Transitions in Care Moderated by Mary Jane Koren, MD The Commonwealth Fund Presented by Kathryn H. Bowles, PhD, RN Mary D. Naylor, PhD, RN Randall Krakauer, MD, FACP, FACR Mark V. Pauly, PhD New York Academy of Medicine April 22, 2008 The patient experience transitioning from hospital to home Kathryn H. Bowles, PhD, RN, FAAN Associate Professor NewCourtland Center for Transitions & Health University of Pennsylvania School of Nursing April 22, 2008 Mr. and Mrs. Jenkins and Family Mr. Jenkins’ Profile • 76 year young Penn grad (C’49, W’52); retired investment broker; active lifestyle • Lives with wife of 50 years in suburban Philadelphia; wife showing signs of cognitive changes • Three children living w/families in other states Mr. Jenkins’ Health History • History of 7 chronic conditions • Under the care of 6 specialist physicians; PCP retired • Taking 9 prescribed medications daily; coping with dietary restrictions • Health problems increasingly interfering with lifestyle Discharge Set for Day 3: Perspectives Patient & Family Health Professionals • Multiple unmet • Health needs met needs • Family able to • Needs additional meet needs help at home • Strong, available • Stressed family support system system VS “The hand-off” • No referral for nurse home visits • Three new medications ordered; verbal + handwritten discharge instructions • Told to schedule follow-up M.D. visit within 7 days At Home 8 Hours Later, Mr. J. • Can’t read discharge instructions • Has questions about medications but does not know whom to call • Is weak, dizzy, and unable to eat • First available M.D. app’t > 2 weeks 2 Weeks Later (before MD visit) Mr. Jenkins is rehospitalized for a 4th time with an admitting diagnosis of acute episode of heart failure ―due to lack of adherence to prescribed therapies.‖ Profile of Study Patients • Age = 76 (65-99) • Chronic conditions = 7 (3-14) • Prescribed medications = 8 (4-14) • Average of 4.6 problems per patient • Nurses addressed 32 different types of problems with 173 patients Patient Factors Contributing to Poor Post-Discharge Outcomes • Multiple conditions/therapies* • Functional deficits • Emotional problems • Poor general health behaviors • Poor subjective health rating* • Lack of support • Cognitive impairment** • Language, literacy and culture System Factors Contributing to Poor Post-Discharge Outcomes • Multiple providers • Inconsistent medical management • Poor communication • Limited access to services (reimbursement) • Narrow perceived accountability • Lack of systems to bridge transitions Consequences • High rates of medical errors and other acute clinical events • Serious unmet needs • Poor satisfaction with care • High hospital readmission rates Elders Hospitalized with Heart Failure (HF) in 2005 • 616,000 index hospitalizations • Readmission rates • 30 days - 27% • 60 days – 39% • 90 days - ~50% • Preventing 1/4 to 1/3 readmissions @ $7,400 per admission = $473 to $621 million savings Source: CMS Evidence-Based Transitional Care A proven approach to enhance quality of care and outcomes among older adults with chronic conditions. Re-envisioning Health Care: Use of Evidence-Based Transitional Care Mary D. Naylor, PhD, RN, FAAN Marian S. Ware Professor in Gerontology Director, NewCourtland Center for Transitions & Health University of Pennsylvania School of Nursing April 22, 2008 Transitional Care Transitional care – range of time services and environments designed to ensure health care continuity and avoid preventable poor health outcomes among high risk populations as they move from one level of care to another or across settings. Evidence-Based Approaches • Targeted interventions aimed at promoting effective ―hand-offs‖ • Comprehensive interventions designed to address ―root causes‖ of avoidable acute care service use Quality Cost Transitional Care Model (TCM) Screening Maintaining Engaging Relationship Elder/Caregiver Coordinating Managing Symptoms Care Educating/ Assuring Promoting Continuity Self-Management Collaborating Unique Features Care is delivered and coordinated …by same APN …across settings …7 days per week …using evidence-based protocol …with focus on long term outcomes Transitional Care Model TCM Nurse conducts PATIENT TCM Nurse comprehensive assessment of TCM Nurse visits the admitted to a hospital visits patient in patient’s and family patient daily during within the past 24 - 48 hospital within caregiver’s goals and needs, hospitalization. hrs 24 hrs of enrollment. and initiates collaboration with patient’s physicians. TCM Nurse collaborates Patient is evaluated TCM Nurse visits Patient with members of the health based on the TCM patient transitioned from consent care team to design and screening and risk hospital to home obtained coordinate evidence-based assessment. within 24 hrs. transitional care plan. TCM Nurse implements care plan, Patient eligible? YES Seven days per week continually reassessing patient’s availability (includes at least status and the plan with the patient, weekly home visits during first family caregiver and primary care month, and at least weekly clinicians. telephone outreach NO Accompanies patient throughout intervention). Average length of care to at least initial is 2 months primary care clinician visits. Standard Discharge Plan PATIENT transitioned Makes referrals for from TCM program: Promotes transition health care or a summary of patient’s goals, to primary care community support progress and continuing needs clinicians. as needed. is sent to patient, family caregivers and primary care clinicians within 48 hrs. Findings from Randomized Clinical Trials Funding: National Institutes of Health, National Institute of Nursing Research, National Institute on Aging (1990-2010) Core Components • Holistic, person/family centered approach • Protocol guided, streamlined care • Team model; shared accountability • Single ―point person‖ across episode of care • Information/communication systems that span settings Barriers to Adoption • Organization of current system of care • Lack of quality and financial incentives • Culture of care Translating Research into Practice Penn research team has formed partnerships with Aetna Corporation and Kaiser Permanente to test ―real world‖ applications of research-based model of care for high risk elders. Funded by The Commonwealth Fund and the following Foundations: Jacob and Valeria Langeloth, The John A. Hartford, Gordon & Betty Moore & California HealthCare Key Indicators of Success • Decisions by Aetna & Kaiser re: adoption • Decisions by other insurers and providers to implement model • Use of findings by CMS and insurers to reimburse evidence-based transitional care Primary Tools of Translation • Web-based modules • Clinical information system Integration of Model within Aetna • Project team and processes • Key decisions • Link to geriatric case management program • Partner with home care agency • Target 200 members in mid-Atlantic region • Clearly define roles and work flow processes Lessons Learned • Making the case is the first step… …focusing on the goal is ongoing • Champions are key… …but it takes a village • Terms of engagement are essential… …but you must be nimble Lessons Learned • Successfully integrating an evidence-based innovation is a major accomplishment …but the proof is in the pudding. Transitional Care Model (TCM): The Value Proposition Randall Krakauer, MD, FACP, FACR National Medical Director Consumer Segment AETNA April 22, 2008 Quality Value = Health Resource Utilization (Costs) Environment: Extant comprehensive system of telephonic care management Question: Does the Transitional Care Model offer greater value in this environment? Goodness of Fit TCM compatible with Aetna’s values and goals. Model is designed to… • Improve care and quality of life among elders coping with chronic illnesses • Enhance communication among providers and across settings • Manage ―high risk patients‖ more effectively and efficiently • Reduce avoidable admissions and readmissions Quality Measures of interest… • Health status and quality of life (QoL) • Members’ satisfaction • Physicians’ satisfaction Health Status + QoL (N=172) Significant improvements in each of the following outcome variables: • self-reported health status (1 item) • symptom status (Symptom Bother Scale) • depression (Geriatric Depression Scale) • functional status (SF-12) • quality of life (one item) Members’ Experience with TCM (N=171) Overall high satisfaction • Mean score of 3.0 on each of the 15 items in survey (1=low satisfaction, 4=very high satisfaction) Physicians’ Experience with TCM (N=25)* Overall high satisfaction with APN involvement in members’ care • Mean score 3.5 on each of the 10 item in (1= strongly disagree, 4 = strongly agree) * Satisfaction data obtained from MDs with at least 3 patients involved in TCM Health Resource Utilization (Costs) (N=154)* Measures of interest… • Rehospitalization rates • Skilled nursing visits • Home visits *154 TCM cases compared to clinically matched 154 controls Hospitalization Rates Reductions in hospitalizations at 3 months post-intervention but not sustained • 0-3 months, 44 TCM vs. 55 controls (20% reduction) • 0-6 months, 105 TCM vs. 101 controls • 0-12 months, 185 TCM vs. 189 controls Skilled Nursing Facility (SNF) Rates Moderate reductions in SNF visits observed between TCM vs. controls • 0-3 months, 5 TCM vs. 9 controls • 0-6 months, 14 TCM vs. 17 controls • 0-12 months, 26 TCM vs. 31 controls Home Visit Rates Use of home visits substantially higher for controls vs. TCM cases • 0-3 months, 252 TCM vs. 426 controls • 0-6 months, 393 TCM vs. 693 controls • 0-12 months, 658 TCM vs. 1108 controls Factors Considered in Interpreting Health Resource Findings • Hospital component of TCM was not implemented in applying model with Aetna’s members • Regional variations in service use: • Hospital use higher in TCM case region • Home health care use higher in control region High Quality Evidence of Reductions = in Acute Readmissions TCM as High Value Proposition for Aetna Next Steps • Pursuing support of TCM for Aetna members involved in UPHS roll out • Incorporate Inpatient portion of the model • TCM proposed for expansion within Aetna as part of 2009 Strategic Plan Aging, Transitional Care, and the Medical Care Spending Crisis Mark V. Pauly, PhD Bendheim Professor, and Professor of Health Care Systems, Business and Public Policy, Insurance and Risk Management, and Economics University of Pennsylvania Wharton School April 22, 2008 Some Stylized Facts • The ratio of seniors to workers is expected to double between now and about 2030. • Government pays for the bulk of medical costs for this population. • Spending per person grows primarily because of beneficial but costly new technology • If spending grows in the future as it has in the past, the tax burden on the economy to pay for elderly medical care will double or more. So What’s New? • Don’t these prospective changes just imply scaling up of today’s care patterns? • If today’s care and its costs are acceptable today, why do more to limit spending in the future? • If total spending is set to rise, does that necessarily mean that the system will have to be MORE efficient than today? Yes, if innovation is a public good. Transitional Care as Innovation • Usually an ―episode of care‖ utilizes different services from different providers. • Lack of evidence-based findings and uncertain nature of the outcomes from care mean that there usually is no single agreed- upon optimal process that can be planned from the start. • Patients/families have values and knowledge that ought to matter, but they do not know enough to manage the care process themselves. The Benefits and Costs of Transitional Care • Sometimes transitional care can avoid future costly interventions with or without any effect on health. • But transitional care that improves outcomes may be desirable even if it increases total cost as long as the value of better outcomes exceeds the additional cost. Characteristics of Desirable Innovations • Rigorous proof of benefit and cost reduction (if any); randomized trials are much preferred to before-and-after observations. • Easy generalization: anyone can find the ingredients and follow the rules. • If the benefits are prospective but the cost is incurred now, some way to finance the investment. Applications to care transitions between hospitals and home • Pay for performance: requires reliable risk adjusted outcomes data. • An alternative model: specially trained professionals doing their job. • The latter is preferred when only ―high level‖ outcome measures are possible and when professionals are already highly motivated to help. Insurance Payment and Transitional Care • Insurers want to figure out how to package the medical home concept in an acceptable way. • They are bedeviled by the chicken-egg problem: an insurer is reluctant to build in cost savings into the premium until it has proof that they occur, but you have a hard time selling insurance that embodies transitional care without lower premiums. Employers as a Driving Force • Insurers will do almost anything if a large employer or a large set of smaller employers wants it in the package and is willing to pay for its cost. • But transitional care seems so far down the value chain… If it was a great idea wouldn’t providers already be doing it, especially in markets with many competing providers? Possible Paths to Improvements • Just telling people what’s good for them won’t work. • Identify better transitional care as a key element of a novel insurance product, and identify nurses as key to that service. • Run it up the flagpole: would a nurse-led care transitional care package attract consumers? • Would having this benefit option attract good workers to my company? Conclusions • Americans will probably prefer to have improved continuity of care—as long as they can have input into the process and the option of bailing out when they want. • Cost savings are probably most valuable as a way of getting in the door to speak about quality improvement. • But the ability to reduce costs must be rigorously demonstrated—not just asserted.