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					             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:

   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

• 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
• Narrow perceived accountability
• Lack of systems to bridge transitions

• 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
    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)

 Maintaining                        Engaging
 Relationship                    Elder/Caregiver

Coordinating                       Managing

                          Unique Features

Care is delivered and
…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,
          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

   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
                                    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
• 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:
• 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
  • Partner with home care agency
  • Target 200 members in mid-Atlantic region
  • Clearly define roles and work flow
                   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

             April 22, 2008
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

Measures of interest…

 • Health status and quality of life
 • 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

Overall high satisfaction

• Mean score of 3.0 on each of the 15
  items in survey
  (1=low satisfaction, 4=very high
        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)

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
• 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.
• 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
• 0-3 months, 252 TCM vs. 426 controls
• 0-6 months, 393 TCM vs. 693 controls
• 0-12 months, 658 TCM vs. 1108
 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
    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
         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
• 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
                       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
• 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
        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
• Rigorous proof of benefit and cost
  reduction (if any); randomized trials are
  much preferred to before-and-after
• 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
     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
• 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?

• 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.