Transcript The Transitional Care Model

Mary D. Naylor, PhD, RN, FAAN
Marian S. Ware Professor in Gerontology
Director, NewCourtland Center for Transitions and Health
University of Pennsylvania School of Nursing
www.transitionalcare.info
TCM010 – Unit 1
March 19, 2013
 Older Adults
 Family Caregivers
 Health Care Clinicians
 Society
Range of time limited services and
environments that complement primary care
and are designed to ensure health care
continuity and avoid preventable poor
outcomes among at risk populations as
they move from one level of care to
another, among multiple providers and
across settings.
 High rates of medical errors
 Serious unmet needs
 Poor satisfaction with care
 High rates of preventable readmissions
 Tremendous human and cost burden
 Center for Medicare and Medicaid Innovation
•
•
•
•
Community-Based Care Transitions Program
Multi-Payer Patient-Centered Medical Home
Shared Savings Program (ACOs)
Payment Innovation (e.g., Bundled Payments)
 Transitional Care Payment Codes
 Federal Coordinated Health Care Office
 Amends title XVIII (Medicare) of the Social Security Act
to cover transitional care services for qualified
individuals provided by a transitional care clinician
acting as an employee of a qualified transitional care
entity, such as a hospital (or a critical care hospital), a
home health agency, a primary care practice, a
federally qualified health center, a long-term care
facility, a medical home, an appropriate communitybased organization, an assisted living center, or an
accountable care organization.
(* Re-Introduced by Reps. Earl Blumenauer (D-Ore.), Thomas Petri (R-Wis.),
Allyson Schwartz (D-Pa.) and Jan Schakowsky (D-Ill.) in September, 2012)
Trajectory 1 (T1)
Relatively healthy adult
with onset of new chronic
illness
Population
At Risk
Acute
Phase
Post
Acute/
Rehab
Phase
Secondary
Prevention
Trajectory 2 (T2)
Adult with multiple chronic
conditions
Trajectory 3 (T3)
Adults at end of life
Adapted from the National Quality Forum (NQF) steering committee on Measurement Framework: Evaluating
Efficiency Across Patient-Focused Episodes of Care. The committee’s report presents the NQF-endorsed
measurement framework for assessing efficiency, and ultimately value, associated with the care over the course of
an episode of illness and sets forth a vision to guide ongoing and future efforts.
 Address gaps in care and promote
effective “hand-offs”
 Address “root causes” of poor
outcomes with focus on longer-term
value
 Stratify population based on needs/risk &
apply EB interventions
• Lower risk groups (T1) – improve “hand-offs”
• Higher risk groups (T2) – interrupt current
trajectory/focus on long-term outcomes
• Adults at end of life (T3) – transition to
palliative care/hospice
Care is delivered and coordinated…
…by same APN supported by team
…in hospitals, SNFs, and homes
…seven days per week
…using evidence-based protocol
…supported by tool box
 Holistic, person/family centered approach
 Nurse-coordinated, team model
 Protocol guided, streamlined care
 Single “point person” across episode of care
 Information/decision support systems that
span settings
 Focus on increasing value over long term
Better
Care
• Enhanced
access
• Reduced
errors
• Increased
satisfaction
Better
Health
Reduced
Costs
• Decreased
• Decreased all-cause
symptoms
rehospitalizations
• Improved
• Reduced ED visits
function
• Total cost savings
• Enhanced
quality of life
(* Based on 3 NIH funded RCTs: Ann Intern Med, 1994,120:999-1006; JAMA, 1999, 281:613-620; J Am
Geriatr Soc, 2004, 52:675-684)
Translating Evidence Into Practice
Penn research team formed partnerships
with Aetna Corporation and Kaiser
Permanente to test “real world”
applications of research-based model of
care among high risk elders.
Funded by The Commonwealth Fund and the following foundations: Jacob
and Valeria Langeloth, The John A. Hartford, Gordon & Betty Moore, and
California HealthCare; guided by National Advisory Committee (NAC)
 Patient screening and recruitment
 Preparation of TCM nurses and teams (e.g.,
online course)
 Documentation and quality monitoring
(clinical information system)
 Quality improvement (case conferences
grounded in root cause analysis)
 Evaluation
 Improvements in all quality measures
 Increased patient and physician satisfaction
 Reductions in rehospitalizations through 3
months
 Cost savings through one year
 All significant at p < 0.05
(Naylor et al., 2011. J Evaluation in Clinical Practice. doi: 10.1111/j.1365-2753.2011.01659.x.)
Would cognitively impaired
hospitalized older adults and
their caregivers benefit
from TCM?
Funding: Marian S. Ware Alzheimer Program, and National Institute
on Aging, R01AG023116, (2005-2011)
www.transitionalcare.info
 Compared three evidence-based innovations
among hospitalized cognitively impaired older
adults and family caregivers, each designed to:
• Improve patients’ and family caregivers’ outcomes
• Reduce preventable rehospitalizations
• Decrease total health care costs
 Enrolled 407 older adults and 407 family
caregivers in prospective clinical trial conducted
over 2 phases
Diagnosis of
Dementia,
19.2%
Executive
Function
deficits
(clock task),
37.6%
Orientation
Recall deficits,
43.2%
 24.9% also had delirium (+ Confusion Assessment Method)
100%
93.4%
79.8%
75%
TCM
67.9%
78.6%
63.7%
50%
ASC/RNC
53.1%
25%
0%
0
P=0.0005
30
60
90
Days
TCM
120
ASC/RNC
150
180
Mean No Rehospitalizations
0.2
P=.0049
0.18
0.16
0.14
0.12
0.1
APN
ASC/RNC
0.08
0.06
0.04
0.02
0
30
60
90
120
Days
150
180
 Analyses re: patient, family caregiver and cost
outcomes ongoing
 About 30% of sample transitioned from
hospitals thru post-acute SNFs to home
 Findings contributed to ongoing work (+ recent
NIH submission) to assess effects of learning
collaborative with SNFs (hospitals and post-SNF
providers) in implementation of evidence-based
transitional care
What do we know about
effects of transitions among
elderly long-term care
recipients over time?
Funding: National Institute on Aging, National Institute of
Nursing Research, R01AG025524, (2006-2011)
www.transitionalcare.info
 Examine the trajectory of changes in each of
multiple HRQoL domains
 Explore relationships between and among the
multiple domains and health + long-term service
use
 Compare the patterns of change among similar
older adults supported by three options (i.e.,
HCBS, ALF, NH)
 Enrolled 470 English- and Spanish-speaking
older adults from 50 sites, who were new
recipients of long-term services and supports
 Included older adults with mild- and moderatecognitive impairment
 Conducted quarterly interviews with adults and
abstracted chart data; conducted
organizational surveys
(Zubritzky et al., 2012, The Gerontologist. doi: 10.1093/geront/gns093)
64%
56%
41%
Aching
(* Symptom Bother Scale)
Shortness of
Breath
Pain
 Overall rates of bothersome symptoms
decreased and general health perceptions
increased (p<0.001)
 Further declines in bothersome symptoms were
associated with increased depression (p<0.001)
and increased hospitalization use (p=0.02)
 Reported rates of bothersome symptoms were
lower for non-white LTSS recipients (p=0.003)
Categorized Depression Score Distribution Over Time
(0-4)
(5-9)
(10+)
11%
7%
6%
6%
5%
26%
32%
30%
28%
32%
63%
61%
63%
65%
63%
0m
3m
6m
9m
12m
 Opportunity to capture the “voice” of
elderly LTSS recipients over time
 Potential for interventions designed to
recognize and manage physical and
emotional symptoms
 Potential for policies that enhance earlier
access to symptom management
Does the TCM add value
to the Patient Centered
Medical Home?
Funding: Gordon and Betty Moore Foundation, Rita and Alex
Hillman Foundation and the Jonas Center for Excellence
(2011-2013)
www.transitionalcare.info
 Compare the health and cost outcomes
demonstrated by community-based older
adults coping with multiple chronic
conditions who receive the PCMH+TCM to
a similar group of older adults who receive
the PCMH only
 Collaboration (co-management) with PCMH
 Focus on patient (and family caregiver)
goals – Goal Attainment Scaling
 Emphasis on prevention of acute resource
use (ED visit, index hospitalization) and
continuity of care when acute event occurs
Diagnoses: 12 (4-24)
Medications: 11 (1-23)
Major Risk Factors: 4 (2-7)
Average PCMH+TCM intervention: 63 days (n=29)
N
Time to
hospitalization
PCMH+TCM
National
Avg.*
ED visits (no
hospitalization)
Acute office
visits
34
0-30 days
3%
20%
0%
0%
34
0-60 days
15%
28%
0%
0%
33
0-90 days
15%
34%
6%
0%
(* Based on Jenks et al., 2009, N Engl J Med. 360:1418-1428)
 Focuses on transitions of high-risk cognitively
intact and impaired older adults across all
settings
 Has been “successfully” translated into
practice
 Has been recognized by the Coalition for
Evidence-Based Policy as an innovation
meeting “top-tier” evidence standards
Key Components for Success
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Champions
Shared goals
Multi-stakeholder involvement
Communication
Data monitoring and reporting
Culture of continuous learning
 Aetna – expansion of TCM proposed as
part of Aetna’s Strategic Plan
 University of Pennsylvania Health System –
adopted TCM (Aetna and Blue Cross
reimbursing)
 Other health care systems & communities –
adopting/adopting
 Informing ACA implementation
Areas in the U.S. implementing TCM
International Locations: Canada, Germany, Ireland, New Zealand, Scotland, Singapore
 Solving complex problems will require
multidimensional solutions
 Evidence is necessary but not sufficient
 Change is needed in structures, care
processes, and health professionals’ roles
and relationships to each other and people
they support
 Carpe Diem!
www.transitionalcare.info