Transitional Care: Improving Healthcare Continuity

1. Translating Research Into Practice www.transitionalcare.info The Transitional Care Model Mary D. Naylor, PhD, RN, FAAN Marian S. Ware Professor in Gerontology Director, NewCourtland Center for Transitions and Health University of Pennsylvania School of Nursing TCM010 – Unit 1 March 19, 2013

2. Perspectives on Chronic Illness Care in the US • Older Adults • Family Caregivers • Health Care Clinicians • Society

3. Transitional Care Range of time limited services and environments that complement primary careand are designed to ensure health care continuity and avoid preventable poor outcomes among at riskpopulations as they move from one level of care to another, among multiple providers and across settings.

4. The Case for Transitional Care High rates of medical errors Serious unmet needs Poor satisfaction with care High rates of preventable readmissions Tremendous human and cost burden

5. Major Affordable Care Act Provisions • Center for Medicare and Medicaid Innovation • Community-Based Care Transitions Program • Multi-Payer Patient-Centered Medical Home • Shared Savings Program (ACOs) • Payment Innovation (e.g., Bundled Payments) • Transitional Care Payment Codes • Federal Coordinated Health Care Office

6. Medicare Transitional Care Act of 2012* • Amends title XVIII (Medicare) of the Social Security Act to cover transitional care services for qualified individuals provided by a transitional care clinician acting as an employee of a qualified transitional care entity, such as a hospital (or a critical care hospital), a home health agency, a primary care practice, a federally qualified health center, a long-term care facility, a medical home, an appropriate community-based organization, an assisted living center, or an accountable care organization. (* Re-Introduced by Reps. Earl Blumenauer (D-Ore.), Thomas Petri (R-Wis.), Allyson Schwartz (D-Pa.) and Jan Schakowsky (D-Ill.) in September, 2012)

7. Context: Acute Care Episode Trajectory 1 (T1) Relatively healthy adult with onset of new chronic illness Post Acute/ Rehab Phase Population At Risk Acute Phase Secondary Prevention Trajectory 2 (T2) Adult with multiple chronic conditions Trajectory 3 (T3) Adults at end of life Adapted from the National Quality Forum (NQF) steering committee on Measurement Framework: Evaluating Efficiency Across Patient-Focused Episodes of Care. The committee’s report presents the NQF-endorsed measurement framework for assessing efficiency, and ultimately value, associated with the care over the course of an episode of illness and sets forth a vision to guide ongoing and future efforts.

8. Address gaps in care and promote effective “hand-offs” Address “root causes” of poor outcomes with focus on longer-term value Different Goals of Evidence-Based Interventions

9. Stratify population based on needs/risk & apply EB interventions Lower risk groups (T1) – improve “hand-offs” Higher risk groups (T2) – interrupt current trajectory/focus on long-term outcomes Adults at end of life (T3) – transition to palliative care/hospice Recommended Approach

10. Transitional Care Model (TCM)

11. Unique Features Care is delivered and coordinated… …by same APN supported by team …in hospitals, SNFs, and homes …seven days per week …using evidence-based protocol …supported by tool box

12. Core Components • Holistic, person/family centered approach • Nurse-coordinated, team model • Protocol guided, streamlined care • Single “point person” across episode of care • Information/decision support systems that span settings • Focus on increasing value over long term

13. Better Health • Better Care Hospital to Home Findings* • Decreased symptoms • Improved function • Enhanced quality of life • Decreased all-cause rehospitalizations • Reduced ED visits • Total cost savings • Enhanced access • Reduced errors • Increased satisfaction • Reduced Costs (* Based on 3 NIH funded RCTs: Ann Intern Med, 1994,120:999-1006; JAMA, 1999, 281:613-620; J Am GeriatrSoc, 2004, 52:675-684)

14. Penn research team formed partnerships with Aetna Corporation and Kaiser Permanente to test “real world” applications of research-based model of care among high risk elders. Funded by The Commonwealth Fund and the following foundations: Jacob and Valeria Langeloth, The John A. Hartford, Gordon & Betty Moore, and California HealthCare; guided by National Advisory Committee (NAC) Translating Evidence Into Practice

15. Tools of Translation Patient screening and recruitment Preparation of TCM nurses and teams (e.g., online course) Documentation and quality monitoring (clinical information system)  Quality improvement (case conferences grounded in root cause analysis) Evaluation

16. Findings (Aetna) • Improvements in all quality measures • Increased patient and physician satisfaction • Reductions in rehospitalizations through 3 months • Cost savings through one year • All significant at p < 0.05 • (Naylor et al., 2011. J Evaluation in Clinical Practice.doi: 10.1111/j.1365-2753.2011.01659.x.)

17. Would cognitively impaired hospitalized older adults and their caregivers benefit from TCM? Funding: Marian S. Ware Alzheimer Program, and National Institute on Aging, R01AG023116, (2005-2011) www.transitionalcare.info

18. Comparative Effectiveness Study • Compared three evidence-based innovations among hospitalized cognitively impaired older adults and family caregivers, each designed to: • Improve patients’ and family caregivers’ outcomes • Reduce preventable rehospitalizations • Decrease total health care costs • Enrolled 407 older adults and 407 family caregivers in prospective clinical trial conducted over 2 phases

19. Cognitive Deficits at Baseline • 24.9% also had delirium (+ Confusion Assessment Method)

20. Time to First Readmission P=0.0005

21. Mean Number of All-Cause Rehospitalizations Through Six Months P=.0049

22. Next Steps • Analyses re: patient, family caregiver and cost outcomes ongoing • About 30% of sample transitioned from hospitals thru post-acute SNFs to home • Findings contributed to ongoing work (+ recent NIH submission) to assess effects of learning collaborative with SNFs (hospitals and post-SNF providers) in implementation of evidence-based transitional care

23. What do we know about effects of transitions among elderly long-term care recipients over time? • Funding: National Institute on Aging, National Institute of Nursing Research, R01AG025524, (2006-2011) www.transitionalcare.info

24. Prospective Observational Study • Examine the trajectory of changes in each of multiple HRQoL domains • Explore relationships between and among the multiple domains and health + long-term service use • Compare the patterns of change among similar older adults supported by three options (i.e., HCBS, ALF, NH)

25. Methods • Enrolled 470 English- and Spanish-speaking older adults from 50 sites, who were new recipients of long-term services and supports • Included older adults with mild- and moderate- cognitive impairment • Conducted quarterly interviews with adults and abstracted chart data; conducted organizational surveys

26. Conceptual HRQoL Model (Zubritzky et al., 2012, The Gerontologist. doi: 10.1093/geront/gns093)

27. Bothersome Physical Symptoms Present at Baseline* (* Symptom Bother Scale)

28. Through Year One… • Overall rates of bothersome symptoms decreased and general health perceptions increased (p<0.001) • Further declines in bothersome symptoms were associated with increased depression (p<0.001) and increased hospitalization use (p=0.02) • Reported rates of bothersome symptoms were lower for non-white LTSS recipients (p=0.003)

29. Depressive Symptoms* Through One Year (* GDS-SF)

30. Preliminary Findings Suggest… • Opportunity to capture the “voice” of elderly LTSS recipients over time • Potential for interventions designed to recognize and manage physical and emotional symptoms • Potential for policies that enhance earlier access to symptom management

31. Does the TCM add value to the Patient Centered Medical Home? Funding: Gordon and Betty Moore Foundation, Rita and Alex Hillman Foundation and the Jonas Center for Excellence (2011-2013) www.transitionalcare.info

32. Quasi-Experimental Study • Compare the health and cost outcomes demonstrated by community-based older adults coping with multiple chronic conditions who receive the PCMH+TCM to a similar group of older adults who receive the PCMH only

33. Modifications to TCM • Collaboration (co-management) with PCMH • Focus on patient (and family caregiver) goals – Goal Attainment Scaling • Emphasis on prevention of acute resource use (ED visit, index hospitalization) and continuity of care when acute event occurs

34. Preliminary Findings (PCMH+TCM only, N= 50) Diagnoses: 12 (4-24) Medications: 11 (1-23) Major Risk Factors: 4 (2-7) Average PCMH+TCM intervention: 63 days (n=29) (* Based on Jenks et al., 2009, N Engl J Med. 360:1418-1428)

35. The TCM… • Focuses on transitions of high-risk cognitively intact and impaired older adults across all settings • Has been “successfully” translated into practice • Has been recognized by the Coalition for Evidence-Based Policy as an innovation meeting “top-tier” evidence standards

36. Key Components for Success Champions Shared goals Multi-stakeholderinvolvement Communication Data monitoring and reporting Culture of continuous learning

37. Implementation Progress Aetna– expansion of TCM proposed as part of Aetna’s Strategic Plan University of Pennsylvania Health System– adopted TCM (Aetna and Blue Cross reimbursing) Other health care systems & communities – adopting/adopting Informing ACA implementation

38. TCM Locations Areas in the U.S. implementing TCM International Locations: Canada, Germany, Ireland, New Zealand, Scotland, Singapore

39. Key Lessons • Solving complex problems will require multidimensional solutions • Evidence is necessary but not sufficient • Change is needed in structures, care processes, and health professionals’ roles and relationships to each other and people they support • Carpe Diem!

40. www.transitionalcare.info