Nancy L. Wilson Department of Medicine-Geriatrics Houston Center for Quality of Care& Utilization Studies Texas Consortium of Geriatric Education

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1 1 Nancy L. Wilson Department of Medicine-Geriatrics Houston Center for Quality of Care& Utilization Studies Texas Consortium of Geriatric Education Centers Care for Elders Governing Council

2 Acknowledge & Confess Slides used with permission from several sources: Eric Coleman, Mark Williams, Alice Bonner, UCSF, Lewin Group. Am not /have not/..been hospital administrator or employee, policymaker, Student and advocate of redesign of care to embrace chronic care approach that fills in the white space between silos--

3 3

4 Overview Chronic Care and Implications for Transitions of Care Common Practices and Models of Transitional Care Care Transitions Project RED Transitional Care Model Project BOOST Policy Opportunities for Expansion and Payment Resources for More Information

5 How are they related? different? Chronic Care Model Care Coordination Care Transitions

6 Chronic Care Model Community Resources and Policies Self- Management Support Health System Health Care Organization Delivery System Design Decision Support Clinical Information Systems Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Outcomes Improved Outcomes

7 Care Coordination: Broader Process than Care Transitions Deliberate organization of care activities among two or more participants to facilitate the appropriate delivery of services Organizing care involves marshalling personnel and other resources to carry out all required patient care activities Generally involves exchange of information among participants

8 Every transition of care involves coordination.. Care Transitions functions have been incorporated in various settings where care coordination may occur--- or is needed.

9 What is Transition of Care The movement of care patients from one health care practitioner or setting to another as their condition and care needs change Occurs at multiple levels Within Settings Primary care Specialty care ICU Ward Between Settings Hospital Sub-acute facility Ambulatory clinic Senior center Hospital Home Across health states Curative care Palliative care/hospice Personal residence Assisted living (c) Eric A. Coleman, MD, MPH 9

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11 Practice Elements Common to Many Models (differences in emphasis) Medication Management Assessing Patient's Understanding/Ability to Follow Care Plan Discharge Support Coaching for Primary Care Physician Visit Use of Home Visits (Not in Project RED or mandated in BOOST) Screening for cognitive ability Use of Centralized Health Record Involving Family and Informal Caregivers Arranging Community-Based Support Services (not consistently comprehensive) From: The Lewin Group, December 16, 2009 Care Transitions Workgroup

12 What is Known? National Examples of Best Practices The Care Transitions Model (Coleman) The Transitional Care Model (Naylor) The Guided Care Model (Boult) Project RED (Jack) Project BOOST (Society Hospital Medicine) 12

13 Where might these models differ significantly? Point of Entry Patient Eligibility Criteria Length and Frequency of Intervention Cost Principal Coordinator of Care and their Credentials Use of Best Practices Emphasis on Self- Empowerment and Training Role with Family/Informal Caregivers

14 Common Strategies At Different Points of Contact During Hospitalization At Point of Discharge Post-Discharge Source: Health Care Leader Action Guide to Reduce Avoidable Admissions

15 Hospital-Based Approaches Boston University Medical Center Ensure effective transfer of clinical information to the patient and ambulatory clinical providers at the time of discharge. National Quality Forum 15

16 16

17 RED : Introduces Role of Discharge Advocate and 11 mutually reinforcing components: 1. Patient education 2. Follow-up appointments 3. Outstanding tests 4. Post-discharge services 5. Medication reconciliation 6. Reconcile DC plan with national guidelines 7. What to do if problem arises 8. Assess patient understanding 9. Written discharge plan for patient 10. Timely transmission of DC summary to PCP 11. Post-discharge telephone reinforcement

18 Exploring computer aided plans

19 Better Outcomes for Older Adults Through Safe Transitions Tool for Identification of High-Risk Patients: 7 Ps Patient and Family/Caregiver Preparation Diagnosis primary cause for hospitalization and other Dx Test results and interpretation Treatment Plan during and after hospitalization Contextualize Follow-up Plans Principal Care Provider identification Who to contact with questions/concerns Warning signs/symptoms and how to respond Outpatient appointments Pending tests Medication Reconciliation Discharge Summary Communication

20 Project BOOST Built on premise that institutions have different experiences/resources with respect to quality improvement programs, available resources, and existing discharge procedures and processes. Project Boost is not a rigidly structured, formalized model Project Boost has produced an open-ended intervention to tailor to institutional circumstances and resources. Website includes a step-by-step institutional assessment and process mapping resource to best tailor an intervention Does not explicitly require someone to staff a care coordinator position, but rather aims to be implemented into daily processes of organizations.

21 Four Key Domains of Care Transitions Model (Coleman) Information transfer Patient and caregiver preparation Self-management support Empowerment to assert preferences

22 Key Elements of Intervention Transition Coach Prepares patient for what to expect and to speak up Provides tools (Personal Health Record) Can begin in hospital -Follows patient to nursing facility or to the home Reconcile pre- and post-hospital medications Practice or role-play next encounter or visit Phone calls 2, 7 and 14 days after discharge Single point of contact; reinforce, ensure follow up

23 Measurement Items:CTM-3 TM 1. The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital. 2. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. 3. When I left the hospital, I clearly understood the purpose for taking each of my medications.

24 Transitional Care Model (Naylor) Nurse Practitioners provide inpatient assessment NPs review medications and goals Design and coordinate care with patients and providers Attend first post discharge MD office visit Direct home care for 1-3 months Conduct home visits at intervals: 7 day call coverage Naylor, M.D. et al J Am Geriatric Soc 52:

25 The Guided Care Model Specially trained RNs based in primary physicians offices GCNs collaborate with 2-5 physicians in caring for high-risk older patients with chronic conditions and complex health care needs

26 Guided Care Nurses Activities Assess needs and preferences in-person Create an evidence-based care guide Monitor patients proactively Support chronic disease self management Communicate with providers in EDs, hospitals, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies in the community Smooth transitions between sites of care Educate and support caregivers Facilitate access to community services

27 Effects of Guided Care Open-ended intervention Higher quality of care Greater physician satisfaction with care High nurse job satisfaction Lower caregiver strain Lower costs of health care 23% in insurance payments in pilot test $85,500 annual net savings per nurse in RCT )

28 What is Known about Annual Costs and Savings? The Care Transitions Model (Coleman) Annual Cost= $74,310 for 379 patients ($196 per patient). Estimated Annual Cost Savings: $844 per patient The Transitional Care Model (Naylor) The total intervention cost was $115,856 ($982 per patient). One study demonstrated mean cost savings of $5000/patient The Guided Care Model (Boult) Early results of randomized studies indicate cost savings of $1364 per patient ($75,000 per nurse) Project RED (Jack) Randomized Studies showed cost savings of $380/patient 28

29 Policy Attention to Complexity of Transitions: What opportunities exist to effect issues related to: Health Literacy Patient Safety Medication therapy management Treatment interventions Standards Guidelines Performance Measures

30 Types of Payment Reform Reward low readmission rates or penalize high rates Generally directed at hospitals, but other providers and practitioners are vital partners Medicare is the most likely immediate major change agent, but other payors will follow

31 Bundling Expanded, DRG-like payment for specific disease episodes Includes pre-hospital care, hospital care, and a timelimited (30-45 days) portion of post-acute services Should include physician component (in Senate bill; not in House bill) Provider assumes performance risk for limited period covered Requires freedom from legal barriers (anti-trust, Stark, gain sharing, etc.)

32 Global Budget/ Accountable Care Organizations Global or capitated account for a defined population over a longer period (say one year) Provider assumes broader performance risk Core provider responsible for broader range of services, over longer period of time Risk /reward relates to utilization control Patient population not necessarily disease-specific Hospital or MD could be core provider (Senate bill, House bill MD-only) Legal barriers same as bundling

33 Care Transitions : Legislative Language Care Transitions Demonstration written in to legislation Care Transitions Measurement Place of Health Technology: Advancing EMR support

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