Les Morgan

Improving care transitions through innovative use of technology

Can you help me find the very best examples of how innovative use of technology can improve care transitions?

Reducing preventable readmissions to the hospital is an important goal for many health systems. The United States has an 18% rate of hospital readmissions within 30 days of discharge. Many of these hospital readmissions are preventable simply by improving care coordination and paying close attention to what happens during a care transition. According to Medicare data, over half of readmitted patients received no care or follow-up in the 30 days after hospitalization. [Citation: Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. Apr 2, 2009;360(14):1418-1428.] After a hospital stay, patients often receive care that is fragmented and uncoordinated. This results in many problems both for the patient and the caregiver. Lack of care coordination drives up the cost of care and leads to errors in care delivery. Poor handling of care transitions also can result in expensive visits to the emergency room, even if there is no readmission to the hospital.

Studies by Coleman, Naylor, and others suggest that interventions targeted toward postacute care transitions can reduce hospital readmission rates by one-third. Many experiments are being conducted across the country to try out different approaches to improving the care transitions process. We need to raise the visibility on some of the promising approaches that might offer near-term benefit if they were more widely-known.

I'm looking for examples of innovative technology and protocols that have the potential to improve care transitions in the near-term in real care systems. I hope you will let me know if you have a working application or well-developed concept paper that deserves wider exposure. The technology interventions I'm looking for will focus on one or more of the following factors:

• Streamlining discharge planning to include better assessment of care transitions issues, with risk assessment for readmission
• Improving communication between clinicians and patients to improve care transitions
• Providing direct patient support during the transition from one care environment to another
• Improving patient self-management to reduce the need for readmission or a visit to the emergency room
• Better medication reconciliation and adherence
• Reducing the cost of patient monitoring and following up with patients after discharge

I'm particularly interested in looking at technology innovations in those categories where some outcome data is available showing improvement on any or all of these outcome variables:

• Rate of hospital readmission
• Emergency room utilization
• Patient and caregiver satisfaction
• Overall cost of care

The Center for Technology and Aging has produced a very good technology overview for this subject that will help you get started. You can download "Technologies for Improving Post-Acute Care Transitions Position Paper" directly from techandaging.org (September 2010, Discussion Draft http://www.techandaging.org/PACTdraftPositionPaper.pdf).

Growth House developed the Care Transitions Search Widget, a free search utility that you can install on your own web site to help your users locate information about improving care transitions and reducing hospital readmissions. The widget is a simple example of how technology can play a role in improving the care transitions process.

Care Transitions Search Widget gets nod from Altarum Institute

The Care Transitions Search Widget that Growth House designed got a nice writeup in an Altarum press release announcing availability of the service for more web sites. Here's a recap of the release:

Growth House is partnering with Altarum Institute, with support from The Commonwealth Fund, to offer a Care Transitions Search Widget that will make it easier for community organizations, hospitals, and other health care organizations to improve the continuity of care for their sickest patients.

The Care Transitions Search Widget is a free Web search tool that can be installed on any website. The design allows clinicians working to improve care transitions to identify, sort, and prioritize Web-based information about the strategies that tend to work in various settings. The widget software is one of the first research and demonstration activities to be conducted by Altarum’s Center for Elder Care and Advanced Illness, led by Joanne Lynn, MD.

The U.S. Department of Health and Human Services recently launched the Partnership for Patients initiative, which aims to reduce rehospitalization within 30 days of hospital discharge by 20 percent. One way to avoid readmission to hospitals after initial discharge is to ensure that transitions to home or nursing facilities are safe and seamless.

Technical support for developing the software tool is being provided by Growth House, which will provide technical support to web sites wanting to install the widget. For support call Growth House at 415-863-3045.

Overview of the Community-based Care Transitions Program

Joanne Lynn has written a brief and informative overview of the Community-based Care Transitions Program (CCTP), which provides funding for improving hospital discharges. This program is hoping to improve care transitions by having Community-Based Organizations (CBOs) partner up under Section 3026 of the Accountable Care Act, and there's quite a lot of money on the table. Download: Summary of the Community-based Care Transitions Program (.docx Word 2010 format) The summary includes some initial recommendations on how to make the program work, specific comments on how the CBO must be set up, what a "root cause" analysis is and why you need one, requirements for informed consent, and whom you should target. Pay special attention to the section on what determines funding past the first two years, which first and foremost demands evidence of improvement. Aside from that no-brainer, other criteria include whether or not the coalition complied with all the other requirements, and evidence that the members of the coalition play well together. The overview summarizes the outcome and process measures that have been published by CMS so far.

Care Transitions Search Widget on mobile devices

Here's a demo of how our free Care Transitions Search Widget runs on mobile devices such as smartphones and tablets. This video includes a Section 508 smackdown in which our technical services site visionteam.com is pitted against health.gov in a compliance cage match. Which site is more 508 compliant? Watch the shocking expose!

Play the video

Partnership for Patients National Patient Safety Initiative

When you go to the hospital you expect that it will make things better, not worse. But there is a dirty little secret about hospitals. On average, one in seven Medicare beneficiaries is harmed in the course of their care, costing the government an estimated $4.4 billion every year. At any given time, about one in every 20 patients have an infection related to their hospital care. Hospitals also sometimes fail to discharge patients into sustainable situations. Nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days (that’s approximately 2.6 million seniors at a cost of over $26 billion every year.)

On April 12, 2011, the Obama Administration launched Partnership for Patients, a new inititiave that seeks to reduce preventable hospital-acquired conditions and reduce preventable hospital readmissions. The drive aims to improve the quality, safety, and affordability of health care by coordinating the efforts of hospitals, employers, physicians, nurses, and patient advocates along with state and federal governments. There's a particular spin on this that is of special importance to those with chronic and complex conditions: better care coordination and care transitions can prevent hospital admissions.

The two goals of Partnership for Patients are to:

• Keep patients from getting injured or sicker by reducing preventable hospital-acquired conditions by 40% by the end of 2013, compared to 2010. Achieving this goal would mean approximately 1.8 million fewer injuries to patients with more than 60,000 lives saved over three years.
• By reducing preventable complications during a transition from one care setting to another, reduce hospital readmissions by 20% by the end of 2013, compared to 2010. Achieving this goal would mean more than 1.6 million patients would avoid preventable complications requiring re-hospitalization within 30 days of discharge.

Meeting these goals has the potential to save up to $35 billion dollars across the health care system, including up to $10 billion in Medicare savings, over the next three years. Over the next ten years, it could reduce costs to Medicare by about $50 billion and result in billions more in Medicaid savings.

Growth House is ramping up to support the care transitions part of this game and released a free search widget that you can install on your own web site to locate high-quality content related to improving care coordination. The widget is designed to look for quality improvement content from the leading websites that are participating in the Partnership for Patients National Patient Safety Initiative. If you want help installing the widget on your web site, give me a ring.

Care Transitions Search Widget

Give a test drive for this new search widget that is optimized to look for high-quality content related to healthcare protocols, improving care transitions, and reducing hospital readmissions. I developed this free widget for use on Growth House using Google's custom search technology. It prioritizes search results based on a carefully-selected list of sites that specialize in evidence-based quality improvement for healthcare. You can add the search code for this widget to your own web site if you like. Just "view source" for the HTML and cut and past the code onto any page you like. You also can get code for the widget from its home page on Google. It would be nice if you would credit Growth House as the developer, but you can also just pretend its yours if you want to. We just want it to get used.

Enter any search term you like. When the results come back you will see three extra tabs at the top of the results. There are tabs for "Hospital Readmissions", "Tools", and "Medicare". Select any tab to filter your results to look for content on those issues as they relate to your search.

Got feedback? Make a comment! What is your favorite web site for care transitions issues? Let us know and maybe we will add it to the priority list for this search engine.

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Preparing Your Children For Goodbye: A Guidebook for Dying Parents

Lori Hedderman's Preparing Your Children For Goodbye: A Guidebook for Dying Parents is an easy-to-read guide to end-of-life care that is specifically designed for use by parents of children and teenagers. It will help seriously-ill parents plan their end-of-life care, prepare their children for their death, and record life memories. Because it is tailored to the needs of parents who are dying it is more specific for that purpose than general reviews of end-of-life issues. It uses a workbook format that includes questions to help you consider issues relating to children, as well as more general questions that will help in planning and trigger memories about the past.

The book is divided into three parts:

• End-of-life issues to consider
• How children cope with death
• A Life Review workbook

The book also includes a Bibliography and a list of "Places to Turn To for Help".

The Life Review process can be used by anyone who is interested in thinking about their own past, even if they do not have children. The process of looking back over your life and thinking about what has mattered most to you is a natural part of facing death. There is a formal discipline called "Life Review" in which people are encouraged to discuss and write down aspects of their past. The workbook puts your life history in perspective and includes sections to capture memories related to your children. You can use the workbook on your own or with someone else. It’s a nice activity for two people to do together using a conversational approach. Conversational life review is helpful with older people who are having memory problems. An adult child can use the conversational method with an elderly parent to help exercise the mind and stimulate interaction. It's an enjoyable way to reminisce about the past and capture memories.

Hospice volunteers could use the book to do life review with patients who want to reflect on their lives. If someone is too sick to take on a major writing project, a volunteer can ask questions from the workbook to help the person recall anything that they want to have remembered. A volunteer could also work with family members to explain life review ideas and introduce the workbook as something they can use on their own.

Lori Hedderman (lorihedderman.com) is a certified school counselor who leads support groups for children whose parents are seriously ill. She conducts bereavement groups and counsels people who have experienced losses. She is trained in both crisis intervention and disaster mental health.

Just Enough: Collected Writings of an Old Gangster

Nancy Jaicks Alexander (1933 - ) is one of the pioneers of the hospice movement. She's been active in the death and dying movement about as long as it has existed in its modern form. Now 77, she retired this year. Her new book, Just Enough: Collected Writings of an Old Gangster, is a short memoir written mainly for her own family and personal friends. Nancy is a dear friend of mine, and I helped her develop some of her private writings into book form.

Elisabeth Kübler-Ross asked Nancy to begin training as a member of her international teaching and workshop staff in 1982. Nancy became one of Elisabeth's "Life, Death and Transition" workshop facilitators in 1985 and continued working on that staff through 1993. The workshops were discontinued in 1994. Unfortunately, none of the stories talk about her time with Kübler-Ross.

The book does cover the development of the first prison hospice in the world. In 1991 Nancy and her husband, Robert Evans Alexander, were among the co-founders of a hospice service inside the walls of the California Medical Facility (CMF), a cavernous penitentiary for men in Vacaville, California. The hospice project was an outgrowth of a support group that Nancy facilitated there for seven years for inmates with AIDS. Twenty-five years ago, at the beginning of the AIDS crisis, there were just twelve inmates who were treated like pariahs because they were carriers of the virus. Today, over 250 inmates are HIV-positive at that facility.

Robert died in 1992 and the California Department of Corrections and Rehabilitation dedicated the hospice to him in 1993. Nancy continued to visit the prison regularly to support inmate hospice volunteers. She retired in 2010 after twenty-five years of community service at the prison. The subtitle "Collected Writings of an Old Gangster" comes from a remark made by one of the prisoners that "Anyone who has done twenty-five years time is an 'OG' (Old Gangster)." She describes the prison as "my sangha, my spiritual home".

Looks can be deceiving. Nancy looks and usually acts like a refined, white-haired matriarch with a Patrician bearing. But nothing is off-limits for her conversations, and her stories don't pull any punches. She can chat with an angry inmate about the indignities of cavity searches as easily as she can speak at a professional forum. It seems you can talk with Nancy about pretty much anything. She is a good writer, and her stories are fun to read.

Room for Change by Susan W. Reynolds

Susan W. Reynolds' new book, Room for Change, has a unique and practical approach that can help you start your engine again after experiencing grief or loss. Making small changes to the physical environment in your home can give you a new perspective on your life. Recovering from grief is about reconnecting with life, and this book can help you do it. (Detailed review begins after the jump.)

Before reviewing the book in detail, I will disclose that I'm a certified Susan Reynolds fanboy. She syndicates some of her writing through her Growth House blog. Susan told me she was working on this book about a year ago, and I've enjoyed watching her pull it together. The final product is polished and innovative.

What I like about Susan's system is that it falls into the "When I got busy I got better" school of applied psychology. She jumps right in with easy, realistic things to do after a loss. In effect, this book starts where other bereavement books leave off. In a refreshing change from the generic grief book format, Susan doesn't spend time on theoretical material about stages of grief, classifications of coping styles, and other professional mantras that are covered extensively elsewhere. This isn't a book about theory, it's a book about about tactics. It's Ninja grief therapy.

Susan is a member of the Association of Design Education and a Physical Therapist. Her training in wellness and ergonomics gave her an "out of the box" perspective on how to help people in grief. Her system is based on the fact that making small changes in your surroundings can result in big changes in attitude. The book grew out of her own recovery process after her husband died of cancer, following a difficult two-year battle. She participated in traditional grief groups and found that a practical approach worked best for her. She uses her blog, "Room for Change", to present her ideas about the role of ergonomics in grief recovery. The book version of her system reflects input from bereavement coordinators and other specialists in the field of death and dying. Her company, Revival Redesign (www.revivalredesign.com) helps people refresh and enliven their personal space using items they already own and love. She is a consultant to hospices on how interior design can help clients feel comfortable and safe. She speaks at bereavement groups to teach her methods to people who have suffered loss.

The basic problem that Susan tackles is that many people feel dead themselves after someone they loved has died. Loss of joy for living, low energy, confusion about goals, and a sense of being overwhelmed are all very common feelings during grief. But it's important to remember that grief is not a mental illness. It's a normal and healthy emotional response to loss. Seeking professional support can be helpful for that relatively small proportion of grieving people who are experiencing depression or complicated grief. But most people, fortunately, have less severe grief reactions that are a universal human experience. "Normal grief" is part of being alive and rarely needs professional care. Even when it is needed, grief therapy is most effective if it is combined with gentle encouragement to pick up the pieces and reassemble them in a new way. Building your new life is the key to getting on your feet again.

Susan's unique approach is to help you look at your physical surroundings with fresh eyes, finding ways to make small changes that will wake you up again. Do you cry every time you look at those pictures covering the wall? Less is more, so maybe you could put some of them in storage and feature one or two that bring back happy memories. Alone at home and feeling miserable? Maybe you could get off your duff and visit the library or community group to be in a supportive public space that provides you with movement of people yet not forced interaction. As your energy returns, you could pack an overnight bag and keep it ready to grab for an outing. Susan's advice is always framed in terms of things you could do, not what you should do. She brainstorms fresh options with you like a caring friend. It's basically girl talk with a reality-based kicker.

Do these proactive, change-oriented examples seem insensitive? Would it be better to just give a big hug and encourage deeper expressions of sadness and misery? Not for me, thanks, not my style. I'm a guy, and we aren't wired that way. In fact, many people with resiliant personalities find bereavement groups to be a downer. Of course we all need emotional support (even guys). But most people respond best to support that reminds them of their own self-worth and innate survival skills. (See: Does a former Marine drill sergeant make a terrible therapist? You be the judge.) Susan's book is on the mark in giving commonsense suggestions that most people can immediately grasp and try out. Try something simple, get immediate payoffs.

Living your own life fully is the most important way to honor those who have died. If you are feeling stuck in the mud following a loss, perhaps Room for Change can help get moving foward again.

Hospices Not Deactivating Defibrillators in Patients

A new national study of hospice patients with implatable cardiac defibrillators (ICD) shows that while almost all hospices admit patients with these devices, only 20 percent of hospices had a question on their intake forms to identify patients with ICDs, and just 10 percent reported having a policy in place to discuss deactivation with patients and their families. On average, nearly 60 percent of patients did not have the shocking function of the ICD deactivated, resulting in pain and suffering for some patients. (See: Brief Communication: Management of Implantable Cardioverter-Defibrillators in Hospice: A Nationwide Survey. Nathan Goldstein, MD; Melissa Carlson, MBA, PhD; Elayne Livote, MPH, MS, MA; and Jean S. Kutner, MD, MSPH. Annals of Internal Medicine, March 2, 2010) The abstract is online at http://annals.org/content/152/5/296.abstract.

"Hospices are the foremost experts at dealing with the complex communication issues surrounding end-of-life discussions with patients and their families," said Nathan Goldstein, MD, assistant professor, Hertzberg Palliative Care Institute, Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine (www.mountsinai.org). "The fact that so few organizations have a policy about deactivation shows how complicated these conversations are."

The idea of turning off a cardiac implant or any other life-sustaining treatment is not easy for people to talk about. Many patients have had these devices for years and see them as a sign of stability. But the consequences of ignoring the issue aren't pleasant. An ICD is a device programmed to detect cardiac arrhythmias and shock the heart back into normal rhythm. ICDs are effective in preventing sudden cardiac death in patients with recurrent arrhythmias, but for patients in hospice care ICD shocks may cause physical and psychological distress for both patients and their caregivers. Patients report that receiving shocks from an ICD is comparable to being kicked or punched in the chest. Receiving ICD shocks has been associated with the development of adjustment disorders, depression, post-traumatic stress disorder, and panic disorder. Family caregivers who observe patients being shocked report feelings of fear, worry, and helplessness, and have been shown to have increased rates of depression and anxiety. For patients with terminal diseases an ICD may no longer prolong a life of acceptable quality, so at some point use of an ICD may become inconsistent with currents goals of care.

"These data indicate that developing a policy to address concerns surrounding ICDs can be highly beneficial in reducing emotional and physical discomfort for hospice patients and their families," said Dr. Goldstein, whose team developed a model policy for ICDs in hospices based on feedback they received from several facilities. The policy includes the necessity for staff to be educated on how ICDs work, identification of patients with ICDs at the time of evaluation and admission, an informed consent discussion with the patient and family about the benefits and burdens of the device, and how to handle the device in an emergency situation.

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