Integrating the management of care transitions: A look at innovative, evidence-based models from the U.S.

5th Annual Discharge Planning Conference

Melbourne, Australia

25th July 2014

Dr. Dennis L. Kodner, PhD, FGSA, Principal, Integrated Care Group, LLC (USA) and Adj. Professor of Medicine, McGill University (Canada) – Email: DLKodner@aol.com

Need to Focus on Complexity

People with chronic , medically complex, long term and disabling

conditions are a major challenge to health systems globally. There are

several reasons for increasing preoccupation and concern::

Populations with so-called ‘complex’ illnesses are growing

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Populations with so-called ‘complex’ illnesses are growing significantly as a result of rapid aging and earlier onset of lifestyle-related chronic illnesses

Health systems are largely geared to acute illness and the short-term treatment of single diseases; not multi-morbid conditions with medical, physical, social and other lifelong consequences

Complex conditions are difficult to manage, relatively expensive, and demand new ways of delivering and organizing care

Need to Focus on Complexity (cont’d)

Improved quality and efficiency are being demanded in the face of growing financial constraints..

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((KodnerKodner, 2012; Goodwin, 2012), 2012; Goodwin, 2012)

Typical Complex Populations

The following complex populations experience gaps in care and/or

poorly coordinated care which frequently lead to an adverse impact on

care experiences and care outcomes::

Frail older people

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Frail older people

People with severe or multi-morbid chronic conditions

People with severe physical disabilities

People with intellectual, developmental or cognitive disabilities

People with serious mental health and/or drug addiction problems..

A Major Population: Frail Older People

About 15-20% of people aged 65+ will eventually need a mix of acute

care and long term care over time. These frail older people present a

complex set of needs and challenges:

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Health impaired; sometimes cognitively and/or mentally

Multiple, ongoing co-morbidities

Dependent in functioning and self-care (i.e., ADL/IADL)

High risk of hospitalization/rehospitalization and institutionalization

A Major Population: Frail Older People (cont’d)

Frequent interactions with providers, and transitions within and between systems, settings and levels of care

Access, coordination and continuity problems

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Difficult to manage and relatively costly

Caregiver burden and stress..

Many Weaknesses in Care of Complex Populations

Despite cross-national differences, we frequently encounter a host of

weaknesses in health care systems that work against effectively meeting

the needs of complex populations in an integrated way::

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Greater emphasis on ‘cure’ vs. ‘care’

Fragmented, misaligned policy-making, planning, regulation and financing

Imbalance between institutional and community services

Many Weaknesses in Care of Complex Populations (cont’d)

Poor collaboration at the organizational and provider levels within and between the various sectors

Lack of a single provider team and/or entity with responsibility

for all care and outcomes..

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for all care and outcomes..

(Kodner, 2011)

Bad Things Often Happen in a Disjointed and Fragmented System

The traditional health care system is poorly joined-up, fragmented and

confusing. As a result, bad things often happen::

Patients get lost

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Needed services fail to be delivered, are delayed or provided in the wrong settings

Quality and patient satisfaction decline

Health outcomes suffer

Care is more costly.

The Solution: ‘Integration’ and ‘Integrated Care’

“Integration is a coherent set of methods and models on the

funding, administrative, organizational, service delivery and clinical

levels designed to create connectivity, alignment and collaboration

within and between the cure and care sectors...[to] enhance quality

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within and between the cure and care sectors...[to] enhance quality

of care and quality of life, consumer satisfaction and system

efficiency for patients with complex problems cutting across

multiple providers, services and settings...[where] the result of such

multi-pronged efforts to promote integration...is called integrated

care.”

(Kodner & Spreewenberg, 2002)

Overall Goals of Integrated Care

Integrated care is a holistic, person-centered , population-based and

coordinated approach to addressing the multiple needs of individuals with

complex conditions who suffer gaps in service as well as fragmented care.

There are three (3) overarching goals::

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1- Better patient journey, experience and satisfaction

2- Improved care outcomes—personal health status, quality of life, etc.

3- Enhanced efficiency and cost-effectiveness..

Care Transitions in Integrated Care: A Special Challenge

“Care transition” describes a continuous process in which the patient ‘s care

shifts from one setting to another. Frail older people and other complex

patient groups are especially vulnerable to poorly managed care

transitions. There are many possible adverse consequences:

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Serious unmet needs

High rates of preventable hospital readmissions

Avoidable medication errors, complications from procedures, infections and falls

Underuse, overuse, or misuse of health care resources, including duplication and waste

Care Transitions in Integrated Care: A Special Challenge (cont’d)

Patient/caregiver and provider confusion

Poor satisfaction with care

Increased health care costs..

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American Case for Care Transition Management

In addition to the considerable human costs, poorly managed care

transitions have a major impact on the U.S. health care system:

Inadequate care coordination—including management of care transitions—is responsible for $25-45 billion USD in wasteful

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transitions—is responsible for $25-45 billion USD in wasteful spending annually due to avoidable complications and unnecessary hospital readmissions .

20% of U.S. fee-for-service Medicare beneficiaries (primarily elderly) discharged from hospital are readmitted within 30-days

50% of these patients had no contact with a physician between first hospitalization and readmission..

U.S.—”Silicon Valley” of Evidence-Based Care Transition Models

The U.S. has become a rich proving ground for evidence-based care

transition models. Numerous models have been developed and tested

over the past 15 years or so. Models largely focus on hospital-to-

home transitions that are designed to reduce readmissions and/or poor

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outcomes, as well as costs. Following are the more well-known models:

BOOST (Better Outcomes for Older Adults through Safe

Transitions –Society of Hospital Medicine

www.hospitalmedicine.org/BOOST

Bridge—Rush University Medical Center, Chicago

www.hmprg.org/programs-projects/illinois-transitional-care-consortium

U.S.—”Silicon Valley” of Evidence-Based Care Transition

Care Transitions Intervention (CTI) (Coleman Model)

www.caretransitions.org

Project RED (Re-engineered Discharge)—Boston Medical Center, Boston

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Boston

www.bu.edu/fammed/projectred/index.html

Transitional Care Model (TCM) (Naylor Model)

www.transitionalcare.info

Coleman Model (1)

The CTI model—developed at an integrated delivery system in Colorado

from 2002 to 2003—is focused on the 65+ population, but may also be

applied to younger adults. Point of entry is through hospital. Patient must

be community-dwelling and have at least one of 11 high-risk diagnoses .

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Intervention is organized around Transition Coach (TC) /Advanced

Practice Nurse and lasts for 30-days post-discharge. Program design:

4 pillars: Medication management, patient-centered record, primary care and specialist follow-up, and knowledge of “red flags”

Pre-discharge: TC conducts hospital visit and uses tools such as Personal Health Record (PHR)

Coleman Model (1) (cont’d)

Post-discharge: TC conducts one (1) home visit 24-72 hrs post-discharge; actively engages patient in medication reconciliation; uses role-playing to transfer skills; and, reviews any red flags that indicate a worsening condition and strategies to address them

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Follow-up: TC makes three (3) follow-up phone calls reinforcing coaching; discusses patient encounters with health care professionals; follows-up with primary care and specialist physicians; and, provides support for patient’s self-management role..

Coleman Model (2)

Supporting evidence:

Lower 30-day readmission; lower readmission after 90 and 180 days (Coleman et al, 2006)

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days (Coleman et al, 2006)

Higher Patient Activation Assessment (PAA) scores (Parrish et al, 2009)

Earlier recognition and resolution of changes in older adult’s health status (Enderlin et al, 2013)

Estimated cost savings for panel of 350 coached patients over 12-months is $300,000 USD (CTI, nd)..

Coleman Model (3)

Performance indicators :

Processes:

1. # coaches trained

2. % acceptance/attrition

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3. % coached patients with Personal Health Record (PHR)

4. % coached patients who report using PHR

5. % coached patients who schedule follow-up PCP appointment

Outcomes:

1. Higher PAA scores

2. % coached patients with increased patient activation

3. % coached patients achieving 30-day health goal

4. Higher Care Transition Measures (CTM) scores (i.e., quality of transition)

Coleman Model (3) (cont’d)

5. Lower ratio of # discrepancies found to # medication reviewed among coached patients (i.e., accuracy of medications)

6. % patients who attend scheduled PCP follow-up visit (i.e., primary care follow-up)

7. % coached patients who can identify all red flag conditions for

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7. % coached patients who can identify all red flag conditions for his/her disease..

Naylor Model (1)

The TCI model, a model of care coordination with an interdisciplinary

approach, is delivered to elderly patients at high-risk of poor post-discharge

outcomes. Patients must have two or more risk factors (e.g., poor self-

health ratings, multiple chronic conditions, history of recent

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hospitalizations, etc.). Point of entry is through hospital (on admission).

Model is organized around Transitional Care Nurse (TCN) and lasts for 30-

90 days post-discharge (60-days average). Program design:

Pre-discharge: TCN performs hospital-based assessment; visits patients daily; collaborates with care team to reduce adverse events and prevent functional decline; develops streamlined, evidence-based plan of care

Naylor Model (1) (cont’d)

Home visit: TCN visits patient within 24-hours of charge to evaluate ADLs/IADLs and safety; recommend adaptations; and , refer to other services

Follow-up: TCN accompanies patient to post-discharge MD visit and subsequent visits; facilitates MD-RN collaboration across episodes of

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subsequent visits; facilitates MD-RN collaboration across episodes of acute illness; conducts weekly home visits for one month; makes weekly patient phone contact if in-person visit not scheduled; provides on-call support (phone/home visit) 7 days per week; actively engages patients and family caregivers with focus on their goals; and, facilitates communication among patient, family caregivers and health care professionals..

Naylor Model (2)

Supporting evidence:

45% reduction in readmission rate (Naylor et al, 1999)

Increased time to readmission/death; reduced readmission rate

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Increased time to readmission/death; reduced readmission rate (Naylor et al, 2004)

Earlier recognition and resolution of changes in older adult’s health status (Enderlin et al, 2013)

Lowered mean total costs by 39% ($7,636 USD vs $12,481 USD) (Naylor et al, 2004)..

Naylor Model (3)

Processes:

1. # patients referred for TCM intervention

2. # patients accepting TCM

3. # patients working with TCN

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4. % eligible patient pop. working with TCN

Outcomes:

1. Higher average PAA scores

2. % patients with increased patient activation scores

3. Lower % TCM patients reporting complications (i.e., complications)

4. % TCM patients demonstrating medication self-management

skills that minimize adverse events as rated by TCN

Naylor Model (3) (cont’d)

5. Higher patient quality of life (QoL) scores on SF-36 (i.e, health-related quality of life)

6. % TCM patients reporting satisfactory care (i.e., patientsatisfaction)

7. % TCM patients with no outstanding medication reconciliation

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7. % TCM patients with no outstanding medication reconciliation items (30-days post-discharge) and % TCM patients with no worsening symptoms (30-days post-discharge)..

Building an Optimum Care Transition Management Model

When taking into account the evidence-based elements of the Coleman

and Naylor interventions as well as related best practices widely found in

other U.S. models, an optimum care transition management model should

contain the following core components:

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Comprehensive discharge planning starting at hospitalization

Medication reconciliation—medications, doses and contraindications

Patient/caregiver education and training using coaching and/or “teach back” methods—medications, self-care, and symptom recognition/management

Personal health record maintained by patient—health status, medications, questions to ask providers, etc.

Building an Optimum Care Transition Management Model (cont’d)

Accurate and timely sharing of patient information

Close, ongoing relationship with patient/family caregiver

Close, ongoing communication, collaboration and coordination

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Close, ongoing communication, collaboration and coordination

between providers

Prompt post-discharge follow-up visit with PCP and specialist(s)

Ongoing patient advocacy..