Improving Care Transitions in Northwest Denver (Text Version)
Slide Presentation from the AHRQ 2011 Annual Conference
Improving Care Transitions in Northwest Denver
Risa Hayes, CPC
Program Manager, CFMC
Integrating Care for Populations and Communities
AHRQ Annual Conference
September 21, 2011
Screen shot showing their "equation" for hospital readmissions and admissions.
Image: A map shows the Northwest Denver Community.
Who is the Community?
- Acute Care Hospitals.
- Home Health Agencies.
- Non-medical Home Care companies.
- Senior Resource Centers.
- Physician Offices.
- Patient Advocates.
- Hospice providers.
- Palliative Care providers.
- Medical Society.
- Mental Health.
- Physician management group.
Why are people readmitted?
- Unmanaged condition worsening.
- Use of suboptimal medication regimens.
- Return to an emergency department:
- Unreliable system support:
- Lack of standard and known processes.
- Unreliable information transfer.
- Unsupported patient activation during transfers:
- No community infrastructure for achieving common goals.
- Unreliable system support:
- Improve care transitions for Medicare beneficiaries in 44 zip codes in NW Denver.
- As evidenced by:
- 2% reduction in 30 day all-cause readmission rate.
What we did:
Community Action Teams:
- Standardized Community PHR.
- Post-acute Care Options Tool.
- PAM®-tailored CTISM.
- Volunteer Advocates.
Image: A blank personal health record form is shown.
- A true NW Denver Partnership.
- Involved a large group of community providers.
- 21,000 printed copies.
- Available online for future use.
Images of all the community partner logos are displayed on the page.
Community Developed Tools
Image: The Post Acute Care Decision Support Tool is shown.
Timeline: Care Transitions in NW Denver
Image: The Care Transitions timeline from 2008 to 2011 is shown.
Outcomes: Care Transitions InterventionSM & Patient Activation Measure®
- Coleman CTISM model1.
- >300 patients coached.
- Patient Activation Measure® (PAM®; Insignia Health)2
Starting to take a role.
Individuals do not feel confident enough to play an active role in their own health. They are predisposed to be passive recipients of care.
Building knowledge and confidence.
Individuals lack confidence and an understanding of their health or recommended health regimen.
Individuals have the key facts and are beginning to take action but may lack confidence and the skill to support their behaviors.
Individuals have adopted new behaviors but may not be ale to maintain them in the face of stress or health crises.
Image: A bar chart shows two surveys taken with the percentages of patient activation measures in a sample size of 49.
Mr. H: A Patient Story
"I feel that I must tell someone about how greatly I benefited from and appreciate the services of the nurse who follows up on patients discharged from your hospital.
She comforted me and helped make several forceful phone calls, and soon all was well. What a great help! What a relief! Thanks."
Image: A line graph of the 30-day readmissions per 1,000 eligible beneficiaries in the target community from 2007 to 2010 is shown.
Northwest Denver: Campaign
Foundation: Determine community
Kick off: Community meeting
Peak: Form Action teams
Peak: Create PHR, PAC tool, Palliative/Hospice curriculum and community talks
Peak: Celebration meeting—June 21st
Outcome: Reduce hospital readmissions and improve patient activation
Evaluation & Next Steps: Apply for CCTP funding AND...
Northwest Denver Connected for Health: Story of Now
Image: A poster titled "How a community came together to reduce readmissions and activate patients...".