 48 hours of discharge Telephone follow-up to ensure adherence to plans Make additional calls or schedule visits to resolve identified problems Use health record to relay information to other providers Track patients progress and address emerging needs at 30 -days post discharge Coordinate with other providers and agencies Interventions Unique to CTI Actively engage patient in medication reconciliation Use role-playing and other tools to transfer skills Perform 3 follow-up phone calls to reinforce coaching , selfmanagement, sharing PHR

Bridging the Gap Providing flexible, tailored programming for each patient’s needs means reducing readmission

Bridging the Gap Providing flexible, tailored programming for each patient’s needs means reducing readmission risk The Bridge Model allows us to serve patients who: • Refuse home visits due to cultural reasons or personal discomfort; • Are cognitively impaired and difficult to coach • Are still too ill to take responsibility for behavior change • Lack caregiver or are otherwise in need of social supports and incapable of making own arrangements • Are geographically beyond our reach Across Partners’ 3 CCTP communities, over 9, 096 patients were enrolled in the Bridge Model as of 9/30/15.

Increasing Bridge Interventions 12/13 -9/15

Increasing Bridge Interventions 12/13 -9/15

Number of Bridge Cases vs CTI Cases

Number of Bridge Cases vs CTI Cases

A UCLA Study on Partners’ Bridge Patients 7/14 -12/14 9. 78% Readmission Rate

A UCLA Study on Partners’ Bridge Patients 7/14 -12/14 9. 78% Readmission Rate

For further information contact: • June Simmons, CEO at jsimmons@picf. org • Or check

For further information contact: • June Simmons, CEO at [email protected] org • Or check our website: picf. org