Care transitions programs in the United States

1. Care transitions programs in the United States Common themes, lessons learned, and broader approaches for improving care Alicia I. Arbaje, M.D., M.P.H. Director of Transitional Care Research Division of Geriatric Medicine and Gerontology Australian Disease Management Association August, 2013

2. Objectives • Describe common themes of current approaches to improving care transitions in the United States • Discuss lessons learned from implementing care transitions initiatives • Present broader approaches for future interventions to improve care transitions

3. 79 year old widower Retired teacher, lives alone Income: small pension Daughter lives 10 miles away, has three teenagers Five chronic conditions Three physicians Eight medications Walter Altman

4. In the past year, Walter has had… 8 Physicians, 6 Social Workers, 5 Physical therapists, 4 Occupational Therapists, 37 Nurses 22 scripts 6 community referrals 8 meds 19 outpatient visits 2 home care agencies 3 hospital admissions 5months homecare 6 weeks sub- acute care 2 nursing homes

5. Walter Confused by care, meds Gets discouraged Adherence to care is poor • Walter’s daughter • Stressed • Reduced work to half-time • Considering rest homes

6. For the chronically ill,the US health care system is Fragmented Discontinuous Difficult to access Inefficient Unsafe Expensive “A nightmare to navigate”

7. Transitions within the U.S. Healthcare Environment Emergency Department Inpatient Hospitalization Operating Room Hospital Floor Critical Care Skilled Nursing Facility Long-Term Care Facility Home +/- Home Health Care Primary Care Specialists

8. Older Adults’ Transition Patterns in the U.S. • 1 in 4 transition annually • 1 in 3 transition 2+ times after discharge • Half of transitions are to hospital and back • The rest are not easily predictable Sato, Arbaje, et al., 2010; Coleman 2003

9. Transitional Care 1.0 • Identification of at-risk patients and transitions • Screen for cognitive/functional impairment • Assess living situation and usual source of care • Provider-provider communication • Provide info to PCP at key transition points • Verbal communication when urgency/uncertainty exists • Timely and quality discharge summaries • Medication management and reconciliation • Address goals of care • Provide support after discharge • Use of home healthcare when appropriate • Enhance self-management • Follow-up phone call/visit Transitionalcare.info Caretransitions.org Guidedcare.org

10. Guided Care:Comprehensive Care for Persons with Chronic Conditions • Specially trained RNs based in primary physicians’ offices • GCNs collaborate with 3-4 physicians in caring for 50-60 high-risk older patients with chronic conditions and complex health care needs

11. Nurse/physician team Assesses needs and preferences Creates an evidence-based “care guide” and a patient-friendly “action plan” Monitors the patient proactively Supports chronic disease self-management Smoothes transitions between caresites Communicates with providers in EDs, hospitals, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies in the community Educates and supports caregivers Facilitates access to community services Boyd C et al. Gerontologist, 2007

12. Impact of Guided Care • Comprehensive primary care can produce better outcomes for multi-morbid older patients. • Increased quality of care • Increased physician and nurse satisfaction • Decreased caregiver strain • Decreased utilization, especially SNF days and ED visits • The results of such models of care may be even better in integrated delivery systems. www.guidedcare.org

13. Common Threads: Coaches, Guides, Navigators • Assessment of symptoms • Understanding of hospitalization, diagnoses, test results, and treatment plan • Medication and self-management • Ensuring follow up and implementation of plan of care • Creation and understanding of emergency plan • Inpatient- or outpatient-based programs

14. Current approach Need for a broader understanding and approach

15. Objectives • Describe common themes of current approaches to improving care transitions in the United States • Discuss lessons learned from implementing care transitions initiatives • Present broader approaches for future interventions to improve care transitions

16. Older Adults Are Not All the Same:Diagnoses alone Do Not Define Risk

17. Common problems in Geriatric populations • Multi-morbidity • Cognitive impairment • Functional impairment and risk of falls • Limited health literacy • Complex medical regimens and treatment burden • Polypharmacy • Polymanagement • Caregiver burden • Frequent transitions across multiple care settings • Hearing or visual impairment • Bowel or bladder incontinence • Pressure ulcers • Malnutrition or dehydration

18. Factors to consider when delivering care during transitions • Competing demands leading to difficulty in prioritization of care plans • Inability of patient to comprehend or implement care plans • Inability to tolerate transitions and changes to care plans • Increased care needs upon discharge • Confusion among health care providers regarding plan of care • Need to incorporate palliative care principles

19. Objectives • Describe common themes of current approaches to improving care transitions in the United States • Discuss lessons learned from implementing care transitions initiatives • Present broader approaches for future interventions to improve care transitions

20. A broader approach

21. Why 2.0? • Many factors affect care transitions • Readmission risk varies and prediction remains poor • Discharge destination matters

23. Key Elements of Effective Strategies • Track measures that are independent of patient factors but relevant to patient outcomes • Factor in features of local health system • Incorporate feedback, comparison to peers • Tailor communication to the situation • Promote access to “the other side” • Consider unintended consequences

24. Possible metrics

25. Summary • Care transitions initiatives often target hospitalized patients and focus on readmission reduction. • Interventions originating outside of the hospital are not as common. • The next frontier is incorporating system-level approaches to a broader range of settings.

26. Contact Information Alicia I. Arbaje, M.D., M.P.H. aarbaje@jhmi.edu Health tips for older adults: www.youtube.com/aarbaje

27. Supplemental information

28. Worlds Apart Pt Home Care SNF LTC

29. Shifting the Center of Gravity Patient Home Care SNF LTC

30. Factors Promoting Ideal Clinician Roles during care transitions

31. Factors affecting care transitions Provider Role Perception Quality Measures Hospital Organizational Characteristics Post-Acute Care Setting Characteristics Care Processes Care Transition Early Readmission Hospital Care Socio-Demographic, Health, and Post-Discharge Environmental Factors

32. Older Adults Readmitted or Dead within 180 Days of Hospital Discharge >75th Percentile (Above 37%) 25-75th Percentile (35% to 37%) < 25th Percentile (35%) 0 mi 200 400 600 800 1000

33. Discharge Destination Matters Less needs More needs

34. Creating recovery scenarios

35. Creating recovery scenarios

36. Who is Eligible? All Patients Age 65+ 25% High-Risk 75% Low-Risk Review previous year’s claims data with HCC software

37. Patient Selection 13,534 Patients of 14 teams/49 physicians 3,383 (25% highest-risk) 904 = Consenting Patients (Baseline Evaluation) 485 in seven Guided Care teams Random Allocation 419 in seven Control teams Boult C et al. J Gerontology, 2008

38. Baseline Characteristics

39. Effects on Quality of Care PACIC 2.1 AGGREGATE 1.3 Activation 1.3 Problem Solving 1.5 Decision Support 1.8 Coordination 1.5 Goal Setting Quality rated in the highest category on PACIC Boyd et al. J Gen Intern Med, 2009

40. Effects on Physician Satisfaction Change in Satisfaction Marsteller et al. Ann Fam Med, 2010

41. Effects on Caregiver Strain Wolff et al. J GerontologyMed Sci, 2009

42. Very satisfied Satisfied Somewhat satisfied Somewhat dissatisfied Dissatisfied Very dissatisfied Satisfaction Items 1= Familiarity with patients 2= Stability of patient relationships 3= Comm. w/ patients; availability of clinical info; continuity of care for patients 4= Efficiency of office visits; access to evidence based guidelines 5= Monitoring patients; communicating w/ caregivers; efficiency of primary care team 6= Coordinating care; referring to community resources; educating caregivers 7= Motivating patients for self management

43. Annual Costs of Guided Care

44. Impact on utilization • After 32 months, Guided Care patients experienced • 29% fewer home health care episodes • 13% fewer hospital readmissions • 26% fewer skilled nursing facility days • 8% fewer skilled nursing facility admissions* • Reduced the use of services in an Integrated Delivery System. • 52% fewer skilled nursing facility days • 47% fewer skilled nursing facility admissions* • 49% fewer hospital readmissions • 7% fewer emergency department visits* Boult C, Arch Int Med, 2011

45. Health Service Utilization, 1st 20 Mos * Boult et al. Arch Intern Med, 2011

46. Health Service Utilization, Kaiser Permanente 8% 9% -7% -15% -17% -21% -47% -49% -52% Boult et al. Arch Intern Med, 2011

47. Technical Assistance for Practices Guided Care: a New Nurse-Physician Partnership in Chronic Care (Springer Publishing Company) Online course for registered nurses Online course for physicians and practice leaders Orientation booklet for patients www.GuidedCare.org/adoption.asp