1 COMPASS Care Coordination
2 Patient experience with COMPASSEnrollment/Case Ascertainment 2 day call We are going to walk you through the WFBMC process to make sure it is clear that 1) patients are met initially in the in patient units and their post acute care coordinator will ask some preliminary questions and start the process of creating a data base that will include for individual patient info and responses to questions and assessments. Patients are given a variety of resource prior to going home, one of which has been the very popular home BP log where patients record their home BP’s such that they can share these with their providers. Only enrollment questions are asked. Like many patients discharged from the acute setting, all COMPASS patients will receive a 2 day phone call. This is a brieff but important check into make sure that they have a confirmed appointment with their PCP. As well the PAC assesses other items such as Concerns with medications, reconciliation, if on Warfarin (VKA) ask to see if they have an INR and if they know the result? New Symptoms since discharge = Confusion, difficulty speaking, vision ambulation, balance coordination, Falls, If they are to follow up with PT, OT, Speech The 7-14 day Stroke Clinic visit date, time and location Signs of stroke and when to come to the ED (facial droop, is one arm weak/numb? (raise arms and hands), when to call 911 Services or resources that the survivor may need (home health, falls prevention, etc.) What things their care giver may be needing to assist with (transportation, bathing, medications, etc) This further data is put into the I pad and web based data platform such that the provider will ultimately get a note with key details of each of these encounters. New symptoms? F/u with PCP? S/S of stroke ? connected to therapy services? Transportation ?
3 PAC Encounter/APP Evaluation7-14 Day Visit PAC Encounter/APP Evaluation This assessment is a patient-reported outcome measure, meaning decisions made to improve a patient’s stroke recovery is based on the patient’s input and perspective. Responses in this assessment will be used to generate an eCARE plan, create referrals, and recommend any community referrals. PAC Perform “Post acute functional assessment” Concerns with medications New symptoms since discharge Follow-up appointment with PCP Signs of stroke and when to come to the ED Services or resources that the survivor may need (home health, falls prevention, etc.) APP Assess stroke complications (UTI, bleeding, Assess risk factors (HTN, lipids, afib, depression) Review hospitalization, imaging etc. Perform a neuro exam Eval for independence in ADL’s – Strong focus on optimizing physical activity. Establish an individualized care plan “eCare plan” Provide referrals to home health, outpatient therapy, and community services Strong emphasis on HBPM and statin use for secondary prevention. Finalize PCP letter Discuss expectations for recovery/ communication challenges
4 APP’s Systematic EvaluationHospital overview Residual Neurological Deficits Stroke Related Complications Lifestyle Management Medication Management Physical Mobility Cognition Depression Risk Factors Falls ADLs IADLs Social Support Caregiver Availability and Capability Transportation Financial Advance Directives Access to Primary Care, HH, others Readmissions We touch upon 19 areas that influence the patients overall health and recovery
5 Generate and Approve eCare PlanGenerate e CARE Plan based upon patient’s input and APP assessment.
6 Individualized eCare Plan ReferralsProvider Referrals Community-based resources Caregiver support referrals Pharmacy assistance programs Medical Referrals ( Home health PT, OT, Nursing, ST , outpatient therapies, in-home aid, social worker, rehab services) Community-based resources ( AAA, community based exercise programs- ymca, silver sneakers, stroke support programs , PACE, meals on wheels, Caregiver support referrals (e.g. AAA Caregiver support specialist, COMPASS CG resources, local support group or CG training program) Pharmacy assistance programs and referrals
7 Example of eCare Plan
8 Community Resources for COMPASS InterventionOutputs Individualized E-Care Plan & COMPASS Website Query Inputs Inputs Support Groups/Faith Community support Stroke Survivor Caregiver Faith Health Area Agencies on Aging* COMPASS Stroke Recovery Community Resources Directory Falls Prevention Chronic Disease and Condition Management DHHS Chronic Disease Management Programs PACE Programs Behavioral Health CareNet Pharmacy Inexpensive meds Financial assistance Assistance with medical management Community Exercise YMCA’s / fitness centers Hospital-based wellness programs Reimbursed exercise programs (Silver Sneakers/Silver and Fit) Rehabilitation Under 60 Uninsured No ability to pay Rural Areas Cognitive
9 Community Resources on eCare PlanQuick access to basic contact information Patient’s local county resources APP is able to choose the Community resources that apply to each patient
10 Sharing the plan with the patientPAC Perform “Post acute functional assessment” Concerns with medications New symptoms since discharge Follow-up appointment with PCP Signs of stroke and when to come to the ED Services or resources that the survivor may need (home health, falls prevention, etc.) APP Assess stroke complications (UTI, bleeding, Assess risk factors (HTN, lipids, afib, depression) Review hospitalization, imaging etc. Perform a neuro exam Eval for independence in ADL’s – Strong focus on optimizing physical activity. Establish an individualized care plan “eCare plan” Provide referrals to home health, outpatient therapy, and community services Strong emphasis on HBPM and statin use for secondary prevention. Finalize PCP letter Discuss expectations for recovery/ communication challenges
11 Benefits of eCare Plan Patient Generated Systematic approachPrioritizes needs Promotes self management Connects patient to resources Summarizes highest concerns Hope to expand this to other chronic diseases
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13 https://www.youtube.com/watch?v=K7dCCTvRxa4
14 Path to recovery, independence and healthNUMBERS Know my numbers Check blood pressure Check blood sugars Monitor lipids WILLINGNESS Willingness to improve my health Take my medications Make lifestyle changes ENGAGE Engage my mind and body Move More Check my mood Connect with my community SUPPORT Support, ask for help for myself and my carers See my primary care provider Use community resources
15 4Department of Physical Therapy, University of British ColumbiaAmy M. Pastva, PT, MA, PhD1; Janet K. Freburger, PT, PhD2; Karen M. Taylor, PT3; Susan Reeves, PT, DPT, NCS3; Meagan L. O’Brien, PT, DPT3; Janice Eng, PhD, BSc(PT/OT)4; Cheryl Bushnell, MD5; Pamela W. Duncan, PT, PhD6 1Doctor of Physical Therapy Division, Duke University School of Medicine, Durham, NC 2Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC 3Department of Physical Therapy, Wake Forest Baptist Medical Center, Winston-Salem, NC 4Department of Physical Therapy, University of British Columbia 5Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC 6Department of Neurology and Sticht Center on Aging Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC
16 At the end of this training session, participants will be able to:Movement Matters Physical Activity, Exercise, and Falls Prevention Recommendations for Stroke Survivors At the end of this training session, participants will be able to: Recognize risks for survivors of stroke. Understand the benefits of incorporating movement in the form of physical activity and structured and progressive exercise, falls prevention, and promotion of self-management into the patient’s individualized plan of care.
17 Do you know that survivors of stroke are at risk for:Movement Matters Do you know that survivors of stroke are at risk for: Being physically inactive. Falling and fracturing a hip. Losing upper limb function. Re-hospitalization. 1. Stroke survivors are at risk for being physically inactive. Over half of survivors don’t achieve activity levels recommended for health and well being. AHA recommends everyone get at least 150 “moderate intensity/active minutes” a week. However, we know that stroke survivors, on average, spend approximately ¾’s of their day lying down or sitting. We also know that inactivity increases the risk for suboptimal brain repair after a stroke and that inactivity increases the patient’s risk of having another stroke. 2. Stroke survivors are also a risk for falling and fracturing a hip. They fall more that twice as often as the general population, and they 4 times more likely to fracture a hip compared to the general population. Falls are most likely to happen in the patient’s home and are most likely to occur soon after transition home from the hospital or a rehab facility. 3. Stroke survivors are also at risk for losing arm function. More than 2/3’s of stroke survivors experience upper limb paresis. As a result of this, they have difficulty with basic, everyday activities of daily living including dressing themselves, bathing, cooking meals, and writing, to name a few. 4. Stroke survivors are also at risk for re-hospitalization when they are discharged home with little or no rehabilitation.
18 Therapists are underutilized in the first 30 days after discharge home following strokeMajority do not receive therapy Underuse of OT Intensity of therapy (# of visits) associated with a decreased risk of hospitalization* Medicare patients discharged home after stroke 31% receive home health therapy (PT/OT) in 1st 30 days 11% receive outpatient therapy (PT/OT) in 1st 30 days 59.2% receive no PT/OT in 1st 30 days Likely greater underuse of OTs Only 18% of patients receive OT in first 30 days compared to 39% of patients receiving PT *Intensity of therapy (# of visits) in the 1st 30 days is associated with a decreased risk of hospitalization in subsequent 30 days *unpublished work in progress by Janet K. Freburger, PT, PhD, Sheps Center, UNC
19 MOVEMENT MATTERS for recovering:Fitness and Health UE Dexterity and Function Safe Mobility and Independence in Home and Community MOVEMENT MATTERS for recovering: In summing up the evidence, we know that movement matter for functional recovery regarding: Fitness and health UE dexterity and function, and Safe mobility and independence in the home and community… Thus, our motto, MOVEMENT MATTERS…
20 The MMAP is based on the following resources:
21 The MMAP is based on the following resources: