Mary D. Naylor, Ph.D., R.N. Marian S. Ware Professor in Gerontology University of Pennsylvania School of Nursing

1. Transitions in Long-Term Care: The Policy ImplicationsBuilding Bridges: Making a Difference in Long-Term Care2007 Policy SeminarSponsored by The Commonwealth FundAcademyHealthWashington, D.C. Mary D. Naylor, Ph.D., R.N. Marian S. Ware Professor in Gerontology University of Pennsylvania School of Nursing

2. Goals • Make the case that health care quality among elderly long-term care (LTC) recipients who require acute care services may be enhanced by: • avoiding preventable acute hospitalizations; and, • improving transitions to and from hospitals when such transfers are needed

3. Goals • Offer policy recommendations to prevent avoidable hospitalizations and enhance necessary care transitions • Propose a research agenda to inform future changes in standards of care

4. Elders 85 and Older: One among the fastest growing age groups in the U.S. Number (in millions) SOURCE: Nursing Staff in Hospitals and Nursing Homes: Is it adequate?, 1996; page 33.

5. short-term services dominated by medical model providers choose + deliver services high tech limited family involvement Payor: Medicare long-term health, social and housing services providers help with ADLs +IADLs low tech family equal partners Payor: Medicaid Acute Hospitals vs. LTC

6. Transitions between LTC and Acute Care Hospitals

7. Nature of Problems • Poor communication • Negative effects of hospitalization • Inadequate discharge planning • Gaps in care during transfers

8. Consequences • High rates of acute clinical events • Serious unmet needs • Poor satisfaction with care • High hospital readmission rates

9. Clinical Barriers to Addressing Problems with Transitions • Providers’ knowledge, skills and resources • Limited use of palliative care • Dearth of quality performance measures

10. Non-Clinical Barriers to Addressing Problems with Transitions • Regulatory challenges • Financial constraints • Pressures from families and health care administrators

11. The Search for Solutions

12. Related Areas of Inquiry • Efforts to fully integrate acute and LTC • Transitional care interventions targeting chronically ill elders • Innovative care models

13. Lessons from Integration Efforts • Described the unique issues and challenges confronting acutely ill, frail elders • Highlighted the benefits of avoiding preventable hospitalizations

14. Lessons from Integration Efforts • Suggested value of: • Early identification of acute care needs • Increased access to selected primary, acute and palliative care services within LTC • Flexible funding and benefits

15. Care Models Designed to Avoid Preventable Hospitalizations • Evercare • Hospital at Home • The Day Hospital • Palliative Care Program in LTC

16. Mrs. Anderson: A Case Study

17. Lessons Learned from Transitional Care Interventions • Identified individual and system barriers to effective transitions • Highlighted importance of multidimensional strategies targeting problems common during “hand-offs

18. Lessons Learned from Transitional Care Interventions • Suggested value of: • Nurse-led, interdisciplinary teams • Streamlined care delivery • Information systems that span settings • Quality measures and other incentives

19. Care Models Designed to Improve Care Transitions • Care Transitions “Coaching” Intervention • Advanced Practice Nurse (APN) Transitional Care Model

20. Mr. Jenkins: A Case Study

21. Policy Recommendations

22. Leutz’s Conceptual Framework • Linkage • Coordination • Full Integration

23. Key Assumptions • The financing and delivery of acute and LTC will continue to be characterized by a patchwork of public and private services and funding

24. Key Assumptions • There is an adequate evidence base to justify: • increasing access to primary care, management of common conditions and palliative care within LTC; and, • use of nurse directed interdisciplinary teams, guided by evidence-based transitional care protocols

25. Proposed Structures, Incentives to Enhance Coordination of Care Delivery • Design, testing and integration of quality measures and monitoring systems • Development of information systems that span settings

26. Proposed Structures, Incentives to Enhance Coordination of Care Delivery • Preparation of current + future providers emphasizing… • geriatrics • palliative care • interdisciplinary team care • advance care planning • transitional care/care coordination • Dissemination of “best practices”

27. Proposed Structures, Incentives to Improve Coordination of Care Benefits • Create incentives to foster adoption of evidence-based models of on-site primary or palliative care and transitional care • Modify Medicare’s Hospice benefit to minimize barriers for use within LTC

28. Research Agenda • Describe impact of transitions • Identify most effective and efficient models to: • avoid preventable hospitalizations • improve care coordination, continuity and transitions • Define financial and other incentives to optimize quality and cost outcomes