Care Transitions Models and Key Technologies for Patients in the Home

Lynn Redington, DrPH, MBASenior Program DirectorCenter for Technology and Aginglredington@techandaging.org

Remington’s 9th AnnualForecasting Think Tank SummitSt. Pete, Florida March 13, 2011

Center for Technology and Aging

Established in 2009 with funding from The SCAN Foundation, located at the Public Health Institute

Mission: Expand the use of technologies that help older adults lead healthier lives and maintain independence

Independent, non-profit resource center on issues related to diffusion of technology for older adults

Technology Diffusion Grants Programs

e.g., Tech4Impact grant (Technologies for Improving Post-Acute Care Transitions “Tech4Impact”)

Post-Acute Care Transitions & Re-admissions

• Avoidable Readmissions:

Opportunity for better care, better health, lower costs

1 in 5 patients readmitted within 30 days of discharge

76% of readmissions are preventable

A $25 billion savings potential

• Call to action:

Improve care transitions (e.g., hospital to home)

Improve care coordination, outreach, patient engagement and

support

References: New England Journal of Medicine, Jencks S, et al “Rehospitalizations among patients in the Medicare fee-for-service program” N England Journal of Medicine 2009; 360: 1418-28.PricewaterhouseCoopers, 2008. The price of excess: Identifying waste in healthcare spending.

Many QI opportunities to reduce hospitalization . . .

Care Transitions Models Improve Processes, Information Flows, and Capacity

• Evidence-based models include:

• Care Transitions Intervention

• Transitional Care Model

• Guided Care

• GRACE

• Others

The Care Transitions Intervention (CTI)

• “The Coleman Model”

• Qualifications: CTI Coach can be layperson

• Length of intervention: 30 days

• Average cost: $196 per patient

• Steps:

• Four pillars--Medication management; Patient-centered record;

Follow-up; Red flags

• Five encounters--Hospital/SNF Visit; Home Visit; 3 Follow-Up Calls

Transitional Care Model (TCM)

• “The Naylor Model”

• Qualifications: Transitional Care Nurses are advanced practice

nurses (BA-prepared nurses under study)

• Length of intervention: 1 to 3 months

• Average cost: $982 per patient

• Steps:

• Visit patient in hospital, home visit w/24 hours, accompany patient to 1st

doctor visit, facilitate clinician collaboration and communications with

patient/family, on call 7 days a week

Guided Care

• Developed at Johns Hopkins University since 2001

• Qualifications: Guided Care Nurse must be an RN

• Length of intervention: For life

• Average cost: $1743 per patient per year

• Steps:

• Conduct comprehensive home assessment, create care guide and action plan for patient, provide monthly monitoring and self-management coaching, coordinate care, facilitate access to community services, engage/educate informal caregivers

GRACE: Geriatric Resources for Assessment and Care of Elders

• “The Counsell Model”

• Qualifications: Nurse practitioner and social worker

• Length of intervention: Long term/indefinite

• Average cost: $1432 per patient per year

• Steps:

• In-home assessment, home visit after any hospitalization, one phone or in-person follow-up per month, collaborate with PCP, hospital discharge planner and others in a team-based approach

How Technologies May Support Care Processes

Home Home

MedicationMedication

ManagementManagement

Video-BasedVideo-Based

EducationEducationTelemedicineTelemedicine

Patient Health RecordsRemote Patient Monitoring

Smart Sensors

Wireless Broadband

Networks

Technology Usage Examples:CTA Grantees that Aim to Reduce Hospitalizations

Medication Optimization Technologies•American Society of Consultant Pharmacists Foundation•Caring Choices•Connecticut Pharmacists Foundation•VA Central California Health Care System•Visiting Nurse Services of New York Remote Patient Monitoring Technologies•AltaMed Health Services, Stamford Hospital•California Association of Health Services at Home•Centura Health at Home•New England Healthcare Institute•Sharp HealthCare Foundation•HealthCare Partners•Catholic Healthcare West

Personal Health Records TechnologiesState Units on Aging and ADRCs in: •California•Rhode Island•Washington 

Evidence-Based Care Transitions QI Evaluation TechnologiesState Units on Aging and ADRCs in:•Indiana•Texas

ADRC = Aging and Disability Resource Center

Focus Area Medication Adherence, Remote Patient Monitoring (RPM)

Population Vets with CHF, hospitalized within past 1-2 years

Technology In-home RPM appliance using POTS,

Med Adherence Algorithm, weight scale, BP cuff

Expected

Benefits

Reduce hospital/ED visits; improve patient activation, QOL &

satisfaction

Workforce

Issues

Care coordinator (RN), MD oversight, Automated clinician alerts,

enabled patients/informal caregivers

Organizational

Readiness

VHA: world’s largest telehealth user, rural health = telehealth

(see next 2 slides for background)

Veterans Health Administration (Central CA)CTA Grant Project

POTS = Plain Old Telephone Service

The Early Adopter Experience: Veterans Health Administration (1 of 2)

• VHA has evaluated, piloted, reevaluated, and deployed telehealth technologies in a continuing process of learning and improvement far beyond adoption in the private sector

• Largest national program--enables detailed analyses

• Home telehealth compared to traditional care models:

– Studies conducted on patients enrolled in the VA’s Care Coordination/Home Telehealth program in 2006 and 2007 show:

• 25% reduction in bed days of care• 20% reduction in numbers of admissions• 86% mean satisfaction score rating

Net cost = $1,600 / patient / year vs.• VHA’s home-based primary care

services = $13,121 / patient / year• Market nursing home care rates

average = $77,745 / patient / year

VHA takes “systems approach” to integrate the elements of the CC/HT program. This includes:

• Product selection• Training• Protocols for patient selection,

management• Data analytics

Since VHA implemented CCHT in 2003, a total of 43,430 patients have been enrolled

Age Distribution of all CCHT Patients

The Early Adopter Experience: Veterans Health Administration (2 of 2)

Indiana State Unit on AgingCTA Grant Project

Focus Area Implementing GRACE care transitions model and technologies

into VAMC Indianapolis

Population Older Vets at high risk for hospitalization and institutional care

Technology Technologies that support GRACE protocols (EHR, automated

prompts, Web-access to protocols and other tools)

Expected

Benefits

improved performance on Assessing Care of Vulnerable Elders

(ACOVE) quality indicators, higher satisfaction, and decreased

hospital readmissions and long-term institutionalization

Workforce

Issues

Team-based approach coordinated by GRACE-trained nurse

practitioner and social worker, increased engagement of patients

and caregivers, local ADRC integrated into process

Organizational

Readiness

VA validates new innovations before taking nationwide; GRACE

intervention originated in Indiana; Counsell is leading project

Focus Area Improving communications, coordination, self-management during

care transitions

Population Patients recently discharged from hospital that are participating in

the Care Transitions Intervention program

Technology EHRs and PHRs(Electronic Health Records, Personal Health Records)

Expected

Benefits

Reduce hospitalizations/re-hospitalizations, improve patient self-

management, improve communications

Workforce

Issues

CTI coach, connected clinicians, increased engagement of

patients and caregivers

Organizational

Readiness

An early adopter, Whatcom County, WA started project in 2001

Washington State Unit on AgingCTA Grant Project

Focus Area Remote Medication Therapy Management

Population Older Cambodian-Americans w/ history of torture/trauma, high

incidence of chronic illness and low literacy rate

Technology Video conferencing, spoken format technology, EMR

Expected

Benefits

Reduce hospital/ED visits; improve meds use; improve access to

culturally concordant providers

Workforce

Issues

Remote pharmacist visit, patient is accompanied by community

health worker. Few providers trained in special needs of this

population.

Organizational

Readiness

Connecticut partner, Khmer Health Advocates, is the only

Cambodian health organization in the US

Connecticut Pharmacists FoundationCTA Grant Project

Diffusion of InnovationsLessons Learned

•Stakeholder readiness to adopt

•Business model/payment model

•Technology/Intervention model

• Evidence base/relative advantage

• Compatibility

• Complexity

•Policy issues

Center for Technology and Aging

www.techandaging.org