Chronic Disease and Prevention
Care Transitions Coach
The Care Transitions Intervention is offered to patients with one or more of six chronic or acute medical conditions:
o Congestive heart failure
o Coronary artery disease
o Chronic Obstructive Pulmonary Disease
o Diabetes Mellitus
If the number of referrals exceeds the program’s capacity priority is given to patients who are 80 or more years old, who are discharged on 8 or more medications, who have well managed secondary psychiatric diagnoses and who are discharged with little or no support at home. Patients with dementia can be included if there is a caregiver who wishes to participate.
In the course of a home visit, the care transitions coach might identify patients whose psychosocial and economic concerns overcome their ability to benefit from coaching, but who are in need of protective services, palliative or hospice care, help for substance abuse, or connection with support services. In such cases, the coach will either direct the patient to the agency or person best suited to help the patient address his needs or contact the agency on the patient’s behalf.
• Decrease 30 day readmissions by 10% by the end of FY 2014.
• Increase patient engagement in self care pre- and post-Care Transitions Intervention and measure using the “Patient Activation Measure.” This validated tool showed an average improvement in engagement of 4 on a scale of 1 to 10 in FY 2013.
• Expand availability of coaching by expanding list of qualifying diagnoses, collaborating with our cross continuum partners (VNA, HVES, FCHCC, CDPA, CHF certified nurses, Respiratory team and SNFs), offering the CTI to patients discharged from the ED and bringing the Care Transitions Intervention to primary care practices.
• Lead cross continuum quality initiative started through the Care Transitions Education Project (CTEP) and implemented by nurses at CDH, VNA & Hospice of Cooley Dickinson, Linda Manor, Calvin Coolidge and Genesis Elaine to systematize and hardwire the delivery of warm handovers for patients transitioning between these facilities and agencies.
• Collaborate with cross continuum partners to improve availability and coordination of care transition services to the community.
• Deliver CTEP curriculum to cross continuum nursing groups to develop and facilitate resulting QI projects implemented by front line nurses.
• CTI participants: Patients with chronic illness will be able to manage their illness in a non-hospital setting resulting in lower costs, reduced hospital readmissions, and improved quality of life.
• CTEP/warm handover participants: Patients will experience increased quality and safety in their transitions between participating facilities and agencies as measured by rate of returns to Ed within 72 hours and 30 day all cause readmission rates.
The Transitions Coach will facilitate the development of self-management skills in both newly discharged patients and patients referred from the community. This will allow patients to stabilize and maintain their health, limiting the need for recurring hospitalizations and Emergency Department visits and improving selected HEDIS measures in the patient setting.
• The patient is knowledgeable about medications and has a medication management system.
• The patient understands and uses the Personal Health Record to facilitate communication and to ensure continuity of care plan across providers and settings.
• The patient schedules and completes a follow up visit with the primary care provider or specialist and is prepared to be an active participant in interactions.
• The patient is knowledgeable about indications that a condition is worsening and knows how to respond.
This program is consistent with Cooley Dickinson Hospital's mission as the program is offered at no cost to the patient, is relatively low cost to administer, and seeks to maximize and expand its partnership with community agencies and facilities. The CTI supports the essential component of chronic disease management, the ability to self manage care. The CTI and CTEP support the Institue for Healthcare Improvement “triple aim” of better care and better health at a lower cost and are consistent with the STAAR initiative to reduce readmissions. CTEP QI projects across the continuum address 2 of the 8 dimensions of care identified in the Massachusetts Strategic Plan for Care Transitions and highlighted in patient satisfaction surveys: continuity and transitions, and coordination of care.
Center for Excellence in Diabetes Education
Patients with diabetes, pre-diabetes or those who are at risk of developing diabetes. We will target patients who are indigent, lack the ability to pay for services (co-pays too high and patients cannot afford the number of co-pays that may be necessary for them to get the care and education they need), have no insurance or have other access to care issues such as race/culture, and mentally disabled. (The target population will be further refined through the needs assessment).
1,561 patients participated in 3,864 visits during a one-year period in 2011-2012
Operate the Center for Excellence in Diabetes Education
All those patients with diabetes, and those at risk who want care, will receive the care they need. Lack of insurance and money will not be a barrier to giving patients the care they need.
• Increase access to CEDE by coordinating referral processes with the Emergency Department, as well as inpatient medical surgical floors, by meeting with new nursing and case management staff via New Hire Training sessions done monthly.
• Create “Care Coordination Group” for collaboration among care/case managers and or appropriate representatives from different areas of the CDHCC to ensure all patients are getting appropriate health care by utilizing existing programs or developing programs that fit the need for people with chronic illnesses. This would include but not limited to, hospital, PHO, VNA, SNF’s, Highland Valley Elder Services and other appropriate programs/agencies such as CEDE and PCP practices.
• Increase access by referring patients with no, or inadequate insurance to Hampshire Health Connect or any appropriate agency help the patient get the appropriate insurance coverage.
• Provide educational programming to patients and their families; purchase or create educational materials.
• Ensure all future handouts regarding diabetes, put into use at CEDE or the hospital, are available in Spanish as well as appropriate literacy levels.
• Have necessary samples and supplies on hand for patients who are indigent.
• Work with the primary care practices to help improve care for patients with diabetes. A plan is currently being developed which will include case conferences with CDPA PCP’s to help bring more knowledge of diabetes care to the practitioners as well as creating a plan for patients that creates a true team approach to care. Another piece of this plan will include identifying “diabetes champions in each practice as well as VNA, each unit of the hospital, and other appropriate areas to be identified.
• Provide the Step Up program:
o Include Pre-diabetic Individuals
o Incorporate Diabetes Prevention Program (DPP) into Step Up curriculum
o Continue 12-Week Exercise Program
o Expand 12-week Core Educational Series to a 16-Week Series.
o Access to Nutrition Counseling for Pre-Diabetic Individuals
o Patient-Directed Follow-Up Sessions
o Increase in Sessions Offered
This project addresses the Massachusetts health priorities of chronic disease management.
A Positive Place (formerly AIDS CARE/Hampshire County)
People living with HIV/AIDS in Hampshire and surrounding counties. Although the overall rate of new infections has decreased over the years in the Commonwealth due to innovative and successful prevention work, A Positive Place continues to see an increased number of clients using our services. In the past three years, APP’s client population grew by nearly double.
In FY 2013, APP served 185 PLWH. Our target population includes: 75 percent male, 24 percent female, and 1 percent transgender; 71 percent between the ages of 40-59, with a breakdown of 40-49 at 39 percent, 50-59 at 32 percent.
In our largely rural area isolation, lack of transportation, stigma, fear, and depression inhibit many PLWH from accessing care; even the less rural areas have limited and scattered medical and social services. Many clients are experiencing the natural effects of aging combined with co-morbid conditions, which is taking its toll and increasing challenges to navigating systems.
A dearth of trauma-specific care for survivors and wait lists for mental health services exacerbates adherence challenges, and a lack of psychiatrists and access to psych medications continues to be a problem, especially for those suffering cognitive impairments from the virus. Many of our clients experience higher rates of chronic disease.
Other barriers to access include poverty, drug addiction, and cultural distrust of our health care system and providers. The lack of culturally competent services/ providers is a significant barrier for our Latino, Black, and MSM clients. Homelessness and/or the risk thereof in a county with a historically high FMR, combine with poverty, court involvement, and addiction, making transiency a way of life and access to services irregular. 20-25 percent of people living with the virus are unaware of their status, thus increasing the risk of transmission.
A subsequent high rate of concurrency, defined as having a diagnosis of HIV and AIDS within two months, (45 percent for Hampshire County compared to 30 percent statewide) points to a vital need for risk reduction efforts, positive prevention education, and public awareness education around screening/testing, and medication adherence.
Based on our stigmatized and marginalized target population and the needs outlined above, critical components of APP treatment and prevention include equal access to and coordination of quality medical care and medication, community-based services and government benefits; trauma-informed/culturally competent services; home-health services; peer support, navigation & advocacy; education around medication adherence and risk/transmission reduction; mental health/substance use support; medical transportation, emergency food assistance, and stable housing.
Accessing these basic needs can be difficult, and is often exacerbated for many of our clients due to substance abuse and histories of trauma, loss of income due to inability to work, histories of incarceration, and other challenges linked to poverty, racism, language, etc.
Our three goals, aligned with those of the National HIV Strategy, are:
1. Increasing access to and retention in care and health outcomes for PLWHA
2. Reducing health disparities based on race, ethnicity, gender, sexual orientation and eliminating health inequities
3. Reducing number of new HIV infections
Frameworks/Tools used to help us meet these goals:
1. Cultural awareness & humility (cultural competency): CLAS
2. Harm Reduction: Motivational Interviewing & Stages of Change
3. Trauma Informed Care - (trauma has been associated with high ART failure, 4x odds)
4. Stratified Data collection & analysis
• All clients will be linked up with an HIV medical care provider, and have at least two documented visits per year.
• Clients will have medical care of PCPs, infectious disease and other specialists, dentists, mental health/substance abuse programs coordinated on their behalf.
• Clients will have social services coordinated and integrated with medical care management.
• Clients will have comprehensive health insurance and medication reimbursement coverage, as well as benefits including SSI, SNAP, etc.
• Clients will have equal access to emergency assistance in the form of food vouchers, emergency utilities and rental assistance, and housing support and advocacy.
• Clients will have medical transportation to health-related appointments.
• Clients will engage in positive prevention and risk reduction activities.
• In order to reach those unaware of their status, infectious disease specialists have committed to engage in increased public awareness efforts around universal screening, testing, and counseling.
Provide confidential, equitable and integrated medical and social case management and health related support services, emergency assistance, risk assessments/reduction, housing assistance, to increase engagement/retention in care, reduce the rate of transmission, and improve quality of life. Services are provided in ACHC office, off-site at infectious disease specialist, and in people’s homes, jail, hospital, treatment program, nursing home, or other location as needed.
This project addresses the Massachusetts health priorities of access to health, and health equity, health reform, chronic disease management.
Cooley Dickinson Hospital • 30 Locust St. (Route 9), Northampton, Mass. • (413) 582-2000
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