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T ransitiona L C are (TLC) Partners for Older Veterans at Home VISN 6, Durham VAMC

T ransitiona L C are (TLC) Partners for Older Veterans at Home VISN 6, Durham VAMC. GRECC Ambulatory Care/HBPC Cristina Hendrix, DNS, NP (program leader) Peggy Becker, LCSW Sara Tepfer, MSW, LCSW (program co-leader) Jeanette Stein, MD

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T ransitiona L C are (TLC) Partners for Older Veterans at Home VISN 6, Durham VAMC

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  1. TransitionaLCare (TLC) Partners for Older Veterans at HomeVISN 6, Durham VAMC GRECC Ambulatory Care/HBPCCristina Hendrix, DNS, NP (program leader) Peggy Becker, LCSW Sara Tepfer, MSW, LCSW (program co-leader) Jeanette Stein, MD Kenneth Schmader, MD Susan Rakley, MD Cathleen Colon-Emeric, MD James Galkowski, PA S. Nicole Hastings, MD Ellie McConnell, PhD, CNS OT Helen Hoenig, MD Social Work Jim Mathues, MOT, OTR/L Gregory Hughes, LCSW

  2. The Durham VAMC TLC Partner Program • Clinical demonstration program • Administered through a competitive RFP process by the Office of Geriatrics and Extended Care (GEC) • Transformation-21 (T-21) initiative to promote the growth and dissemination of patient-centric alternatives to institutional extended care.

  3. VA Statistics At A GlancePercentage of Male vs Female 1 US Census Bureau, 20092 National Center for Veterans Analysis & Statistics, 2010

  4. VA Statistics At A GlanceRacial Distribution 1 US Census Bureau, 20092 National Center for Veterans Analysis & Statistics, 2010

  5. In 2008, almost 14% of people in the US were 65 or older, whereas almost 40% of US veterans were 65 or older. • Projected Number of Living WW II Veterans (as of 9/30/2009): 2,272,000

  6. Percent Distribution of Inpatient Care By Age* *2001 National Survey of Veterans (NSV)

  7. TLC Partner Program* Older veterans admitted to Durham VAMC Risk for complicated home discharge Low High Usual discharge care • TLC NP/PA conducts hospital visit(s) before discharge • Determines if OT/SW home visits are needed OT/SW visits needed? Yes No TLC NP/PA conducts home visits within 2-3 days of discharge and PRN OT and/or SW visit within 5 days of discharge and PRN TLC NP/PA conducts home visits within 2-3 days of discharge and PRN Handoff to PCP, HBPC, etc after 30 days of hospital discharge *Based on Naylor’s Transitional Care Model (LDI Issue Brief, 9(6): 1-4, 2004 Apr-May

  8. TLC Partner Program*VISN 6, Durham VAMC GRECC/HBPC Older veterans admitted to Durham VAMC Risk for complicated home discharge Low High Usual discharge care • TLC NP/PA conducts hospital visit(s) before discharge • Assesses goals and needs of patients/caregivers • Determines if OT/SW home visits are needed OT/SW visits needed? Yes No TLC NP/PA conducts home visits within 2-3 days of discharge and PRN OT and/or SW visit within 5 days of discharge and PRN TLC NP/PA conducts home visits within 2-3 days of discharge and PRN Handoff to PCP and/ or HBPC after 30 days of hospital discharge

  9. Anticipated Program Outcome

  10. Anticipated Program Outcome

  11. Sustainability of the TLC Program 1 in 5 older adults will be readmitted within 30 days of hospital discharge Using Durham VAMC data, this translates to 12 out of 60 readmission within 30 days Naylor and colleagues have demonstrated a 25% decrease in readmission (0-3 months) and 55% SNFadmission (0-3 months)

  12. Ave hospital LOS: 4 days Ave hospital cost per day: $2,500 Reduce readmission by 3 patients per month In one year, reduce cost by $360,000 Ave LOS at CLC: 83 days Ave CLC cost per day: $438.36 Reduce admission by 5 patients per year In one year, reduce cost by $181, 919. 40 Cost Savings $541,919.40 - $358,877.00 (operating cost of TLC in 1 year) = $183,042.40 (savings)

  13. TLC Update • Begin hiring of staff • Pull data for analysis of risk factors • Meet regularly with the team • Partner with IT to establish consult mechanism • Disseminate information to hospitalists • Begin patient/caregiver enrollment in August

  14. Thank you

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