Anuj K Dalal presents information on a PCORI research grant: Relative patient benefits of a hospital-PCMH collaboration within an ACO to improve care transitions.

1. 1
Relative patient benefits of a hospital-
PCMH collaboration within an ACO to
improve care transitions
Anuj K. Dalal, MD, FHMAnuj K. Dalal, MD, FHM
BWH Hospitalist ServiceBWH Hospitalist Service
Associate Physician, Division of General Medicine,Associate Physician, Division of General Medicine,
Brigham and WomenBrigham and Women’s Hospital’s Hospital
Instructor, Harvard Medical SchoolInstructor, Harvard Medical School
Co-InvestigatorCo-Investigator

2. 2
Disclosures
• None

3. About the Principal Investigator
3
Dr. Jeffrey L Schnipper

4. 4
Goals of this Talk
• To describe the design of the newly funded PCORI
study:
– “Relative patient benefits of a hospital-PCMH
collaboration within an ACO to improve care
transitions”
• To review the several components of the intervention
• To discuss early experience and potential implications
for communities

5. Description of study design
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6. 6
Specific Aims
• Aim 1: To develop, implement, and refine a multi-faceted,
multi-disciplinary transitions intervention with
contributions from hospital and primary care personnel
across several PCMHs within the Partners Healthcare
Pioneer ACO.
• Aim 2: To evaluate the effects of this intervention on post-
discharge adverse events, functional status, patient
satisfaction, and emergency department and hospital
utilization within 30 days of discharge.
• Aim 3: To understand barriers to and facilitators of
successful implementation of this intervention across
practices

7. 7
Rationale
• Partners is increasingly focused on improving value for
patients and is now a “Pioneer Accountable Care
Organization (ACO)”
– Partners hospitals have several financial incentives to reduce 30-day
readmissions
– As part of the ACO effort, most primary care practices will soon
become Patient-Centered Medical Homes (PCMH)
– In theory, both Partners hospitals and primary care practices will
have a vested interest in preventing readmissions
• An ideal transition requires efforts of inpatient and
outpatient personnel
– BUT, there are limits to how much can be provided by the hospitals
alone without participation and complete buy-in of primary care
practices

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Conceptual Model: Ideal Transition in Care
Burke, Kripilani, Vasilevskis, and Schnipper. JHM 2013.

9. Our PCORI Proposal
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In the era of ACOs, can hospitals and
PCMHs collaborate to fortify this bridge?

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Intervention
Burke, Kripilani, Vasilevskis, and Schnipper. JHM 2013.
Dischargeplanofcare
Inptandouptpharmacistmedrec
Web-baseddischargemodule
AutomatednotificationofTPADsFocusededucationandteachback
Engagecaregiversandcommunityservices
Automatedtriggerofpalliativecareconsult
EMR,careteam
identification,videoconf
VNA
assessment;disease-specificmonitor
Timelypost-dischargef/u

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Intervention: Main Components
• Hospital
– Inpatient medication safety interventions*
– Inpatient “discharge advocate” (DA)
• Primary Care Practices (PCMHs)
– Nurse “Responsible Outpatient Clinician” (ROC)/Patient Coach*
– Multi-disciplinary post-discharge clinic visit: ROC*
/pharmacist*
/PCP
• Both Hospital and PCMH
– Interventions for high-risk patients (e.g., telemedicine)†
– Advance care planning‡
– Information technology (e.g., video-conferencing, pending tests)‡
• Other
– Visiting nurse intervention
†
Available, but requires a better payment mechanism
‡
Being worked on as part of an existing project
*
Require additional personnel, currently under-resourced

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Methods
• Patients
– 1800 patients admitted to BWH or MGH
– Affiliated with 50 Partners’ primary care practices “primed” to
become PCMHs
• Study Design: “Stepped Wedge”
– Randomize order in which each practice implements the
intervention (once achieve “primed” status)
• Outcomes Assessment: 30 days post-discharge by phone
interview and medical record review:
– Adverse events
– Patient satisfaction and functional status
– Health care utilization (e.g., ED visits, readmissions, etc.)
– Preventability of readmission via 360-degree review
(patient/family, inpatient attendings, PCP)

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Methods
• Mixed Methods
– Evaluate facilitators of and barriers to implementation via
provider surveys and focus groups
– Iteratively refine intervention components
• Subgroup Analyses
– Who benefits the most? (e.g., elderly, low health literacy,
etc.)
• Engage Patient and Caregiver Stakeholders
– Patient and family advisory council
– Patient/family representation on study steering committee

14. Stakeholder Engagement
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Step in CER Process Purpose of Patient Engagement Method(s) of Engagement
Topic Solicitation Is this an important topic? • Patient and Family Advisory Council
Framing the Question Is the specific research question important? • Patient and Family Advisory Council
Creation of Conceptual
Framework
Is the proposed conceptual framework compatible with
patient/caregiver experience? Is there anything
missing?
• Patient/Caregiver representation on Steering Committee
Selection of comparators
and outcomes
How do we design this intervention such that it is truly
"user-friendly" to patients and their caregivers?
• Patient and Family Advisory Council Meetings, emails and
conference calls as needed.
• Patient/Caregiver representation on Steering Committee
What post-discharge outcomes do you care about most? • Patient and Family Advisory Council Meetings, emails and
conference calls as needed, with participation of research
staff*
• Patient/Caregiver representation on Steering Committee
Data Collection Is this survey process appropriate? Are the proposed
questions clear and meaningful?
• Patient and Family Advisory Council Meetings, pilot testing of
research questions, emails and conference calls as needed, with
participation of research staff
Analysis Plan Are we enrolling the correct patient population? Have
we identified appropriate patient subgroups?
•Patient and Family Advisory Council Meetings, with participation
of research staff
•Patient/Caregiver representation on Steering Committee
Reviewing and interpreting
results
How is the study progressing?
Are the results of the study believable?
• Patient/Caregiver representation on Steering Committee
Translation How do we best explain the results to other patients
and the public?
• Patient and Family Advisory Council Meetings
• Patient/Caregiver representation on Steering Committee
Dissemination How do we best engage other patients when we
disseminate the findings?
• Patient and Family Advisory Council Meetings
• Patient/Caregiver representation on Steering Committee
Mullins, C. D., et al. (2012). JAMA 307(15): 1587-1588

15. A detailed description of selected
intervention components
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General Description
• Goals:
• Standardization of function
– Each unit, service, hospital, and practice may do things
differently, and with different personnel
– But hopefully, all achieving the same ends
• Liberal use of checklists to ensure activities are completed
• Reduction in redundancy in tasks, except where necessary
• Process redesign and standardization may result in greater
efficiency, but additional personnel still needed
– Some of these tasks have never been adequately resourced,
rarely performed

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Inpatient Discharge Advocate
• Goals:
– Point person for patient, family, post-discharge providers
– Coordinate discharge plan with the patient, caregivers,
hospital team, and outpatient team
• Communicate and manage expectations with patient/family re:
discharge plan, follow-up appointments
• Coordinate communication among clinicians for timely
decision-making and handoffs in care (e.g., fax discharge
documents, facilitate care team emails)
– Educate and prepare patient and caregivers for discharge
• Resolve barriers to executing post-discharge plan (e.g., filling
prescriptions, transportation)
• Perform safety checklist (e.g., adequate monitoring, discharge
documentation, follow-up)

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Responsible Outpatient Clinician (ROC)/Patient Coach
• Goals:
– Serve as a bridge between inpatient stay and outpatient
clinic
– Modify post-discharge plan as needed
– Coach patients and caregivers so that they are best able
to carry out the post-discharge plan

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ROC/ Patient Coach Activities
• While patient is still in the hospital:
– Ask patient about most important goals for recovery period
– Discuss reasons for and importance of keeping follow-up
appointments
– Remind patient to bring discharge instructions, personal
medical record, follow-up calendar, medication list, pill
bottles
– Review use of personal medical record
– Discuss barriers to keeping post-discharge appointments
and explore ways to overcome them
– Use teach-back to confirm understanding

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ROC/ Patient Coach Activities (continued)
• During post-discharge clinic visit:
– Review patient’s goals for the recovery period, discuss how
best to meet them
– Review discharge summary, patient instructions, follow-up
appointment calendar, patient’s PMR, VNA notes
– Review test results finalized since discharge
– Begin patient coaching
• How to monitor medical conditions at home
• How to manage behavioral changes
• Danger signs to watch for
• How to use medical devices (e.g., glucose monitor)
• How to keep a personal medical record

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ROC/ Patient Coach Activities (continued)
• Make 3 phone calls during the month after discharge
– Perform coaching activities as above
• For high-risk patients, conduct home visits
– Evaluate patient/caregiver’s ability to carry out plan at home
– Perform coaching activities as above
• For all activities
– Use role-playing and teach-back as needed
– Contact inpatient providers as needed
– Identify barriers to self-management and explore ways to
overcome barriers with patient, caregiver, and PCP
– Communicate with PCP, makes plans/arrange follow-up as
needed
– Document findings in the EMR

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Outpatient Pharmacist
• Goals:
– Ensure patient is discharged on the correct medication
regimen, understands that regimen, and is adherent with that
regimen
• Confirm med rec done correctly, update EMR
• Identify and resolve discrepancies between discharge regimen and
what patient thinks s/he should be taking
– Screen for barriers to adherence, early side-effects, and
address as needed
– Coach patient/caregiver regarding issues of medication
safety
• Work on strategies to maximize med adherence
• Identify medication red flags,
• Provide contingencies when problems arise

23. Potential implications – what will we learn?
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Early Experience with Study
• ACO leadership is supportive
– Believe it is the right thing to do
– Believe it will require additional resources
– Willing to work together across traditional silos
– Are they willing to open their pockets?
• Everyone feels financially constrained
• ROI is a leap of faith
• Incentives are still not completely aligned

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Early Experience with Study
• Patient and caregiver engagement
– Changes dynamic of steering committee meetings
– What components of the intervention do they really
care about?
– How does it feel to receive this intervention?
– What outcomes do they care about?
– Does an adverse event mean to same thing to patients
as they do to clinicians?

26. Discussion
• Implications for communities
– Should communities be embracing the move towards
consolidation, ACOs, PCMHs?
– What are the cons?
• Might mean less choice of providers, might feel more
“corporate”, might mean less time with MDs and more
time with other providers, etc.
– What are the pros?
• Might mean better coordination of care, better access to
data, different ways to provide care outside a visit, more
proactive care
– Does the answer depend on who you are?
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27. Thank You!
• Questions? Comments?
• Special thanks to our PCORI team:
– Nyryan Nolido, MA
– Gwen Crevensten, MD
– Eric Weil, MD
– Cherlie Magny-Normilus, NP
– Asaf Bitton, MD, MPH
– Maureen Fagan, DNP, MHA
– David Bates, MD, MSc
– Lipika Samal, MD, MPH
– Stephanie Labonville, Pharm D
– Joe Frolkis, MD
– Namita Mohta, MD
– Jackie Somerville, RN, PhD
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28. Additional Info
• The remaining slides provide additional information about the
intervention components and study design
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Inpatient Medication Safety Intervention
• Goals:
– Ensure accurate medication reconciliation
• In-depth med rec at admission and discharge
• Communication with post-discharge providers re: discharge
medication regimen, reasons for changes, etc.
– Educate patients/caregivers about the discharge
medication regimen
• Help understand discharge regimen (indications, special
instructions, how and why different from before)
– Prepare patients/caregivers to take medications safely
and correctly after discharge
• Minimize adverse drug events

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Other Inpatient Care Providers
• Goal: Standardize and distribute work
• Primary nurse:
– Talk with ROC, learn about patient, communicate
– Document discharge patient instructions
• Behavioral changes, final discharge plan, red flags, discharge
status
– Educate patient and family
• Identify active learner, review instructions, use teach-back
– Give patient personal medical record to use
• Unit coordinator:
– Schedule follow-up appointments based on time-frame,
patient/caregiver and provider availability
– Give patient calendar of follow-up appointments

31. 31
Partners Healthcare at Home (PHH)
• Goals:
– Assess patient’s home situation, current services, and level
of support
– Ensure ability of patients/caregivers to manage their
medical conditions at home
• Take medications, perform wound care, modify health-
related behaviors (e.g., diet), manage follow-up appointments
• Assist /teach patients/caregivers to perform these activities
until independent or no longer needed
– Communicate with members of the transition care team
• Document findings in EMR, communicate with inpatient and
outpatient care team by group email re: discharge plan

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Other Outpatient Providers: PCP
• Goals:
– Evaluate status of active medical problems compared with
discharge and post-discharge visits based on discharge summary
and VNA notes
– Discuss advance directives as needed
– Follow up on any other issues raised by discharging team, visiting
nurse, ROC, outpatient pharmacist, and communicate with these
providers as needed (i.e., outpatient specialists)
– Arrange for additional follow-up as needed (e.g., closer
monitoring of chronic conditions, social worker or psychiatric
follow-up, palliative care services)

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Interventions for High-Risk Patients
• Home visits by patient coach
• Telemedicine programs:
– CHF: weights
– Diabetes: POC glucose testing
– Hypertension: blood pressures

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Advance Care Planning
• Automatic trigger tool for inpatient palliative care
consultation
• Structured consultation regarding goals of care
discussion with patients, caregivers, and providers
• Communication with outpatient providers so
discussion can be continued
• Documentation in the EMR

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Information Technology
• Web-based discharge ordering module (BWH)
• Automated system to alert providers of results of tests
pending at discharge
• Group email capability linked to robust application
that identifies care team members (Partners Enterprise
Patient Lists)

36. Analysis
• Quantitative
– Primary Outcome: Adverse events within 30 days of discharge
• Logistic regression adjusted for study month, arm, and confounders
• Clustered by nursing unit, practice, attending, and PCP
– Secondary Outcomes:
• Preventable adverse events
• Duration of ameliorable adverse events
• Patient satisfaction
• ED and hospital readmission
• Change in functional status
– Subgroup analyses: elderly, low health literacy, high co-morbidity,
high risk for readmission
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37. Analysis
• Qualitative
– Grounded theory method
• Analyze focus groups and interviews re: barriers and
facilitators of implementation
– Mixed methods
• Are certain facets consistently implemented with high fidelity
and associated with improved outcomes?
• Where success is variable, can it be linked to choice of
implementation components, low intervention fidelity?
• Can low intervention fidelity be linked to certain contextual
factors?
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