1. health and fitness

With
h Gratitude
TRANSITIONAL CARE MODEL
From
m Evid
Evidence
nc to Impact:
mpact An Interdisciplinary
nt di ciplin
Approach to High Value Healthcare
Mary D. Naylor, Ph.D., RN
Marian S. Ware Professor in Gerontology
Director, NewCourtland Center for Transitions and Health
University of Pennsylvania School of Nursing
21st Florence Cellar Conference on Aging
Frances Payne Bolton School of Nursing
Case Western Reserve University
April 17, 2015
Perspectives on Chronic Illness Care
in the US
• Older Adults
• Family Caregivers
• Health Care Clinicians/Teams
• Societal
Univ. of Pennsylvania
Health System
Independence Blue
Cross of Phila.
Aetna Corporation
Kaiser Permanente
Other Health Systems
and Communities
CMS QIOs
PCMHs
Patients & Families
Ron Barg
M. Brian Bixby
Partners
Kathryn Bowles
Alexandra Hanlon
Research
Res
search
Team
eam
Karen Hirschman
Kathleen McCauley
Mark Pauly
Sponsors
S
J. Sanford Schwartz
Elizabeth Shaid
National Institute of Nursing Research, National Institute on Aging, Presbyterian Foundation
for Philadelphia, Marian S. Ware Alzheimer’s Program-Penn, National Alzheimer’s Association,
The Commonwealth Fund, Jacob & Valeria Langeloth Foundation, The John A. Hartford
Foundation, Inc., Gordon & Betty Moore Foundation, California HealthCare Foundation,
Rita & Alex Hillman Foundation, Jonas Center for Nursing Excellence, The Robert Wood
Johnson Foundation
Transitional Care
Range of time limited services and
environments
onments that are designed
d
d to ensure
health
h care continuity
conti
an
and
nd avoid
d preventable
poor outcomes
outcom among
g at risk populations as
they move from one level of care to another,
among multiple health care team members
and across settings such as hospitals to
homes.
(Adapted from, J Am Geriatr Soc, 2003, 51(4): 556-557.)
What problems are we trying to solve?
• High rates of patient safety/medical errors
during common healthcare transitions
• Serious unmet patient/family needs
• Poor patient care experiences
• High rates of preventable rehospitalizations
• Tremendous human and cost burden
What does published research tell us?
• 21 RCTs of diverse “hospital to home”
innovations targeting primarily chronically ill
adults
• 9/21, + impact on at least one measure of
rehospitalization plus other health outcomes
• Effective interventions
ƒ Multidimensional and span settings
ƒ Use inter-professional teams with primarily nurses, as
“hubs”
(Naylor, et al., 2011. THE CARE SPAN--The Importance of Transitional Care in Achieving Health
Reform. Health Affairs, 30(4):746-754.)
What are the goals of evidencebased interventions?
Transitional Care Model
Screening
• Most address gaps in care and
promote effective “hand-offs”
• In contrast, the Transitional Care
Model addresses “root causes” of poor
outcomes with focus on longer-term
value
Engaging
Older Adult &
Caregivers
Maintaining
Relationship
Coordinating
Care
Managing
Symptoms
Educating/
Promoting SelfManagement
Assuring
Continuity
Collaborating
Unique Features (Hospital to Home)
Care is delivered and coordinated…
…by same advanced practice nurse
(APN) supported by team
…in hospitals, SNFs, and homes
…seven days per week
…using evidence-based protocol
…supported by decision support tools
Lessons from
Rigorous Evaluation
of the TCM
Core Components
• 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
1
TCM
In multiple NIH funded
clinical trials, the TCM has
consistently demonstrated
observable improvements
improvement
in at risk, chronically ill
older adults’
adults care
experiences and health
outcomes, while reducing
re
healthcare costs.
(Based on NIH funded RCTs: Ann Intern Med, 1994,120:999-1006; JAMA, 1999, 281:613-620; J Am Geriatr
Soc, 2004, 52:675-684); and NIH funded CER: J Comp Eff Res, 2014, 3:245-257.)
Hospital to Home Findings*
Decreased symptoms,
Improved function,
Enhanced quality of life
BETTER
CARE
Enhanced access,
Reduced errors,
Enhanced care
experience
BETTER
HEALTH
(* 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)
(Based on 3 NIH funded RCTs: 1Ann Intern Med, 1994,120:999-1006; 2JAMA, 1999, 281:613-620; 3J Am
Geriatr Soc, 2004, 52:675-684)
at 26
weeks**
at 52
weeks***
TCM's Impact on Total Health Care Costs*
$7,636
$12,481
TCM
Group
Control
Group
$3,630
$6,661
Dollars (US)
* Total costs were calculated using average Medicare reimbursements for hospital readmissions, ED visits, physician
visits, and care provided by visiting nurses and other healthcare personnel. Costs for TCM care is included in the
intervention group total.
** Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, & Schwartz JS. Comprehensive
discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-620.
*** Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, & Schwartz JS. Transitional care of older adults
hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684.
Funding:
Marian S. Ware
Alzheimer
Program,
and
National Institute
on Aging,
R01AG023116,
(2005-2011)
Cognitively impaired
hospitalized older adults
and their caregivers
have achieved
increased benefits from
TCM relative to other
evidence-based
solutions.
(Naylor et al., 2014, J Comp Eff Res, 3:245-257; McCauley et al., 2014.
Am J Nurs, 114(10):44-52.)
2
TCM
In NIH and foundation
funded comparative
effectiveness studies, the
TCM has achieved
improved outcomes and
reduced costss relative
re
ela
ative to
other evidenc
evidence
ce–
cce
e–ba
based
b
ased
interventions among at risk
chronically ill older adults
and their family caregivers.
Cognitive Deficits at Baseline
DX
Dementia/
Delirium,
19.2%
Executive
Function
deficits
(clock task),
37.6%
Orientation
Recall
deficits,
43.2%
24.9% also had delirium (+ Confusion Assessment Method)
Time to First All Cause Rehospitalization
or Death, N=407
Propensity Score Weighted Mean No. of
Rehospitalization Days Through Six Months
100%
Predicted Mean No. of Rehospitalization Days
Proportion Rehospitalized or Died
3
Wilcoxon (Breslow) test, p=0.022; Log Rank test, p=0.055
75%
50%
25%
0%
0
30
60
90
days
120
150
2.5
2
1.5
1
0.5
180
0
30
ASC
Funding:
Gordon and
Betty Moore
Foundation, Rita
and Alex Hillman
Foundation and
the Jonas Center
for Nursing
Excellence
(2011-2014)
RNC
60
TCM
The integration of the
TCM within the Patient
Centered Medical Home
(PCMH) suggests
improved outcomes for
chronically ill older
adults.
90
ASC
120
RNC
150
Findings PCMH+TCM Study
• When compared to outcomes
demonstrated by a PCMH only group,
the PCMH+TCM group demonstrated:
¾ improved emotional health and quality
of life,
¾ increased time to first rehospitalization
or death.
(Naylor et al., 2013. J Comparative Effectiveness Research, 2(5):457-468.)
But success requires both…
TCM
3
Replication of cli
clinical
and economic
outcomes of rigorous
rigorou
findings has been
demonstrated in diver
diverse
health systems and
communities.
Translational research projects funded by The Commonwealth Fund and the Jacob and Valeria Langeloth,
The John A. Hartford, Gordon & Betty Moore, and California HealthCare foundations; each guided by a
National Advisory Committee (NAC); service line supported by local payers.
180
TCM
Rigorously
tested
translation tools
Active partnership
and commitment
of local health
system and
community
leaders and staff
as well as payers
We built and tested translation tools
•Patient screens and recruitment scripts
•Online seminars to prepare TCM nurses,
teams and sites
•Documentation and quality monitoring
protocols
•Performance improvement procedures
(case conferences grounded in root cause
analysis)
•Evaluation
www.transitionalcare.info
We demonstrated success in
translation with UPHS and Aetna (CER)
• Improved quality metrics
• Enhanced patient experience with care
and physician satisfaction
• Reduced 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.)
UPHS currently operates a TCM
service line
Findings suggest TCM within UPHS is
working and continually improving
• Located within Penn Home Care and
Early Program (2009
099-2013)
Hospice Services
• Reimbursed by local payers (IBC and Aetna)
using case rate with defined performance
expectations
• Implemented using a learning health system
framework that has enabled ongoing
improvements
• Over 700 patients enrolled, up to 90 day intervention;
significant reductions in rehospitalizations thru 90 days
• Findings used to refine program to include longer term
follow-up
Revised Program (2014
44-Present)
• Up to 90 day intervention with up to 9 month follow up,
over 100 patients enrolled to date.
ƒ improvements in symptoms (pain, shortness of breath)
ƒ decreased fall risk
ƒ experience with care mean rating 9.7 (of possible 10)
Cumulative Rehospitalizations for Program
TCM at UPHS, Feb-Dec 2014
Local Adaptations
of the
Funding:
Robert Wood
Johnson
Foundation
(2014-2016)
Transitional Care
Model
Phase I
National Survey of Health Systems
(N=516)
TCM
4
32%
Replicating or adapting
the TCM (n=352)
68%
Improving care
transitions among
elderly long-term care
recipients is central
but must be grounded
in appropriate
measures of success.
Funding:
National Institute
on Aging,
National Institute
of Nursing
Research,
R01AG025524,
(2006-2011)
(Zubritzky et al., 2012, The Gerontologist. doi: 10.1093/geront/gns093)
Conceptual HRQoL Model
(Zubritzky et al., 2012, The Gerontologist. doi: 10.1093/geront/gns093)
Depressive Symptoms*
Project
ct ACHIEVE
Through One Year
Achieving Patient Centered Care and Optimized
Health In Care Transitions by Evaluating the
Value of Evidence
Categorized Depression Score Distribution
Over Time
(0-4)
(5-9)
We have a great
deal to learn and to
contribute regarding
regardin
transitional care
practices that align
with the changing
needs of older
adults.
(10+)
11%
7%
6%
6%
5%
26%
32%
30%
28%
32%
63%
61%
63%
65%
63%
0m
3m
6m
9m
12m
Funding:
Patient-Centered
Outcomes
Research
Institute
(2015-2017)
• Penn
• $15
is a lead site
million, 3-yr project
• Only
transitional care
study funded
What is this study designed to
ACHIEVE?
Findings
s from
rom
m TCM
TCMs
T
body of evidence
suggest
sug
ug
gg
gest the need for a
rerre
e-en
envisioned
e
nvisioned care
delivery strategy for
or
chronically
chronic
nica
ally ill adultss th
that
hat
are at
at-ris
rrisk,
sk, in need of
longer term palliative
care and end of life care.
• Identify the transitional care services and
outcomes that matter most to patients and
their family caregivers.
• Compare how evidence-based transitional
5
TCM
care services are meeting these needs.
• Develop recommendations to spread highly
effective, patient-centered care transitional
care programs.
Upstream: Primary Care + TCM Strategy for
“At Risk” Chronically Ill Adults
Screening
AT-RISK
Transitional Care
Monitoring
Implementation of care
plan collaboratively
developed by
patients/caregivers,
PCPs and APNs
Community-based
patients and family
caregivers
Downstream: System’s Strategy for
Hospitalized Chronically Ill Adults
Engaged patients/
caregivers,
improved symptom
status, prevention of
hospitalizations/ED
visits
STABLE
(Gordon and Betty Moore Foundation, Rita and Alex Hillman Foundation, and the Jonas Center for Nursing
Excellence, 2011-2014)
Population
of
Older
Adults
with MCCs
Hospital
Phase
Post
Acute/
Rehab
Phase
Palliative Care
Long-Term
Follow-up
Level 1
Stable following
acute episode of
illness
Level 2
Unstable following
acute episode of
illness
Level 3
Adults nearing end
of life
(Current transitional care model design with UPHS)
The TCM…
Key Lessons
• Focuses on transitions of at-risk cognitively intact
and impaired chronically older adults across all
settings
•Solving complex problems will require
multidimensional solutions
• Has been “successfully” translated into practice
•Evidence is necessary but not sufficient
• Has been recognized by the Coalition for EvidenceBased Policy as an innovation meeting “top-tier”
evidence standards
• Has placed a spotlight on the critical role of nurses
• Will result (hypothesis currently being tested) in
greater health care value if applied as a system’s
approach
•Change is needed in structures, care
processes, and health professionals’
roles and relationships to each other and
the people they support
•Carpe Diem!