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Interventions

quoteThe 9th SOW contract required that projects use evidence-based intervention models. The Care Transitions QIOSC produced a summary of these models and the level of evidence for each9. The Care Transitions Intervention (CTISM) is a coaching intervention triggered by hospitalization that reduces hospital readmissions through developing patient and family self-management capability. All participating QIOs were offered CTI training for staff and for appropriate providers in their communities through the theme support contract. QIOs were expected to measure intervention results continuously and to adapt or abandon interventions that did not produce promising results.

In the 9th SOW, each QIO community implemented interventions to address all three drivers of readmissions as well as formal programs and homegrown (locally developed) programs which address multiple drivers. Table 1 below shows the implemented interventions by community. This list includes all interventions that were implemented at any time throughout the duration of this project. Not all interventions are currently underway.

There are a number of well described and evidence-based interventions that can reduce unwanted readmissions10 . Recent studies by Coleman11 and Naylor12 suggest that interventions targeting comprehensive transitional care from the hospital to the community can reduce readmission rates by approximately one third. Quality improvement work with selected home health agencies has reduced re-hospitalizations. The Veterans Health Administration has reduced re-hospitalization significantly through use of a care coordination program utilizing the conceptual framework of programming and feedback13. Improved health care processes at and after discharge correlate with reductions in early re-hospitalization14. Many of these interventions are best deployed through protocols that depend on the coordinated actions of more than one provider, and on effective incorporation of patients, families and community health support agencies. quote

The following table (Table 1) summarizes implemented interventions by driver of rehospitalizations. These were the widely used interventions and the readmission drivers they are intended to remediate for the 9th SOW communities.

Table 1: Interventions by Driver TableAdobe Acrobat PDF

The Proportion of Transitions Table

To guide intervention planning, CMS and the Care Transitions Theme Support Center developed a Proportion of Transitions Table (PTT) to supply each QIO with the expected contribution of each provider to total transition activity occurring within the targeted population. The PTT resulted from analysis of all FFS Medicare claims for residents residing in the zip-code identified community for the calendar year 2007, to attribute transitions occurring within 30 days of hospital discharge to individually identified providers. The PTT will be updated annually throughout this project when the 2008 and 2009 data are available.

Only those transitions beginning with a hospital discharge are included in the PTT. Each transition is assumed to have 2 participants, a sending provider and a receiving provider. Every hospital discharge is attributed to that hospital as a sender, and each hospital readmission is attributed to that hospital as the receiver. Providers are designated as ‘targeted’ if they were identified by the QIO as a target of recruitment for the project. Any provider not designated as ‘targeted’ is included in the PTT as ‘non-targeted.’ Additionally, providers are categorized as being “In-Area” or “Out-of-Area”. In-area providers are either targeted by the QIO and/or are providers who are physically located within the community zip codes. Out-of-Area providers are not targeted by the QIO and they are located outside of the community zip codes.

Providers are further categorized as ‘inpatient’ or ‘outpatient’15. Numbers of transitions, either as a sender or receiver, are tallied per targeted institution or are attributed to that institution as a simple proportion of all transitions counted for the targeted population. Each transfer of a patient to home is counted in its’ own category labeled “home” and every readmission of a patient from home is attributed to “home” as the sender. The resulting table therefore has a cell for each targeted inpatient and outpatient providers, for home, and then the remaining providers are grouped into the following categories: Inpatient Out-of-Area (or non-targeted inpatient providers); Outpatient In-Area (for those non-targeted outpatient providers); Outpatient Out-of-Area (for those non-targeted outpatient providers not within the community zip codes); HHA/Hospice Not in Community (HHA and Hospice are reported separately from other settings). Each of these providers and categories are listed along the row as senders, and the same along the column as receivers. Numbers in each cell in the body of the table indicates how often each pairing occurs during a year of transitions for the population (see Sample PTT/Transitions Grid).

The benefit of identifying a population that can be largely mapped to a finite set of providers is most evident from the PTT. If there are a large number of providers involved in delivering medical services to the population, QIOs either must rely on a few targeted providers to make large enough reductions in readmissions to affect the population readmission rate, or have adequate staff devoted to the project to reasonably affect processes and practices at a large number of institutional and non-institutional settings, including home health agencies and physician offices. Communities in which the medical service patterns extend well beyond the group of providers targeted by the project will have larger proportions of transitions attributed to ‘non-targeted’ providers.

QIO-Developed Tools

The following tools and resources were developed by QIOs participating in the Care Transitions theme in the 9th SOW. These reference materials may be of assistance when developing your community strategy and resources. For additional information, please contact the Integrating Care for Populations & Communities National Coordinating Center (ICPC NCC) or the individual QIO as the developer of the resource.

Interventions & Resources

Coaching

Personal Health Records

  • Care Transitions Intervention PHRAdobe Acrobat PDF
    This is the original personal health record designed by Dr. Eric Coleman that provides the framework for the 4 pillars of the CTI Intervention.
  • Top 10 reasons to complete a PHR: PAAdobe Acrobat PDF
    This is a one-page document to illustrate the reasons for completing a PHR.
  • PHR: NY
    • English VersionWord Document
      This is an example of a custom designed PHR that includes the entire framework of the CTI Intervention.
    • Spanish VersionsWord Document
      This is the same custom designed PHR in Spanish.
  • PHR (English & Spanish): TXAdobe Acrobat PDF
    Here is another customized version of the PHR in English and Spanish. The medication record insert can be found in the next section.

Patient Activation/Self Management

Discharge/Transfer

Disease-Specific Tools

  • Heart Failure passport resources: MI
    This link provides multiple educational resources for patients and providers pertaining to heart failure.
  • Heart Failure SBAR Form: GA Adobe Acrobat PDF
    This 2-page form provides information for nurses to discuss changes in a patient’s condition using the Situation, Background, Assessment, and Recommendation format.
  • Dialysis Communication Form: PAWord Document
    This one-page dialysis communication form was designed to provide critical patient information as they transition from the nursing home to dialysis and back
  • COPD Red Flag Magnet: NJAdobe Acrobat PDF
    This COPD red flag magnet was designed as an educational tool for COPD patients.
  • HF Red Flag Magnet: NJAdobe Acrobat PDF
    This HF red flag magnet was designed as an educational tool for HF patients.

Setting Specific

Palliative Care/Hospice

  • 10 Facts Physicians Need to Know About POLST: PAAdobe Acrobat PDF
    This ten facts for physicians POLST tool was designed to educate physicians regarding POLST (Physician Orders for Life-Sustaining Treatment).
  • 10 Reasons to Consider a Hospice Consultation: PAAdobe Acrobat PDF
    This ten reason hospice consultation tool was designed to educate physicians concerning specific conditions that could qualify patients for hospice services.
  • Hospice Interview to Reduce Readmissions: NJWord Document
    This four-page hospice interview format was designed to assist the QIO in determining the dynamics of the hospice agency and how they could support the hospice in designing processes to reduce preventable hospital admissions.
  • Hospice Change Package: NJAdobe Acrobat PDF
    This three-page hospice change package was developed for hospice agencies to improve their processes to reduce acute care hospitalization, improve the quality of care and to improve communication when transitions occur.

Physician Office

  • Physician Practice Communication Needs Assessment: NYWord Document
    This is a one-page concise physician practice needs assessment tool to assist the QIO in determining areas for communications process improvement between the physician practice and other healthcare providers.
  • Physician Practice Assessment Form: NJWord Document
    This one-page physician practice interview format was designed to assist the QIO to determine the dynamics of the physician practice and how they could support the practice in designing processes to improve communication between providers and reduce hospital readmissions.
  • Physician Practice Change Package: NJWord Document
    This two-page physician practice change package was designed to assist the practice improve office systems, increase patient education, establish linkages with other providers and track and analyze hospital readmissions.
  • Post-It Note Template: NJAdobe Acrobat PDF
    This post-it note template was designed to inform patients and family that the physician practice is working to prevent unnecessary hospitalizations.
  • Notepad Template with Reminders: NJAdobe Acrobat PDF
    This notepad template was designed to provide reminders for the physician practice regarding safe care transitions.

Home Health

  • HH Interview to Reduce Readmissions: NJWord Document
    This five-page home health agency interview format was designed to assist the QIO in determining the dynamics of the home health agency and how they could support the agency in designing processes to reduce preventable hospital admissions.
  • HH Change Package: NJAdobe Acrobat PDF
    This three-page hospice change package was developed for home health agencies to improve their processes to reduce acute care hospitalization, improve the quality of care and to improve communication when transitions occur.
  • HH Quality Improvement campaign Best Practice Intervention Packages (BPIP)
    (Please note these downloads require a free log-in)

SNF

  • NH Interview to Reduce Readmissions: NJWord Document
    This five-page nursing home interview format was designed to assist the QIO in determining the dynamics of the nursing home and how they could support the facility in designing processes to reduce preventable hospital admissions.
  • SNF/Rehab Hospital Change Package: NJAdobe Acrobat PDF
    This four-page skilled nursing facility/rehab hospital change package was developed for SNF/Rehab Hospitals to improve their processes to reduce acute care hospitalization, improve the quality of care and to improve communication when transitions occur.
  • Discharge Poster: TXAdobe Acrobat PDF
    This SNF discharge poster was designed as a reminder for staff to review necessary elements of a safe transition to home prior to discharge.
  • Monthly Readmissions Reporting Form for SNFs: TXAdobe Acrobat PDF
    This monthly readmissions reporting form was designed for skilled nursing facilities to document hospital readmissions and interventions implemented with a status report update.

Miscellaneous

9. Remington Report, January 2010
10. Improving care transitions and reducing hospital readmissions: Establishing the evidence for
community-based implementation strategies through the care transitions theme, (Remington Report, January 2010)
11. Coleman E, Parry C, Chambers S, Min S: The Care Transitions Intervention Arch Intern Med. 2006; 1822-1828
12. Naylor M, McCauley K: The effects of a discharge planning and home follow-up intervention on elderly hospitalized with common medical and surgical cardiac conditions. J Cardiovasc Nurs. 1999; 14 (1): 44-54.
13. Gittel JH. Fairfield K, Bierbaum B, Head W, Jackson R, Kelly M, Laskin R, Lipson S, Siliski J, Thornhill T, Zuckerman J: Impact of relational coordination on quality of care, post operative pain and functioning, and the length of stay: a nine hospital study of surgical patients. Med Care 38: 807-819, 2000
14. Philips CO. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA. 2004; 291: 1358-67.
15. ‘Inpatient’ Provider examples: Short-term (General and Specialty) Hospitals, Federally Qualified Health Centers, Alcohol/Drug Hospitals, Medical Assistance Facilities, Critical Access Hospitals, Long-Term Hospitals, Hospital Based Renal Dialysis Facilities, Rehabilitation Hospitals, Children's Hospitals, Psychiatric Hospitals, Skilled Nursing Facilities
‘Outpatient’ Provider examples include: Hospices, Independent Renal Dialysis Facilities, Home Health Agencies, Comprehensive Outpatient Rehabilitation Facilities, Rural Health Clinics, Community Mental Health Centers, Outpatient Physical Therapy Services

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