August 7, 2019

Care Management’s Challenges and Opportunities to Reduce the Rapid Rehospitalization of Frail Community-Dwelling Older Adults

Community-based frail older adults, burdened with complex medical and social needs, are at great risk for preventable rapid rehospitalizations. Although federal and state regulations are in place to address the care transitions between the hospital and nursing home, no such guidelines exist for the much larger population of community-dwelling frail […]
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Community-based frail older adults, burdened with complex medical and social needs, are at great risk for preventable rapid rehospitalizations. Although federal and state regulations are in place to address the care transitions between the hospital and nursing home, no such guidelines exist for the much larger population of community-dwelling frail older adults. Few studies have looked at interventions to prevent rehospitalizations in this large segment of the older adult population. Similarly, standardized disease management approaches that lower hospitalization rates in an independent adult population may not suffice for guiding the care of frail persons. Care management interventions currently face unique challenges in their attempt to improve the transitional care of community-dwelling older adults. However, impending national imperatives aimed at reducing potentially avoidable hospitalizations will soon demand and reward care management strategies that identify frail persons early in the discharge process and promote the sharing of critical information among patients, caregivers, and health care professionals. Opportunities to improve the quality and efficiency of care-related communications must focus on the effective blending of training and technology for improving communications vital to successful care transitions.
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http://gerontologist.oxfordjournals.org/content/50/4/451.abstract

August 7, 2019

Project BOOST: Care Transitions for Older Adults Implementation Guide

The Society of Hospital Medicine Care Transitions Implementation Guide: Project BOOST: Better Outcomes for Older adults through Safe Transitions
The Society of Hospital Medicine Care Transitions Implementation Guide: Project BOOST: Better Outcomes for Older adults through Safe Transitions
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https://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/html_CC/Implementation.cfm

August 7, 2019

NTOCC: Improving on Transitions of Care—How to Implement and Evaluate a Plan

The Executive Summary outlines for you the concepts, process and how to use the guidebook titled Improving on Transitions of Care: How to Implement and Evaluate a Plan. In using the guidebook each transition point is treated as an exchange. Each exchange is where communication occurs and where evaluation may […]
The Executive Summary outlines for you the concepts, process and how to use the guidebook titled Improving on Transitions of Care: How to Implement and Evaluate a Plan. In using the guidebook each transition point is treated as an exchange. Each exchange is where communication occurs and where evaluation may occur.
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http://www.ntocc.org/Portals/0/ImplementationPlan.pdf

August 7, 2019

NTOCC Transitions of Care Checklist

This list provides a detailed description of effective patient transfer between practice settings. Implementing this process developed by NTOCC can help to ensure that patients and their critical medical information are transferred safely, timely, and efficiently.
This list provides a detailed description of effective patient transfer between practice settings. Implementing this process developed by NTOCC can help to ensure that patients and their critical medical information are transferred safely, timely, and efficiently.
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http://www.ntocc.org/Portals/0/TOC_Checklist.pdf

August 7, 2019

Nurse identified hospital to home medication discrepancies: implications for improving transitional care

Care transitions are clinically dangerous times, particularly for older adults with complex health problems. This article describes the most common medication discrepancies identified by nurses during patients’ (n = 101) hospital to home transition. Findings indicated that medication discrepancies were astoundingly widespread, with 94% of the participants having at least […]
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Care transitions are clinically dangerous times, particularly for older adults with complex health problems. This article describes the most common medication discrepancies identified by nurses during patients' (n = 101) hospital to home transition. Findings indicated that medication discrepancies were astoundingly widespread, with 94% of the participants having at least 1 discrepancy. The average number of medication discrepancies identified was 3.3 per participant. Medication discrepancies were identified in virtually all classes of medications, including those with high safety risks. Evidence-based best practices to reduce transition-related medication discrepancies are presented.
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https://www.rwjf.org/pr/product.jsp?id=71888

August 7, 2019

NTOCC My Medicine List (French)

(French Version) This form helps you gather important information about your medications. Filling this list out prior to visiting your doctor or entering the hospital will help ensure your health care providers know what medications you are already taking. When your doctor writes you a new prescription or changes your […]
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(French Version) This form helps you gather important information about your medications. Filling this list out prior to visiting your doctor or entering the hospital will help ensure your health care providers know what medications you are already taking. When your doctor writes you a new prescription or changes your medication ask them to update your My Medicine List. Working with your doctors to fill out the form will help you better understand what medications you should be taking.
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http://www.ntocc.org/Portals/0/My_Medicine_List_French.pdf

August 7, 2019

NTOCC My Medicine List (Spanish)

(Spanish Version) This form helps you gather important information about your medications. Filling this list out prior to visiting your doctor or entering the hospital will help ensure your health care providers know what medications you are already taking. When your doctor writes you a new prescription or changes your […]
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(Spanish Version) This form helps you gather important information about your medications. Filling this list out prior to visiting your doctor or entering the hospital will help ensure your health care providers know what medications you are already taking. When your doctor writes you a new prescription or changes your medication ask them to update your My Medicine List. Working with your doctors to fill out the form will help you better understand what medications you should be taking.
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http://www.ntocc.org/Portals/0/My_Medicine_List_Spanish.pdf

August 7, 2019

Patients’ discharge experiences: Returning home after open-heart surgery

PURPOSE This study explored patients’ narratives of technology in heart surgery and recovery. METHODS A narrative inquiry was conducted with a sample of 16 individuals. Interviews were completed 2 to 4 days after transfer from cardiovascular intensive care, and 4 to 6 weeks after discharge. Participants completed journals between these […]
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PURPOSE This study explored patients' narratives of technology in heart surgery and recovery. METHODS A narrative inquiry was conducted with a sample of 16 individuals. Interviews were completed 2 to 4 days after transfer from cardiovascular intensive care, and 4 to 6 weeks after discharge. Participants completed journals between these 2 time periods. RESULTS Discharge and the return home were highlighted as key transitions. These transitions were driven by a technological script that included teachings and texts provided upon discharge. Complicating participants' narratives were their own personal dramas and self-characterizations of vulnerability, as they struggled to incorporate this script into the particularities of their daily lives. CONCLUSION Comprehensive conceptualizations of technology that involve the associated logics and pathways of recovery provide deep insights into patients' stories of recovery from heart surgery. It is salient that discharge programs consider the ways that technology enters into patients' narratives, and also consider dialogical approaches to communication, education, and supportive interventions that are offered at multiple intervals and continue in the home.
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https://www.ncbi.nlm.nih.gov/pubmed/20561868?dopt=Citation

August 7, 2019

NTOCC My Medicine List (English)

(English Version) This form helps you gather important information about your medications. Filling this list out prior to visiting your doctor or entering the hospital will help ensure your health care providers know what medications you are already taking. When your doctor writes you a new prescription or changes your […]
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(English Version) This form helps you gather important information about your medications. Filling this list out prior to visiting your doctor or entering the hospital will help ensure your health care providers know what medications you are already taking. When your doctor writes you a new prescription or changes your medication ask them to update your My Medicine List. Working with your doctors to fill out the form will help you better understand what medications you should be taking.
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http://www.ntocc.org/Portals/0/My_Medicine_List.pdf

August 7, 2019

NTOCC Taking Care of MY Health Care (French)

French Language Version— Taking Care of MY Health Care has been a much anticipated consumer tool. The tool was developed by the NTOCC Tools and Resources Work Group. It has been through numerous reviews with the group, by social workers, and a literacy review. The NTOCC Advisory Task Force approved […]
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French Language Version— Taking Care of MY Health Care has been a much anticipated consumer tool. The tool was developed by the NTOCC Tools and Resources Work Group. It has been through numerous reviews with the group, by social workers, and a literacy review. The NTOCC Advisory Task Force approved it on September 16, 2008 at their meeting in Washington DC. This tool was developed as a guide for patients and their caregivers to use so they can be better prepared when they see a health care professional on what kind of information and questions they need to ask. NTOCC’s goal was to keep it simple; as a guide, to open the lines of communication and at the minimum to provide them with a convenient, simple format to have an updated list of their medication and what the next step in their care would be.
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http://www.ntocc.org/Portals/0/Taking_Care_Of_My_Health_Care_French.pdf

August 7, 2019

NTOCC Taking Care of MY Health Care (Spanish)

Spanish Language Version— Taking Care of MY Health Care has been a much anticipated consumer tool. The tool was developed by the NTOCC Tools and Resources Work Group. It has been through numerous reviews with the group, by social workers, and a literacy review. The NTOCC Advisory Task Force approved […]
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Spanish Language Version— Taking Care of MY Health Care has been a much anticipated consumer tool. The tool was developed by the NTOCC Tools and Resources Work Group. It has been through numerous reviews with the group, by social workers, and a literacy review. The NTOCC Advisory Task Force approved it on September 16, 2008 at their meeting in Washington DC. This tool was developed as a guide for patients and their caregivers to use so they can be better prepared when they see a health care professional on what kind of information and questions they need to ask. NTOCC’s goal was to keep it simple; as a guide, to open the lines of communication and at the minimum to provide them with a convenient, simple format to have an updated list of their medication and what the next step in their care would be.
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http://www.ntocc.org/Portals/0/Taking_Care_Of_My_Health_Care_Spanish.pdf

August 7, 2019

Understanding information and education gaps among people with type 1 diabetes: A qualitative investigation

OBJECTIVE Many patients with type 1 diabetes struggle to self-manage this chronic disease, often because they have a poor knowledge and understanding of the condition. However, little attention has been paid to examining the reasons for this poor knowledge/understanding. To inform future educational interventions, we explored patients’ accounts of the […]
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OBJECTIVE Many patients with type 1 diabetes struggle to self-manage this chronic disease, often because they have a poor knowledge and understanding of the condition. However, little attention has been paid to examining the reasons for this poor knowledge/understanding. To inform future educational interventions, we explored patients' accounts of the education and information they had received since diagnosis, and the reasons behind gaps in their diabetes knowledge. METHODS Semi-structured interviews were conducted with 30 type 1 diabetes patients enrolled on a structured education programme in the UK. Data were analysed using an inductive, thematic approach. RESULTS Patients' accounts illustrated a number of knowledge deficits which were influenced by various lifecourse events. Reasons for deficits included: diagnosis at a young age and assumption of decision-making responsibility by parents; lack of engagement with information when feeling well; transitions in care; inconsistency in information provision; and, lack of awareness that knowledge was poor or incomplete. CONCLUSION Patients' knowledge deficits can arise for different reasons, at different points in the lifecourse, and may change over time. PRACTICE IMPLICATIONS: The delivery of individualised education should take account of the origins of patients' knowledge gaps and be provided on a regular and on-going basis.
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https://www.researchgate.net/publication/44694461_Understanding_information_and_education_gaps_among_people_with_type_1_diabetes_A_qualitative_investigation

August 7, 2019

PtC3: Centered Coordinated Care

The cost of fragmented, inefficient chronic care is high. Medicare beneficiaries with four or more chronic conditions account for 80% of Medicare spending,1 which totaled $402 billion in 2006. American medicine stands at a worrisome crossroads as the first baby boomers near retirement age. Without prompt transformation, chronic care in […]
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The cost of fragmented, inefficient chronic care is high. Medicare beneficiaries with four or more chronic conditions account for 80% of Medicare spending,1 which totaled $402 billion in 2006. American medicine stands at a worrisome crossroads as the first baby boomers near retirement age. Without prompt transformation, chronic care in America will soon become unsustainably expensive (Box 1).2 The answer may be Patient-Centered Coordinated Care (PtC3). PtC3 is an assessment-based interdisciplinary approach to integrating health care and social support services in which a patient’s individual needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored through a high touch approach.
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http://www.medicarepatientmanagement.com/issues/04-03/mpmMJ09-CareCoordination.pdf

August 7, 2019

NTOCC Taking Care of MY Health Care (English)

Taking Care of MY Health Care has been a much anticipated consumer tool. The tool was developed by the NTOCC Tools and Resources Work Group. It has been through numerous reviews with the group, by social workers, and a literacy review. The NTOCC Advisory Task Force approved it on September […]
Read More
Taking Care of MY Health Care has been a much anticipated consumer tool. The tool was developed by the NTOCC Tools and Resources Work Group. It has been through numerous reviews with the group, by social workers, and a literacy review. The NTOCC Advisory Task Force approved it on September 16, 2008 at their meeting in Washington DC. This tool was developed as a guide for patients and their caregivers to use so they can be better prepared when they see a health care professional on what kind of information and questions they need to ask. NTOCC’s goal was to keep it simple; as a guide, to open the lines of communication and at the minimum to provide them with a convenient, simple format to have an updated list of their medication and what the next step in their care would be.
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http://www.ntocc.org/Portals/0/Taking_Care_Of_My_Health_Care.pdf

August 7, 2019

Aging and Disability Resource Center (ADRC) Development and LTC Options

The Aging and Disability Resource Center Program (ADRC), a collaborative effort of AoA and the Centers for Medicare & Medicaid Services (CMS), is designed to streamline access to long-term care. The ADRC program provides states with an opportunity to effectively integrate the full range of long-term supports and services into […]
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The Aging and Disability Resource Center Program (ADRC), a collaborative effort of AoA and the Centers for Medicare & Medicaid Services (CMS), is designed to streamline access to long-term care. The ADRC program provides states with an opportunity to effectively integrate the full range of long-term supports and services into a single, coordinated system. By simplifying access to long-term care systems, ADRCs and other single point of entry (SEP) systems are serving as the cornerstone for long-term care reform in many states.
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http://www.aoa.gov/AoAroot/AoA_Programs/HCLTC/ADRC/index.aspx

August 7, 2019

NTOCC Informational Slidedeck

Download this presentation to learn more about how transitions of care impact your safety and how NTOCC is working to ensure improved transitions for you and your family.
Download this presentation to learn more about how transitions of care impact your safety and how NTOCC is working to ensure improved transitions for you and your family.
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http://www.ntocc.org/Portals/0/Consumer.pps

August 7, 2019

Problems after discharge and understanding of communication with their primary care physicians among hospitalized seniors: a mixed methods study

BACKGROUND Communication and coordination with primary care physicians (PCPs) is recommended to ensure safe care transitions for hospitalized older patients. Understanding patient experiences of problems after discharge can help clinical teams design more patient-centered care transitions. OBJECTIVE To report older patients’ experiences with problems after hospital discharge and investigate whether […]
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BACKGROUND Communication and coordination with primary care physicians (PCPs) is recommended to ensure safe care transitions for hospitalized older patients. Understanding patient experiences of problems after discharge can help clinical teams design more patient-centered care transitions. OBJECTIVE To report older patients' experiences with problems after hospital discharge and investigate whether PCPs were aware of their hospitalization. DESIGN Prospective mixed methods study. SETTING: Single academic medical center. PATIENTS Hospitalized patients and PCPs. MEASUREMENTS Telephone interviews of frail, older general medical patients conducted 2 weeks after discharge to elicit patient problems after discharge, such as: (1) obtaining medications, or follow-up appointments; and (2) perceptions of hospital physician communication with their PCP. For each patient interviewed, their PCP was faxed a survey 2 weeks after discharge to assess awareness of hospitalization. RESULTS: Forty-two percent (27) of patients reported 42 different post-discharge problems. The most frequently reported problems were difficulty with follow-up appointments or tests (12). Other reported problems included readmission and return to the Emergency Department (10), problems with medications (8), not-prepared for discharge (8), and hospital complications or questions (4). Thirty percent of PCPs were unaware of patient hospitalization. Patients were twice as likely to report a problem if their PCP was unaware of the hospitalization (31% PCP aware, vs. 67% PCP not aware; P < 0.05). CONCLUSION This study suggests that many frail, older patients reported problems after discharge and were twice as likely to do so when the patient's PCP was not aware of the hospitalization. Systematic interventions to improve communication with PCPs during patient hospitalization are needed.
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https://onlinelibrary.wiley.com/doi/abs/10.1002/jhm.668

August 7, 2019

Chronic care Coordination Program

The Chronic Care Coordination (CCC) program has resulted in significant cost savings for KP Colorado. An analysis of services and care costs for patients in the six months prior to enrolling in CCC and in the six months following enrollment in CCC yielded $1900 savings per patient per year (as […]
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The Chronic Care Coordination (CCC) program has resulted in significant cost savings for KP Colorado. An analysis of services and care costs for patients in the six months prior to enrolling in CCC and in the six months following enrollment in CCC yielded $1900 savings per patient per year (as a result of decreased hospitalizations, SNF admissions, and ED visits).
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http://www.innovativecaremodels.com/care_models/13/results

August 7, 2019

Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up

BACKGROUND The transition between the inpatient and outpatient setting is a high-risk period for patients. The presence and role of the primary care provider (PCP) is critical during this transition. This study evaluated characteristics and outcomes of discharged patients lacking timely PCP follow-up, defined as within 4 weeks of discharge. […]
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BACKGROUND The transition between the inpatient and outpatient setting is a high-risk period for patients. The presence and role of the primary care provider (PCP) is critical during this transition. This study evaluated characteristics and outcomes of discharged patients lacking timely PCP follow-up, defined as within 4 weeks of discharge. METHODS This prospective cohort enrolled 65 patients admitted to University of Colorado Hospital, an urban 425-bed tertiary care center. We collected patient demographics, diagnosis, payer source and PCP information. Post-discharge phone calls determined PCP follow-up and readmission status. Thirty-day readmission rate and hospital length of stay (LOS) were compared in patients with and without timely PCP follow-up. RESULTS The rate of timely PCP follow-up was 49%. For a patient's same medical condition, the 30-day readmission rate was 12%. Patients lacking timely PCP follow-up were 10 times more likely to be readmitted (odds ratio [OR] = 9.9, P = 0.04): 21% in patients lacking timely PCP follow-up vs. 3% in patients with timely PCP follow-up, P = 0.03. Lack of insurance was associated with lower rates of timely PCP follow-up: 29% vs. 56% (P = 0.06), but did not independently increase readmission rate or LOS (OR = 1.0, P = 0.96). Index hospital LOS was longer in patients lacking timely PCP follow-up: 4.4 days vs. 6.3 days, P = 0.11. CONCLUSIONS Many patients discharged from this large urban academic hospital lacked timely outpatient PCP follow-up resulting in higher rates of readmission and a non-significant trend toward longer hospital LOS. Effective transitioning of care for vulnerable patients may require timely PCP follow-up.
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http://onlinelibrary.wiley.com/doi/10.1002/jhm.666/abstract

August 7, 2019

Transition of care for hospitalized elderly patients–development of a discharge checklist for hospitalists

BACKGROUND Discharge from the hospital is a critical transition point in a patient’s care. Incomplete handoffs at discharge can lead to adverse events for patients and result in avoidable rehospitalization. Care transitions are especially important for elderly patients and other high-risk patients who have multiple comorbidities. Standardizing the elements of […]
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BACKGROUND Discharge from the hospital is a critical transition point in a patient's care. Incomplete handoffs at discharge can lead to adverse events for patients and result in avoidable rehospitalization. Care transitions are especially important for elderly patients and other high-risk patients who have multiple comorbidities. Standardizing the elements of the discharge process may help to address the gaps in quality and safety that occur when patients transition from the hospital to an outpatient setting. METHODS The Society of Hospital Medicine's Hospital Quality and Patient Safety committee assembled a panel of care transition researchers, process improvement experts, and hospitalists to review the literature and develop a checklist of processes and elements required for ideal discharge of adult patients. The discharge checklist was presented at the Society of Hospital Medicine's Annual Meeting in April 2005, where it was reviewed and revised by more than 120 practicing hospitalists and hospital-based nurses, case managers, and pharmacists. The final checklist was endorsed by the Society of Hospital Medicine. RESULTS The finalized checklist is a comprehensive list of the processes and elements considered necessary for optimal patient handoff at hospital discharge. This checklist focused on medication safety, patient education, and follow-up plans. CONCLUSIONS The development of content and process standards for discharge is the first step in improving the handoff of care from the inpatient to the posthospital setting. Refining this checklist for patients with specific diagnoses, in specific age categories, and with specific discharge destinations may further improve information transfer and ultimately affect patient outcomes.
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http://onlinelibrary.wiley.com/doi/10.1002/jhm.129/abstract