Transcript Slides

Care Transitions Innovation
(C-TraIn)
Honora Englander, MD
Assistant Professor of Medicine
Oregon Health & Science University
September 27, 2013
Objectives
Describe transitional care gaps and challenges among
socioeconomically disadvantaged adults
Describe the Care Transitions Innovation (C-TraIn), including:
1. How the program was developed, including securing institutional
support
2. What the C-TraIn intervention entails
3. The program’s experience to-date, including single site
implementation and expansion across the
regional Coordinated Care Organization
Discuss some lessons learned from the C-TraIn experience
Care Transitions Innovation
(C-TraIn)
RARE Networking Collaborative Webinar
September 27, 2013
Honora Englander, MD
[email protected]
Outline
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Background – rationale and design
C-TraIn description
Experience to date
Successes, challenges, lessons learned
Next steps
Q&A
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Background
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Transitions of care are increasingly recognized as
target for quality improvement
Expected to be a source of cost savings
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Pre discharge Intervention
Post discharge Intervention
Patient education
Timely follow-up
Discharge Planning
Timely PCP communication
Medication Reconciliation
Follow-up phone call
Appointment scheduling before
discharge
Patient hotline
Home visit
Bridging Intervention
Transition coach
Patient-centered discharge instructions
Provider continuity
No single intervention was regularly associated with
lower readmits; bridging were most promising
Hansen, Annals 2012
Transitions Among Socioeconomically
Vulnerable Adults
• Few studies have focused on uninsured, low-income
publicly insured patients
• Different needs, may have different responses to
interventions
• At risk for poor health outcomes
• Many are high-utilizers of the system
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Readmissions are complicated…
Medical,
Behavioral
Hospital
Readmission
Postdischarge
care
Socioeconomic
Community
Kansagara, Englander, et al JAMA, 2011
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Transitional care gaps reflect broader
system fragmentation
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Numerous contributors to readmission risk
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Interventions to reduce readmissions not well
studied in diverse populations
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No off-the-shelf fixes; key to tailor interventions to
local setting, address systems and population needs
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Brief History of C-TraIn
• Health System M&M and one patient’s story
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Needs assessment and Program Development
OHSU (6/09-6/10)
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Mixed methods survey of 116 inpatients who were
uninsured or low-income publicly insured
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Multidisciplinary provider focus groups
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Mapped needs to specific components of C-TraIn
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Local Needs Assessment
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Patients and providers described poor quality
transitions for uninsured and low-income publicly
insured adults
Opportunities to improve patient education,
access to outpatient medications and care, and
coordination between in- and outpatient care
Englander, Kansagara, Journal of Hosp Med 2012
Davis, Devoe, et al JGIM, 2012
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“So all of a sudden I [went] from this controlled
setting here with people watching out for me and
taking care of me… to, I'm out there in the real world
bounding around… and no real place to live as of yet.
You know, it's just like, it's like a big roll of the dice.”
-Hospitalized Patient
-Englander, Kansagara; JHM 2012
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“The package that leaves the hospital now…more
often than historically, includes a PICC line, Foley
catheter, oxygen--without a plan for when those
are to be stopped and without communication to
anyone about who's in charge next. Sometimes we
end up with [the patients] coming back to see us
months after they've been discharged. They've
been wearing a Foley catheter all that time! It's
amazing the way those balls can get dropped.”
-PCP
Davis, Devoe et al, JGIM 2012
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Transitional Care Deficiencies
• Communication
• Patient education
• Access to care
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Early Experience at OHSU
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Started in 2010 as a hospital-funded intervention
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Targeted adults living in the tri-county area who were
uninsured, Medicaid, Medi-Medi, and low-income
Medicare
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Multi-component transitional care intervention
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3 partnering clinics
• OHSU Internal Medicine Clinic, Old Town Clinic, Virginia Garcia
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The Health Commons Grant
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July 2012: $17.3 million to support a system of care
for high risk Medicaid adults
Scale up C-TraIn from 1 to 5 sites, including:
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OHSU Medical and Surgical
Legacy Mt Hood, Legacy Good Sam, Legacy Emmanuel hospitals
Broader network of primary care clinics
Goal:
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Achieve the triple-aim
Learn lessons to inform CCO transformation efforts
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4 Core C-TraIn Components:
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Transitional Care Nurse
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Pharmacy Consultation
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Hospital and Clinic Linkages
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Monthly quality improvement meetings with
multidisciplinary providers across the care
continuum
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Transitional Care Nurse Role
(Starts on admission through 30 days post-DC)
• Needs assessment upon hospitalization
• Personal health record
• Cross site communication and care coordination
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inpatient teams, PCPs, specialists, outreach workers, ADS, others
• Home visit
• Follow up calls, clinic visits, text messaging
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Pharmacy consultation
(Inpatient intervention, provides post-DC
consultation to TCN)
• Detailed medication reconciliation
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Corroborate w/ PCP, outpatient pharmacies, family/ caregivers
• Tailor medications to simple regimens, formulary
alternatives
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Provision of 30 days of C-Train formulary meds for uninsured and
Medicare without Rx coverage (OHSU only)
• Communication with outpatient pharmacies
• Patient education re meds, side effects
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Low health literacy/ numeracy
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Pill card
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C-TraIn Pill Card
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Dosing the Intervention
Different doses for patient being discharged to skilled
nursing facility, RCP, etc.
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Patient Stories: Anticipatory Planning
and Enhanced Education
• Middle aged man with diabetes, secondary
blindness, and poor social support admitted with a
diabetic foot ulcer requiring surgery. Started on
insulin in the hospital.
• In- and outpatient pharmacists collaborated to preload insulin pens
• Nurse home visit reinforced self-management and
follow-up plan
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Patient stories: Home Visit Guides Care
• Elderly woman with heart failure admitted with
lower extremity cellulitis. After discharge she didn’t
answer phone so nurse went to home which was a
safety hazard in complete disarray.
• Nurse contacted PCP who arranged for home
health and a social work referral prompted Adult
Protective Services to assist in clean up and
maintenance of home.
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Patient Stories: Pharmacy Consultation
• Middle aged man with unstable housing and
schizoaffective disorder assaulted and admitted as
trauma with c-spine and jaw fractures, liver
laceration
• Pharmacy consult revealed he had stopped
antipsychotics (? trigger for assault)
• C-TraIn team facilitated cross-site communication w
PCP and outpatient MH
• Timely PCP f/u: food insecurity given jaw pain,
arranged meals-on-wheels delivery
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C-TraIn Stories: Systems Integration
Cross-site collaboration
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Inpatient and outpatient pharmacists
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Transitional care nurse and clinic panel managers
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Coordination with primary care partners
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Building on connections with Skilled Nursing
Care plan spans the continuum of care:
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Glucometer example
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Outcomes
Primary: 30-day readmissions and ED visit rates
Secondary:
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Transitional care quality (CTM-3)
Mortality
Timely access to outpatient care
Other grant-wide metrics, including admission rates
across community, total cost-of-care, etc
Using experience to inform and build a system of care
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CTM-3 (Care Transitions Measure)
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.
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Experience to Date
• >600 patients served to date, >200 in year 1 of the
Health Commons Grant
• Completed a randomized trial at OHSU
• Using findings to tailor intervention to best achieve
the triple aim goals
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Successes
• Highly-committed, multidisciplinary teams
• Improved communication across hospital and
ambulatory settings
• Shift to anticipatory transitional care planning
• Lessons extend beyond C-TraIn population
• Triple-aim outcomes
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Challenges
• Patient identification – who to target, how to
engage
• Anticipatory planning in a fast-moving system
• Addictions remain key challenge for engagement
• Primary care capacity to manage highly complex
patients with numerous care teams
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Lessons Learned
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Diverse needs of this population challenge scope of
transitional nurse role
Training in social determinants of health is key
Importance of embedding staff within Care Mgt and
pharmacy teams
Value of work that spans care continuum, home
multi-disciplinary meetings (including clinic
partners) optimizes work flow and outcomes
Project manager role critical to scaling improvement
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Program Evaluation
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Creating dashboard to track key activities and
outcomes
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Patient and provider surveys and interviews
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Evaluation team comparing pre-post claims data
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Outcomes reported quarterly (see Health Commons
website for most recent dashboard)
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Next Steps in Year 2 of Health Commons
Grant
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Continuous quality improvement within and across
sites
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Continued alignment across grant interventions to
optimize model of care and data systems
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Program evaluation to be in full-swing
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Beginning sustainability conversations with key
stakeholders
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Implications for RARE network
• Socioeconomically vulnerable adults may have
different needs
• No off the shelf fixes: context is key
• Value of Hospital-community partnerships
• Importance of executive leadership support
• Value of C-TraIn lessons for all hospitalized patients
• Optimize standard work around transitions of care
• While focus on readmissions is important, also look at
other measures of quality
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Acknowledgements:
Thank you to large multidisciplinary CTraIn team across OHSU, Legacy, and
numerous community sites
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Questions?
Honora Englander, MD
C-TraIn Director
[email protected]
HEALTH SHARE OF OREGON
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Maggie Weller
C-TraIn Project Manager
[email protected]
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Supplemental Slides
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C-TraIn Team Roles
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Intervention Lead: Strategic vision and alignment
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Hospital MD Leads: Provide input on workflow
improvement; inform in-patient staff of C-TraIn
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Transitional Care Nurses: patient education,
multidisciplinary care coordination, engaging with community
resources, home visits, follow up phone calls
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Hospital Pharmacy Leads: health literacy assessment,
patient education, prescribing guidance
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Partner Clinic Champions: Provide input on workflow
improvement; inform out-patient staff of C-TraIn
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Project Manager: Track and drive completion of goals
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Case Loads
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14 patients per month per 1.0 transitional care
FTE
Initially targeted higher (~20 patients/ month)
with goal to have more low-dose C-TraIn patients,
but experience suggests paucity of lower need
patients
Pharmacy team (0.3 FTE per 1.0 transitional care
nurse) able to see higher case loads, depending
on timing of consult
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Readmission risk prediction models have been developed
for hospital comparison and clinical intervention purposes
Most models in both categories perform poorly
Most models have relied on comorbidity and utilization
data
Few models have examined social determinant variables
Kansagara, Englander JAMA 2011
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Kansagara, JAMA, 2011
•
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Mixed methods survey of 116 inpatients who were
uninsured or low-income publicly insured
Mapped needs to specific components of C-TraIn
Englander, Kansagara JHM 2011
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"We don’t have a community contract where
everybody acknowledges their role… ‘my role as the
sender is to do these things’, ‘my role as the
recipient is to do these things’…the ‘who will’ and
‘how’ of the handoff. We never get close to that
sort of formality, which is really what any smart
handoff or transition would require."
-Healthcare administrator,
Davis, Devoe et al, JGIM 2012
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Resources
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Health Commons Web site
http://www.healthcommonsgrant.org/
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C-TraIn SharePoint site (for project teams)
https://healthshareoforegon.sharepoint.com
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Questions ?
Upcoming RARE Events….
Stay tuned for the next RARE Webinar in October.
RARE Action Learning Day – November 11, 2013
Crown Plaza Hotel, Plymouth, MN
Registration now open!
Future webinars…
To suggest future topics for this series,
Reducing Avoidable Readmissions
Effectively “RARE” Networking
Webinars, contact Kathy Cummings,
[email protected]