-

J

Unpacking the Post disch

disch

Post-ED Tele ED Telephone Call

VISN20 Jenny Richardson, MS, RN, CNSVISN22 Kristina M. Cordasco, MD, MPH, MApril 18, 2012 
- -

PACT 

The Patient Aligned CareTeaThe Patient Aligned Care Tea

VHA’ d l f h M di VHA’s model of the Medica

y Each Veteran working g to ether 

health care professionals to plan whole -person care and life person care and life -long 

long 

and wellness. 

◦ Partnershi i h V hips with Veterans ◦ Access to care using diverse meth◦ Coordinated care among team me

◦ Team -based care with Veterans as 

based care with Veterans as 

center of their PACT 
Goal for the Goal for the 

Patient’s View of PACT Patient’s View of PACT 

Relationship Comprehensive Access 

• I can get care 

h d

 h I 

Relationship 

over time 

• I have a Team 

h k 

Comprehensive 

services 

• My Team takes

 f h b lk 

• 

when and how I need it 

who knows me 

as a person 

care of the bulk of my needs 
PACT Demonstration Labora

PACT Demonstration Labora

• Evaluate the effectiveness and impact of VHA’s PACT m• Develop and test innovative solutions for the core com

PACT model 

1. PACT Demonstration 

Coordinating Center: 

2. VISN 4 Center for Ev

VISN 4 Center for EvPACT (CEPACT): Phi

3. VISN 11 PACT Demo

Laboratory: Laboratory: Ann Arbo

Ann Arbo

4. VISN 20 PACT Demo

Laboratory: Portland, 

5. 

VISN 22 Veterans Ass

Improvement LaboraSepulveda, CA. 

6. VISN 23 PACT Demo

Laboratory: Iowa City
Goal of Today Goal of Today s Presentat

Goal of Today s Presentat

’s Presentat

y Describe our experiences with 

Describe our experiences with to improve the transitions betwdifferent sites of care 

Inpatient ED 

Home Home 
Transitions in Care Transitions in Care 

y Potentially problematic Potentially problematic y Associated with Adverse Events 

◦ Medication Errors (Forster, 2005) ◦ Missed Test Results (R 2005) (Roy, 2005) 

y Approximately 1 in 5 patients d

from the hospital is readmitted day s (J , ) encks, 2009)
Clinical Initiative Clinical Initiative 

y Overarching Goal: Improve the 

Overarching Goal: Improve the care across transitions 

y The postdischarge telephone ca

strategy used for decreasing rehospitalizations. (Hansen, 2011) 

PortlandVA Goal: Increase the pPortlandVA Goal: Increase the p

of patients contacted after disc

telephone by Primary Care telephone by Primary Care 
Already in place in 2011... Already in place in 2011... 

y Patients had telephone appointm

for 3 business days after discharfor 3 business days after dischar

◦ Calls made by RN associated w

ownPA PACT l team et 

y VISTA emails: back-up system 
Already in place

... 

y T l f l h ll d 

Template for telep

hone call docu

◦ General assessment 

◦ Medication reconciliation ◦ Pending/needed appointments Pending/needed appointments 

y D d d l ll D

e

dicated note title automaticall

connected to encounter 
What needs to improve? What needs to improve? 

y Process unreliable – reaching 1

reaching 1

discharges 

y VISTA email fatigue y Should we contact patients ear

Should we contact patients ear

y Significant editing of note tempRevised Goal = contact at lea

di h i i b h disc

harging patients by t

he s

business day after discharge 
Methods Methods 

• RN education for 11 clinics RN education for 11 clinics 

• Evidence base regarding transitio• NCM hi f NCM ownership of process 

• Data review 

• Appointments and encounters 

• Individual RN champions Individual RN champions • Moved up call to 1 business day 

discharge 

• Met with multiple stakeholders Met with multiple stakeholders 
• Worked with Inpatient Ward Se

• Implementationf o semi-automa

p rocess in CPRS 

• Alert RNs one day after disch






In Conclusion

, 

y All clinics reached 2 day goal of 

50% 

y ED visits / Rehospitalizations wi

wi

days of discharge 

◦ Downward trend for patients 

in < 2 business day

s

y Development of policy documey R i i f RN t t l t Revision 

of RN no

t

e templa

te 

y Random monthly audits of telep

appointments started Jan 2012 
jeannette.richard
PACT Follow-Up Care an

Coordination After EmergeCoordination After Emerge

Department Care – A Pilo

Project

Kristina M. Cordasco, MD, MPH, MS

VI

SN 22 VA Assessment 

& Improvement L

(VAIL)

Kristina.Cordasco@va.gov 
Today’s Presentation 

1) Introduce the problem of inadequate commun

coordination of care post Emergency Departmcoordination of care post Emergency Departm

discharge 

2) Describe Greater Los Angeles’ proof-of-conce

innovation for communicating and coordinatin

care with PACT teams care with PACT teams 

3) Discuss the potential impact on PACT perform

having a reliable and systematic method of communicating urgent and specific ED followneeds 

4/17/2012 VAIL-PACT VISN22 
Context 

• VAIL uses evidence-based quality impro

methods to support PACT transformatiomethods to support PACT transformatio

– Sponsors local Quality Councils that review and s

PACT innovations 

• VAIL identified post-ED communication a

coordination with PACT as an area of cocoordination with PACT as an area of co

– Continuity Measure – Access Measures 

4/17/2012 VAIL-PACT VISN22 
Problem 

• With no systematic and reliable method 

communicating and arranging for post communicating and arranging for post -E

follow-up needs: 

• Patients were often being told by ED clinicians t

to see their PACT providers ( Continuity) 

• When there was uncertainty about whether the 

could walk could walk-in they were sometimes being told in, they were sometimes being told 

clinicians to return to ED for follow-up ( Contin

• Patients were being told to call their PACT team

Patients were being told to call their PACT team

appointment in 2 days as a “safety mechanism” their symptoms got worse ( Access) 

4/17/2012 VAIL-PACT VISN22 
• 

My patient -

• An 85 year male Veteran seen in the West Los 

Angeles ED and diagnosed with pneumonia and 

a mild CHF exacerbation a mild CHF exacerbation. He was started on an He was started on an antibiotic and his diuretic was increased. The ED doctor thought he needed close follow-up . Unsure this patient could get this follow-up in primary care, patient to return to the ED in 2-3 days for reassessm

3 days later, his 80 year 3 days later, his 80 year -old wife drives them 2 ho

old wife drives them 2 ho

return to the ED, and then they wait 2 hours to see in the room and ask how he is doing. The wife say

much better his energy and breathing are both bettmuch better, his energy and breathing are both bett

swelling in his legs is completely gone.” • My first thought – this could have been done ove

4/17/2012 VAIL-PACT VISN22 
AIM 

• To develop and test, as a proof of conce

a systemati c and bl 

reli ablemechanism fo

providers to communicate with PACT te

members about patients needing urgent members about patients needing urgent 

specific follow-up care 

– Done as a VAIL Quality Council Innovat

Done as a VAIL Quality Council Innovat

Project (Sepulveda Clinic) 

4/17/2012 VAIL-PACT VISN22 
STEP 1: Assessin

g the Evidence 

• Limited in scope • Some return ED visits, like rehospitaliza

are preventable are preventable 

• About 20 About 20

-25% of ED patients will return 

25% of ED patients will return 

to 90 days 

• 30 day ED return rate for Sepulveda clin

patients is 20% patients is 20% 

4/17/2012 VAIL-PACT VISN22 
STEP 2 – Forming a multidisciplin

PACT

-ED t k h ld k

s

t

a

k

e

h

older wor

kgroup 

• 1 Organizer/Facilitator (me) • 2 Emergency Department Clinicians • 1 Primary Care Physician • 1 PACT RN Care Mana

ger 

• 1 PACT Lead Clerk • 1 Clinical Applications Coordinator (PharmD wit

Care Experience) 

4/17/2012 VAIL-PACT VISN22 
STEP 3–Exploring and understandin

PACT processes, expect ti f t 

t

ations, 

frus

t

Need to incorporate Limits in PA

Limits in PA

commun

ications 

into team time 

ED workflow; multiple in-person a

part-time providers availabil

with high turnover 

4/17/2012 VAIL-PACT VISN22 
STEP 4- Developing a CPRS Tool 

• E b dd d d i i i l E

m

b

edd

e

d an a

d

ministrative consult request i 

nt

aftercare instructions note that the ED providers 

• Templated consult request prompts ED provider

specifics of follow-up care needs

• Consult request transmitted to primary care and 

PACT RN care mana

ger 

• PACT RN care manager works with the team to a

f ll o ow-up care nee

d as appropria

te 

– Phone call, nurse visit, PCP visit, etc – As administrative consult, RN can close consult w

comment 

4/17/2012 VAIL-PACT VISN22 
Aftercare Instructions

4/17/2012 VAIL-PACT VISN22 
Templated Consult Request

4/17/2012 VAIL-PACT VISN22 
Consult Received in Primar

y Care

4/17/2012 VAIL-PACT VISN22 
STEP 5 - PDSA C

ycles 

• PDSA cycle 1: ED Provider in workgrou

in and signed consult for one patient in and signed consult for one patient 

• PDSA c

ycle 2: Selected ED 

providers u

for one team’s patients in Sepulveda clin

• PDSA cycle 3: Selected ED providers u

for two teams’ patients in Sepulveda clin

• PDSA cycle 4: All ED providers use too

Sepulveda patients Sepulveda patients 

4/17/2012 VAIL-PACT VISN22 
Example #1 – Sign/Symptom 

Rhk ec

heck 

• ED communication: Symptoms/Sign rec

5 d d lli d i f l 5 

days: re

dness, swelling, an

d pain of le

• RN C M 

Care 

Manager response: “C ll d 

“C

all

e

d pt 

him post ER. He said his L lower leg stil

red but better still taking Cephalexin Inred but better, still taking Cephalexin. In

f/u appt made 07/12/2011 but he said he need it. Advised to call for app t if le

g not 

getting worse after antibiotics. Pt agreed plan” 

4/17/2012 VAIL-PACT VISN22 
Example #2: Care Coordination 

• ED request: Coordination of care for wo

“ ti t d t h l ECHO “patient needs transesophageal ECHO a

Holter monitor before neuro f/u with Dr. 

neurology neurology. “

• RN Care Manager response: “Echo: Sch

for 6/23/2011; Holter monitor: 6/30/2011; for 6/23/2011; Holter monitor: 6/30/2011; Neurology: to be scheduled after by ser

4/17/2012 VAIL-PACT VISN22 
ED Providers Liked and Used Too

100

7080905060

#Consults

203040

0

10

20

Oct 1st Oct 7th Oct 14thOct 21stOct 28thNov 4thNov 11thNov 18thNov 25thDec 2nd Dec 9thDec 16thDec 23r

4/17/2012 VAIL-PACT VISN22 
Used For a Variet

y of Indications

4/17/2012 VAIL-PACT VISN22 
PACT Team Pers

pectives 

• Useful for preventing walk-ins • Report that patients seem to appreciate 

are bi d dh h i b

eing contacte

d an

d t

hat t

he primary 

team knows about their ED visit and foll

needs 

• RN Care Managers report some difficulty RN Care Managers report some difficulty

balancing this with other daily work

4/17/2012 VAIL-PACT VISN22 
Impact on PACT performance 

measures

? 

• Too early to tell but early indications p

Too early to tell... but early indications p

• Of 16 patients for whom this tool was us

Of 16 patients for whom this tool was us

February 2012, 1 had a “walk-in” visit to care within 14 da

ys and none had a retu

within 30 days 

– Overall 30 day return ED visit rate for patients= 20% 

4/17/2012 VAIL-PACT VISN22 
Next Steps 

• Work with newly-formed West Los Ange

Council to expand to the West Los AngeCouncil to expand to the West Los Ange

– Continue to refine, adapt, and monitor proce– Incorporate a Veteran into our workgroup 

• Continue assessing effects on post-ED w

ED -revisit rate revisit rate 

• If continues to show benefits, VAIL will a

assembling tool and processes into a paassembling tool and processes into a pa

would enable other healthcare systems 

4/17/2012 VAIL-PACT VISN22 
VAIL ED-PACT Communication

Wk M or

kgroup 

Mem

bers 

Fredalin Braden, RN

Kristina Cordasco, MD, MPH, MSHS

Jonie Hsiao, MD

Tracy Lemle, RN

Vanessa McIntyre 

Deepti Pisupati, MD

Hyun-Sung Song, PharmD

Diane Suzuki, MD

4/17/2012 VAIL-PACT VISN22 
Questions/Comments

Kristina.Cordasco @va.gov

4/17/2012 VAIL-PACT VISN22 
                                       

     

                                       

                                   

                                       

                                 

                                

                                   

                                   

                           

                                     

                               

                            

                        

                                       

             

                                      

         

                               

     

               

                                       

                                        

                                   

               

4/18/2012 12:00pm Unpacking the Post-discharge or Post- Patient Aligned Care Teams (PACT) Cordasco, Kristina 

ED Telephone Call Demonstration Labs Richardson, Jenny 

Reviewing the trending data for 12 months: Was the n value and in terms of real numbers how many pt

admits were avoided?

How does the ED doc identify PACT team when a PC physician is not identified in CPRS or veteran is

unassigned?

In Greater Los Angeles PACT team assignment is indicated on the top ribbon of the display for each

patient in CPRS (middle of screen and visible when in any tab). On initiation of our project, we did

realize many of our ED clinicians did not know that this information was there and therefore we

needed to orient the ED clinicians to this. Unfortunately, this pilot currently only works for patients

who are assigned to a PACT team, which is a limitation and should be addressed in future work.

Regarding the CPRS note standardization: it would be important to be able to use the notes better in the

future, it is important to standardize. Also to remind providers to get full details.

We have a template for hospital discharge follow up that is reflected in the Compass report but we do

not have a templated note for ER discharge: Does the compass report reflect ER discharges also?

The compass does not reflect ED discharges. However, ED visits are included in the Compass

continuity measure and decreasing ED revisits is an aim of the pilot.

Each provider has an RN care manager‐is the ED list populated for each provider CM, or does the CM for

the provider populate their own ED list?

There is no populated list of ED patients. Each CM tracks, as needed, the ED patients for whom the

CM receives an ED follow‐up consultation.

I thought ED phone calls were mandatory regardless (as a performance measure) whether or not a

consult is placed??

ED phone calls are not mandatory at this time.

Kristina: are all the ED's using this consult at this time or what is the time frame to start this

This is being done as a pilot in one clinic in Greater Los Angeles Healthcare System. If and when this

will be spread to other sites has not been determined, and will depend on our results as we

incrementally spread to other clinics and healthcare systems.
                                   

                               

                             

                             

                               

                                       

                       

                           

                                         

   

                                  

                                 

                                     

                      

                                   

         

                                     

                     

                                         

                                

4/18/2012 12:00pm Unpacking the Post-discharge or Post- Patient Aligned Care Teams (PACT) Cordasco, Kristina 

ED Telephone Call Demonstration Labs Richardson, Jenny 

If the patient is a Telehealth patient, for example for CHF monitoring and the Telehealth team calls the

patient after discharge, does that count toward the measure or does it count against the continuity

measure?

The Telephone follow up note template requires an encounter to be completed, however, if there’s

not patient contact, what note do you use so it does not have to be encountered.

Do you use a Report of Contact rather than an actual 2 day follow up note?

In Fayetteville, AR as long as the patient has a PC team assigned there is a VISTA email that the team

gets about the patient being in ER or admitted to our facility.

We could get our ADPAC to share this file report and email generated info?

Now that home Telehealth is embedded in PACT in some VA. Is there a way to integrate HT in the

ED/DC follow‐up pathway?

We discussed this possibility locally. However, as our ED follow‐up program is more than a phone call

and the RN Care Manager is triaging the patient’s follow‐up care needs, in consultation with the PCP

when needed, we thought it would be most efficient for the PACT RN Care Manager to do this work

directly. However, ideas and testing of other models are certainly welcome.

Does the data for 2 day follow up calls include hospital discharges to patients discharged to other than

home i.e. acute care facilities?

Do you find that several consults are placed because as earlier stated follow up in primary care is the

standard.

This does occur occasionally, and is dependent on the ED Physician.

It will very helpful if appt with the PACT RN and PACT PCM is added and coordinate since the DH date.

Can you advise how to view the RN modified template from Portland? Interested for CBOC use