Post-Transition Risk Assessment and Appropriate Follow-up www.HQOntario.ca
www.HQOntario.ca
Presenter Disclosure Presenter(s) • Dr. Tara O’Brien • Quality Improvement Coaches, HQO Relationships with commercial interests: • Grants/Research Support: Not Applicable • Speakers Bureau/Honoraria: Not Applicable • Consulting Fees: Not Applicable • Other: Not Applicable www.HQOntario.ca 2
Disclosure of Commercial Support • This program has received no commercial or financial support • This program has received no in-kind commercial or financial support • Potential for Conflict(s) of interest: No speaker has received payment or funding from any for-profit organization No organization has a product that will be discussed in the program www.HQOntario.ca 3
How to Participate Today www.HQOntario.ca
Asking a Question on the Webinar All participants are muted but you can ask a question or comment by: Typing a question or comment into the chat box located here 5
Objectives • To understand why post-transition risk assessment & activating appropriate follow up is important to transitions in care • To understand what the risk assessment tool (LACE) is and how to use it • To describe some best practices/examples in Risk Assessment and follow-up in Ontario • Identify how using RA tools can improve continuity of care for their patients to improve patient experience www.HQOntario.ca 6
Background • Care transitions – transfer of a patient between different settings and providers • Continuity of care - related to both the quality of care and the experience of care • Seamless transition - coordination of services and providers, effective sharing of relevant information, and proper post-transition follow up. www.HQOntario.ca 7
POLL # 1 Working on improving Transitions? A. We have worked on improving transitions in the past. B. We are currently working on improving transitions. C. We are in the planning phase of working on improving transitions. D. We don't have any plans yet to work on improving transitions www.HQOntario.ca 8
Hospital Readmissions Increased cost of care Patient Dissatisfaction Poor coordination at discharge Provider Frustration Compromised Safety www.HQOntario.ca 9
HQO Improvement Packages Chronic Disease Management Transitions Supporting of Care Health Independence www.HQOntario.ca 10
Transitions improvement package Individualized care planning Medication Reconciliation Health literacy Risk assessment and follow-up care planning www.HQOntario.ca 11
Optimizing Transitions from hospital to Home Patient experiene on continuity and transition of care in 2010/11; source NRC Picker provided by OHA Hospital patients who knew whom to call if they needed 80 help ED patients who knew whom to call if they needed help 62 Hospital patients who knew when to resume usual 52 Where could we be? activities Hospital patients who knew side effects to watch for 64 Best Ontario hospitals ED patients who knew side effects to watch for 70 reach 85-90% on some quetions . ED patients who knew how to take new medications 83 80 Hospital patients who knew the purpose of medications 59 Hospital patients who discussed danger signals to watch for 51 ED patients who knew danger signals to watch for 0 50 100 www.HQOntario.ca 12
Poll #2 • What experience have you had using risk-assessment tools to reduce readmissions 1. We are currently using a risk-assessment scoring tool to assess our patients 2. We are investigating using risk-assessment scoring tool to assess our patients 3. We would like to use risk-assessment scoring tools but don’t know where to start 4. Risk-assessment scoring tools – do we need that? www.HQOntario.ca 13
LACE Risk Scoring Tool www.HQOntario.ca
Assessing Patient at Risk for Admission High Risk Patients Moderate Risk Patients Patient has been admitted 2 Patient has been admitted or more times in the past once in the past year. year. Patient is unable to teach Patient or family caregiver back, or the patient or family has moderate degree of caregiver has a low degree confidence to carry out self- of confidence to carry out care at home. self-care at home. Institute for Healthcare Improvement, How-to-Guide: Creating an Ideal Transition Home, 2009. www.HQOntario.ca 15
Risk Scoring – Why? • Enables the development of a post-acute care plan based on the assessed risks, needs and capabilities of the patient and family caregivers • Triage high-risk to more intensive forms of post- discharge follow-up www.HQOntario.ca
Objectives • To identify risk factors for adverse outcomes after hospital discharge • To critically analyze the evidence regarding post- discharge transitions • To consider various strategies for improving transitions in care
Objectives • To identify risk factors for adverse outcomes after hospital discharge • To critically analyze the evidence regarding post- discharge transitions • To consider various strategies for improving transitions in care
High risk time post-discharge • Acute excacerbations of chronic illness • Shorter inpatient stays • Major drop off in care
Why post-discharge time period is high risk • Medication changes • Physician communication • Collaboration • Poor patient education • Lack of in-home support
• 21.1% of US Medicare patients with a medical hospitalization readmitted within 30 days of discharge • Total cost to US Medicare of 30 day readmissions estimated to be $17.4 billion (in 2004) • In 50% of cases with readmission within 30 days, no outpatient physician visit between discharge and readmission Jencks et al, NEJM 2009; 360: 1418-28
• Two key points (in favour of GIM): – No single disease accounts for more than 8% of readmissions – Even in heart failure, there are more readmissions for conditions other than heart failure than there are for heart failure Jencks et al, NEJM 2009; 360: 1418-28
• Why are patients readmitted? – Patient characteristics – Health care system characteristics Dhalla, O’Brien, Ko and Laupacis, Healthcare Quarterly 2012
• Patient characteristics – Medical • Heart failure, COPD, dementia, etc. • Psychiatric illness and substance use disorder • Polypharmacy • Functional status Dhalla, O’Brien, Ko and Laupacis, Healthcare Quarterly 2012
• Patient characteristics – Medical • Heart failure, COPD, dementia, etc. • Psychiatric illness and substance use disorder – Non-medical • Low educational attainment, health illiteracy, poverty, limited fluency in English/French, lack of a robust social network Dhalla, O’Brien, Ko and Laupacis, Healthcare Quarterly 2012
• Health care system characteristics – Fragmentation • E.g. hospitals don’t deliver home care – Access to primary care • ~10% of Canadians do not have a family physician – Information continuity • Discharge summary available < 30% of the time – Provider discontinuity • Hospitals don’t see most patients after discharge Dhalla, O’Brien, Ko and Laupacis, Healthcare Quarterly 2012
Health Care Systems Characteristics – Fewer physician house calls • Massive decline (>70%) over last 100 years - Lack of access to urgent care
A tool to estimate the risk of readmission • The LACE index – Clinical prediction rule derived and internally validated using data collected for the OAtH study (4812 patients at 11 hospitals) – 48 potential predictors considered, including functional status (Walter index) and support at home (lives alone vs. not) – Externally validated using data from 1 000 000 patient records from CIHI-DAD L = length of stay A = acuity of admission C = Charlson comorbidity index E = number of ER visits in last 6 months van Walraven et al, CMAJ 2010
1/8/2014
Prediction of readmission using the LACE index 180000 60% 165000 30-day Death or Unplanned Readmission (%) 150000 50% 135000 Number of Admissions 120000 40% 105000 30% 90000 75000 60000 20% 45000 10% 30000 15000 0 0% 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 LACE Index Score Van Walraven et al, CMAJ 2010
HARP tool • Age (65-84, 85+) • Place patient is discharged to (acute, home care, other) • Number of Acute admissions, 6m prior (1/2/3/4+ vs 0) • Number ED visits (last 6 months) • Top Case Mix Groups: COPD, CHF, IBD, GI obstruction, cirrhosis, diabetes
Objectives • To identify risk factors for adverse outcomes after hospital discharge • To critically analyze the evidence regarding post- discharge transitions • To consider various strategies for improving transitions in care
1/8/2014
1/8/2014
• Population – Single hospital in a very poor area of Boston – 749 patients randomized • Intervention – Low-intensity pre-discharge visit (~45 minutes) • coordination of care, medication reconciliation, education – Discharge summary – Post-discharge pharmacist telephone call Jack et al, Annals of Internal Medicine 2009; 150: 178-87
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