Patrick Luib, MS, ANP-BC, Manager of Geriatric Clinical Services 1

1. Practice Patterns among Nurse Practitioners in a Transitional Care Pilot for Medicare Advantage and Medicaid Managed Long-term Care Patients Patrick Luib, MS, ANP-BC,Manager of Geriatric Clinical Services1 Claudia Beck, MS, ANP-BC, Director of Clinical Support Services1 Peri Rosenfeld, PhD, Senior Evaluation Scientist2 Daniel Kurowski, MPH, Research Analyst I2 1CHOICE 2VNSNY Center for Home Care Policy & Research

2. Objectives • Describe the components of the Nurse Practitioner (NP) led Transitional Care (TC) Program designed for Medicare Advantage and Dual Eligible Medicaid Managed Care Long Term Care Patients • Discuss the Methods, Data collection and Findings of the Survey of NP Practice Patterns • Outline components of the full evaluation plan for the NP-TC program

3. VNSNY CHOICE Guiding Principles • VNSNY CHOICE Health Plans: • Offer benefits that improveaccess to appropriate care, including assistance with navigating an increasingly complex health care system • Shift the focus of care from the institution to the home and community • Believe care management is the cornerstone of all managed care plan options and all members are assigned to a care manager; multi-disciplinary care management facilitates integration across all care settings • Target and customize interventions

4. VNSNY CHOICE Health PlansManaged Care Plans for High-Cost Chronically Ill Dual-Eligibles

5. VNSNY CHOICE: Transitional Care Protocol • NP-led, interdisciplinary set of interventions aimedatreducingpreventablere-hospitalizations by • Improvinghealth care coordination and continuityacross settings • Providingmember-centric TC plan • Providingcritical information to IDT • Following up on unmetneedswith IDT

6. Why NP led? Distinguishing NP from RN role

7. NP Practice Patterns • This presentation is the first component of a larger evaluation study that examines the activities of NPs engaged in a TC program • The full evaluation will analyze process measures (such as fidelity to the model) and outcomes measures (e.g. determination whether the NP program results in lower hospitalizations and ER visits) are in progress.

8. Methodology • Designed and piloted data collection instrument for the 8 NPs to use daily • Data collected on daily activities for 10 work days (two weeks in November 2011) • Obtained 100 percent response rate but three surveys were eliminated from analysis due to inaccuracies • Follow-up key informant interviews were conducted with 5 NPs

10. Number and Types of Patients Served by NPs

11. Average Distribution of Daily Care Activities

12. Direct Care: Types of Visits • Home Visits comprise over half the time spent in Direct Care • Almost one-quarter of the Direct Care takes place in the hospital, prior to discharge • Other direct care activities include visits to rehab settings/nursing homes

13. Indirect Care: Measures of Time and Effort

14. Care Communication Activities

15. Themes from NP Interviews • Program barriers include • Late notification of hospital discharges • High level of frailty of patient population • Program facilitators: • Solid administrative support, including frequent meetings and check-ins • Existence of strong pool of clinical colleagues and contacts

16. Themes from NP Interviews (cont) • NP Model characterized as “The Cadillac” • Special set of clinical management skills • Able to negotiate hospital and physician relationships • Benefit of Advanced Practice competencies, e.g. Ability to interpret lab work and prescriptive privileges (helpful with medication reconciliation) • Able to address overlooked or underlying social/behavioral/environmental issues

17. Next Steps • Complete evaluation study (quasi-experimental design) to examine outcomes (hospitalization and ER rates) of patients in NP-TC program as compared to comparable home health care patients receiving usual care • Results expected by end of year.