29 Oct Critical Thinking Exercise This is a two-part assignment where you will use the following case study from HIMSS: the-evolution-of-a-transitions-of-care-program-jefferson.pdf For
Assignment: Critical Thinking Exercise
This is a two-part assignment where you will use the following case study from HIMSS: the-evolution-of-a-transitions-of-care-program-jefferson.pdf
For this assignment, review this document and submit the following components:
1. Problem Definition – Identify one problem introduced in this case study. There are multiple problems that are identified, choose the one that you think is the most important here.
2. History, context, and data – Identify two to six factors that are information that describes the problem that is included in the case study. For example, what type of data was collected? Was there an event that created the problem?
3. Assessment – How is the data used to analyze the problem? What are the root causes?
4. Solution – You have the choice of identifying the solution from the case study or you can propose your own.
IMPORTANT NOTE: The assignment should be written and submitted in outline form. Under each numbered heading above, answer with concise bullet points. You should paraphrase what the author has written—NO COPY AND PASTE from the case study.
Purpose: The two assignments work together to demonstrate how the analysis approach in critical thinking is applied to a healthcare problem and how the SBAR is the writing format used to document the critical thinking process.
HIMSS Davies Award Case Study Transitions of Care 1
The Evolution of a Transitions of Care Program
Primary Contact Information:
• Tina Sokolowski- Vice President Population Health Services
Clinical Project Lead:
• Laura Gontz- Director Care Coordination
IT Project Lead:
• Kyle Cibak – Director Actuarial Informatics
Since the passage of the Affordable Care Act in 2010, healthcare has
undergone a paradigm shift from a volume-based fee-for-service to an
outcomes-based payment model. For Jefferson Health and other providers
employing a continuum of care model (a cohesive care system that guides
and tracks patients over time through a comprehensive array of services
spanning all levels of care), this transformation has placed an outsized focus on
improving an integral part of the patient journey: the transition from one
service level of care to the next. Strategic communication is a key driver in
effectual and proficient patient care across the healthcare continuum,
particularly in transitions of care, with numerous studies demonstrating that
effective communication increases patient safety, saves costs, and reduces
duplicative work. And so, in autumn 2018, Jefferson Health launched a
multidisciplinary effort to develop a comprehensive transitions of care program
that would be both replicable and sustainable, address communication
challenges, and mitigate fragmentation through the patients’ acute care
journey. Emphasis was also placed on establishing goals to ensure our program
fostered accountability and collaboration in a multidisciplinary service deli very
structure that provides the right care, to the right patients, at the right time—to
treat each person holistically. While initial improvements in outcomes for
patients with ambulatory sensitive conditions were impacted by the COVID-19
pandemic, the team is confident that the comprehensive transitions of care
program will rapidly return to pre-pandemic levels of success. The health system
now has tools to identify patients discharged from all locations in a timely
HIMSS Davies Award Case Study Transitions of Care 2
manner without our nurse team sifting through spreadsheets and risk scores to
locate them. Custom templates were developed in our EHR to guide our staff in
consistent evidence-based scripted calls during our transition of care
connection. Disease-specific questions and care plans were built to direct our
attention to a patients’ ambulatory sensitive conditions which included self –
management plans, and barriers to follow up care. As members of
comprehensive primary care (CPC+), we are tasked with attempting to
contact 75% of patients transitioned out of an inpatient, or post-acute setting.
As a result of our efforts, our patient population is successfully engaged 78% of
the time and we have seen a significant reduction in our Hospital Readmissions
Reduction Program (HRRP) year over year with a savings of 18%.
Lessons learned include:
A high-quality transition is achieved when all patient referrals and transitions
meet the six Institute of Medicine aims of high-quality health care. From this
perspective, referrals and transitions should be:
• Timely: Patients receive needed transitions and consultative services
without unnecessary delays.
• Safe: Referrals and transitions are planned and managed to prevent
harm to patients from medical or administrative errors. Care
coordination has been defined as “the deliberate organization of
patient care activities between two or more participants involved in a
patient’s care to facilitate the appropriate delivery of health care
• Effective: Referrals and transitions are based on scientific knowledge
and executed well to maximize their benefit.
• Patient-centered: Referrals and transitions are responsive to patient and
family needs and preferences.
• Efficient: Referrals and transitions are limited to those that are likely to
benefit patients and avoid unnecessary duplication of services.
• Equitable: The availability and quality of referrals and transitions does
not vary by the personal characteristics of patients.
The journey through our transition of care program has shown there are
numerous steps to success as well as a great many patient outcomes to
measure. Initial focus was on identification of patients to outreach. We quickly
learned that it is the quality of the outreach and defining a successful outreach
that adds impact.
HIMSS Davies Award Case Study Transitions of Care 3
Define the Clinical Problem and Pre-Implementation Performance Transitions of care have become an important target for the Triple Aim of
improving care quality and the patient care experience, improving the health
of our population, and reducing cost. Most research to date has focused on
hospital-to-home care transitions, and numerous studies have shown major
gaps in care during these transitions. For instance, communication across sites
happens infrequently, follow-up needs are not consistently identified, and few
patients have timely outpatient follow-up care after hospital discharge. More
recent studies have shown that most patients do not meaningfully benefit from
early outpatient follow-up. Transitional care resources would be best allocated
toward ensuring that highest risk patients receive follow-up within 7 days.
Given Jefferson Health’s robust annual patient volumes (approximately 127,000
admissions and 517,000 ED visits), the evolution from a fee-for-service to an
outcomes-based payment model put in stark relief the need to close any gaps
that may exist in transitional care across the health system. One area of
increased focus was the identification and prevention of readmissions for
ambulatory sensitive conditions. These readmissions are frequently related to
the index admission discharge and represent a poor outcome for the patient.
CMS also imposes heavy fines on hospitals who perform poorly in this area.
Additionally, as insurers develop utilization management (UM) policies that
deny payment for these services, these readmissions also have a negative
fiscal impact on the health system’s bottom line. Performance for 30-day
readmission rate of ambulatory sensitive conditions was 11.88% in 2018 prior to
implementation. Our readmission rate goal for our commercial population is
10.2 to achieve top quartile.
Prior to developing a comprehensive transitions of care system, Jefferson did
not have a consistent method of identifying these patients, nor did we have
templates that allowed our team to address the specific needs of these
extraordinarily complex patients. Our EHR limited the discharges we could see
to inpatients from our hospital system, excluding those patients who were being
discharged from outside hospitals. As a result, the health system lacked insight
into what was happening in these situations. In 2020, we reached or attempted
to reach only 72% of our patient attributed to primary care. Although we
attempted to reach 72%, only about 30% of patients followed up with a
physician within 7 days, due to factors such as lack of transportation, lack of
patient awareness to importance of follow up, and appointment availability.
Design and Implementation Model Practices and Governance
One of the major goals of Jefferson’s Population Health department has been to
unite teams and services under one common reporting structure. We needed to
HIMSS Davies Award Case Study Transitions of Care 4
share what we learned, replicate what worked in our division, and listen to new
enterprise teams who suggested changes.
In spring 2021, Jefferson Population Health brought together a team of healthcare
professionals to form three temporary action groups all centered on transitions of care
and preparation for the excess days in acute care measure. Analytics was able to provide
us with our baseline EDAC scores for the subset of patients wi th a Jefferson primary care
provider. Using this information, we set out to quickly make actionable changes to
improve our performance. Our (TAG) deliverables were to improve technology to monitor
and optimize transition of care workflows, identify barriers, adjust processes and leverage
digital health to expand capacity. We transitioned our team to leverage two new risk
adjustment models in support of transitions of care activities. The population health team
worked directly with our Jefferson hospitals inpatient care management team to create a
standard of care and communication across the care continuum based on highest risk
and utilization of patients. The Director of Care Coordination and her team of early
adopters offered ongoing support to new teams, employees, and service lines, which
allowed for growth and system integration. In January 2019, a standard Epic playbook for
transitions of care and care coordination documentation was built and distributed for
education. This playbook was also updated with changes and upgrades.
With this new enhanced process in place, it was our aim to increase the
proportion of our patients with a follow up appointment within 7 days and
further decrease our significant readmission costs.
HIMSS Davies Award Case Study Transitions of Care 5
Clinical Transformation enabled through Information and Technology
Jefferson’s transitions of care program utilizes a three-phased approach: Risk,
Screening, and Transitioning.
In the Risk phase, EPIC at Jefferson utilizes a two-step risk stratification process
that incorporates (1) an algorithm-based method, which uses data such as
demographics, utilization, co-morbid conditions, and other metrics; and (2)
care team perception of risk to segment the population into three risk tiers
(High, Medium, Low).
The algorithm-based method utilizes the metrics shown in the screenshot below
to calculate a General Risk Score. These metrics include demographic
information such as age and insurance type, utilization including a hospital
admission or ED visit within Thomas Jefferson University Hospitals, Inc. (TJUH), the
existence of co-morbid conditions including COPD, Diabetes, CHF, Liver
Disease, Depression, CAD, Hypertension, and chronic kidney disease, and other
metrics that have been shown to increase readmission risk such as substance
abuse and dementia. Risk scores are automatically and continuously
calculated as soon as information is entered and/or changes in a patient’s
record (i.e., new hospital admission to TJUH).
The risk tiers are determined based on the following points:
•0 – 3 points: Low Risk
•4 – 5 points: Medium Risk
•6 – 9 points: High Risk
HIMSS Davies Award Case Study Transitions of Care 6
The second step of the Risk phase includes the ability to refine the risk score
based on a practitioner and/or care team’s information or clinical intuition.
EPIC at Jefferson utilizes a Smart Phase to allow both the Primary Care Provider
and the RN Care Coordinator to change a patient’s risk score.
Jefferson Hospital Center City Division also calculates a LACE+ score on all
inpatient and observation discharges. Like the general risk score, this score is
based on demographics, utilization, co-morbid conditions, and other metrics.
Jefferson chose to utilize the LACE+ score due to its power to predict death or
urgent readmission post hospital discharge.
Patients from Jefferson affiliated hospitals with a LACE+ score of 59 and above
are placed on the registered nurse care coordinator caseload. Lower risk
patients with a Lace+ score below 59 are placed on the caseload of a
transitions of care focused health coach. These health coaches are certified
medical assistants with training in TOC, appointment scheduling, primary care
quality, and social determinants of health.
HIMSS Davies Award Case Study Transitions of Care 7
To identify the patients with a Jefferson primary care provider appropriate for
the transitions of care outreach, the analytics team developed a report of all
available acute or post-acute discharges. This reporting combined Epic-
sourced discharge information with admission, discharge, and transfer (ADT)
notifications provided through Jefferson’s participation in the regional health
information exchange. Each discharge was then assigned to the appropriate
care team member based on the patient’s primary care provider and risk
score. The assignment of discharges is automatically sent directly to the team
for outgoing calls, via a daily morning email.
HIMSS Davies Award Case Study Transitions of Care 8
The Screening phase focuses on the review of key information related to an
individual’s health situation to identify the need for health and social services.
The care coordinator’s objective in screening is to determine if a client would
benefit from such services. In such situations, a care coordinator or care
coordination assistant reviews the medical record—to the extent possible—
relevant to the “Four Domains”: Social Support, Chronic Disease and Self-
Management, Mental Health, and Health Trajectory.
The Transitioning phase focuses on moving a patient across the health services
continuum safely. To maintain continuity of care, this phase’s activities entail
the complete execution of the patient’s level of care transition through
communication with key individuals at the next level of care or setting, the
patient, caregiver, and members of the healthcare team. Care transition
contacts are excellent opportunities to assess patients for greater needs and
help through care coordination services. Now, it is standard practice for staff
from Jefferson’s Care Coordination team to reach out to the patient within two
business days of discharge from an acute or post-acute setting. Services
provided in this stage include but are not limited to
• Summarizing what happened during an episode of care
• Assisting in securing durable medical equipment (e.g., glucose meter, scale,
• Assisting in scheduling transportation services (if needed)
• Conducting a medication review
• Conducting an in-home needs assessment
• Coordinating/scheduling follow up appointments within 7 days of discharge
(Primary Care, Specialist, Ambulatory services)
Four key focus areas of review and teach back for the patient and/or patient’s
support system include:
• Medication changes and adherence
• Patient self-evaluation tools for signs and symptoms
• Stressing the importance of provider follow up
• Discussion on how and when to communicate changes/issues with your
primary care provider
HIMSS Davies Award Case Study Transitions of Care 9
In October 2021, we implemented the use of Epic MyChart Care Companion to
electronically contact our lowest risk patients post discharge for individuals who have
a chart account. This change was implemented so that the existing team could reach
more patients and provide a greater focus on the “rising risk” patient population. As
an example, a series of questions would appear as follows:
When patients answer these questions and screen positive for needing
assistance, a best practice advisory alerts the nurse. This patient will then
receive a direct phone call to assist them in their need.
HIMSS Davies Award Case Study Transitions of Care 10
Improving Adherence to the Standard of Care
Throughout the evolution of Jefferson’s transition of care program, two key
areas of focus were (1) the team’s ability to contact patients and (2) for the
team to make a reasonable effort to do so.
Currently, it is our policy to make two attempts to contact the patients post
discharge. For high-risk patients, this is primarily done by a phone call.
However, patients can indicate their preferred method of communication.
Each practice’s outreach attempts and successes are tracked and distributed
monthly. We use this data to look for issues with workload, documentation, or
report errors. Monthly distribution makes it possible to identify issues quick ly and
Today, with enhanced reporting capabilities that show not only the number of
calls made but also the percentage of those calls that are successful , our
analytics team monitors:
• Successful TOC Percentage (Based on the CPC+ Definition)
• Successful Patient Contacts (As a Percent of All Acute Events)
• Successful Patients Contacts (As a Percent of Successful TOCs)
HIMSS Davies Award Case Study Transitions of Care 11
Improving Patient Outcomes
Transition of care interactions and seven-day follow–up visits with a primary
care provider or specialist position have been shown to decrease hospital
readmissions and increase positive patient outcomes. Our patient population is
successfully engaged 78% of the time. During our initial TOC contact and 7-day
follow up visit, we frequently uncover issues or “good catches” that could
correlate to poor patient outcomes.
While it is difficult to link these actions to reduced readmission rates in the time
of a global pandemic, we achieved a decrease in 30-day readmissions from
9.7% in FYQ3 2018 to 8.4% currently. Additionally, we have seen a significant
reduction in our hospital HRRP penalty year over year. This is primarily due to
the increased complexity of the ambulatory sensitive patients served and not a
decrease in average readmissions. The team is dedicated to delivering safe
transitions of care and are always looking for the latest processes and data to
deliver excellent care to our patients. We will continue to monitor these
HIMSS Davies Award Case Study Transitions of Care 12
initiatives as well as the new excess days in acute care measures to ensure we
are providing a valuable service to our patient population.
HIMSS Davies Award Case Study Transitions of Care 13
Accountability and Driving Resilient Care Redesign
To increase the transparency in our performance throughout the transition of
care continuum, a dashboard was developed using the Qlik visualization
software. This dashboard summarizes near real-time Epic information and allows
population health leadership to be able to monitor performance from patient
outreach to successful contact and eventual follow up visit. This data is initially
presented in aggregate with the ability to drill down to the individual patient
level in support of identifying areas of further process improvement. Clinicians
can use this data to identify high utilizers and increase surveillance of those
individuals. Our population health nurse practitioners can be deployed to see
high utilizers in home to offer real-time interventions. Having this information
readily available has not only provided insight into the outcomes of our current
process, but also allowed us to rapidly evaluate the impact of workflow
changes. This ability has given our team the ability to adapt at the speed of
business, ensuring we are optimizing our processes to care for the patients we
HIMSS Davies Award Case Study Transitions of Care 14
HIMSS Davies Award Case Study Template 15
HIMSS Global Conference Audience Guidance (This will not be published)
Topic Guidance: Check three which apply to this case study
Clinical Informatics and Clinician Engagement
Clinically Integrated Supply Chain
Consumer/Patient Engagement and
Consumerization of Health
Culture of Care and Care Coordination
Data Science/Analytics/Clinical and Business
Disruptive Care Models
Grand Societal Challenges
Health Informatics Education
Health Information Exchange
Data Integration, and Standards
Healthcare Applications and Technologies
Enabling Care Delivery
Healthy Aging and Technology
Improving Quality Outcomes
Innovation, Entrepreneurship, and Venture
Leadership, Governance, and Strategic Planning
Population Health Management and Public Health
Precision Medicine and Genomics
Process Improvement, Workflow, and Change
Social, and Behavioral Determinants of Health
User Experience (UX)
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