Transitions of Care in Population Health

Question 1

Define what constitutes care transitions

Answer 1

transitions occur:
 Home to hospital
 Extended-care facility to hospital
 Hospital to home
 Hospital to extended-care facility
 Hospital Rx to Community Rx
 Extended-care facility to hospital
 Extended-care facility to home
 ER to primary care
 ER to community services
 FQHC to primary or specialty care
 Primary care to specialty care
 Curative care to Palliative/Hospice care
 Dental office to pharmacy
 Any time a patient moves from one level of care to another as care needs
change

Question 2

How has the current model of care in the US made transitions more difficult?

Answer 2

sharing medical records (diff medical record systems)

Question 3

Explain the importance of transition care management to
patients

Answer 3

Address an expectation of continuity of care,especially within a health care system

Question 4

Explain the importance of transition care management to health care providers/health systems

Answer 4

Reimbursements are tied specifically to readmission rates
Cost avoidance

Question 5

Explain the importance of transition care management to insurers

Answer 5

cost avoidance
improved outcomes

Question 6

Identify patients for whom transitions of care services are especially important

Answer 6

especially important for ACOs
 Elderly
 Patients living alone
 Patients with caregivers
 Patients with complicated therapies/multiple medications: asthma/COPD, heart failure, renal disease
 Patients with limited health literacy
 Patients without a PCP
 Patients with comorbid psychiatric illness or SUD

Question 7

What is an ACO?

Answer 7

accountable care organizations are groups of hospitals, providers, and community partners who come together, along with a health plan, to improve patient outcomes and reduce health care costs be delivering highly coordinated care

Question 8

In an ACO we will help our patients

Answer 8

avoid unncessary trips to the ER
better manage medications
address SDOH
reduce preventable hospital admissions

Question 9

Identify key individuals who should be included of the transitions process

Answer 9

 Patient
 Caregiver
 Physician/Advanced practice provider
 Nurse/Medical Assistant
 Social worker
 Case manager
 PT/OT/ RT
 Community health worker
 Pharmacists/Technicians

Question 10

What can go wrong w/o good TOC?

Answer 10

 Wrong medications, diagnosis, or treatment
 Delay in treatment or diagnosis
 Duplicate tests, medications or treatments  Increased $
 Patient/caregiver confusion
 Reduced patient satisfaction
 Poor outcomes/treatments not adhered to
 Slower recovery
 Patients lost to follow-up

Question 11

Describe how pharmacy can impact transitions of care to improve outcomes

Answer 11

 At the time of admission  Throughout care
 At the time of discharge  After discharge