S U S A N A LT F E L D, P H D 1 , A N T H O N Y P E R RY, M D 2 , VA N E SS A FA B B R E , M S W 3 , G AY L E S H I E R , M S W 2 , A N N E B U F F I N G T O N, M P H 1 A N D R O BY N G O L D E N, A M , L C S W 2

1 U N I V E R S I T Y O F I L L I N O I S AT C H I C A G O, 2 R U S H U N I V E R S I T Y M E D I C A L C E N T E R , 3 U N I V E R S I T Y O F C H I C A G O

IMPROVING CARE TRANSITIONS FOR OLDER ADULTS: THE ENHANCED DISCHARGE PLANNING PROGRAM

DEVELOPING A DEEPER UNDERSTANDING OF CARE TRANSITIONS

• Patient and caregiver needs• Intervention processes

WHAT IS TRANSITIONAL CARE?

Coordination of care from one setting to another: • Hospital to home• Hospital to skilled nursing facility• Skilled nursing to home• Within hospital – unit to unit

IMPROVING CARE TRANSITIONS – WHY?

• 19.6% of Medicare patients are re hospitalized within 30 days of hospital discharge (Jencks, S. et al., (2009). Rehospitalizations among patients in the Medicare fee-for-service program, NEJM, 2009)

• 19% of patients experience an adverse event within 3 weeks of hospital discharge

• U.S. health care spending associated with potentially preventable readmissions estimated at $12 billion to $17.4 billion per year (MedPAC. (2007). Promoting Greater Efficiency in Medicare)

• 40-50% of hospital readmissions are linked to social problems and lack of community resources (Proctor et al, (2000) Adequacy of home care and hospital readmission for elderly congestive heart failure patients)

IMPROVING CARE TRANSITIONS• Promote patient safety• Enhance patient satisfaction • Promote communication between care settings• Prevent re-hospitalization by addressing major causes of

adverse outcomes• Psychosocial factors affecting the access to and utilization of

quality post-discharge care

EVIDENCE-BASED INTERVENTIONS TO IMPROVE CARE TRANSITIONS

• BOOST (Williams)• Project RED (Jack)• Care Transitions Intervention (Coleman)• Transitional Care Model (Naylor)• Illinois Transitional Care Consortium Bridge (Altfeld,

ITCC) • Enhanced Discharge Planning Program (Altfeld, Golden,

Rooney, Perry et al)

EVIDENCE-BASED INTERVENTIONS TO IMPROVE CARE TRANSITIONS

• BOOST • Project RED • Care Transitions Intervention • Transitional Care Model • Illinois Transitional Care Consortium Bridge• Enhanced Discharge Planning Program

How are they different?

EVIDENCE-BASED INTERVENTIONS

• BOOST – hospital based, discharge planning/teaching intervention• Project RED - hospital based, discharge planning/teaching

intervention• Care Transitions Intervention – hospital to home, advanced

practice nursing model, care coordination through home visits• Transitional Care Model – hospital to home, transitions coach,

enhanced communication across levels and between providers • Illinois Transitional Care Consortium Bridge – social work

coordination, emphasis on post d/c follow up• Enhanced Discharge Planning Program

ENHANCED DISCHARGE PLANNING PROGRAM

• Telephone intervention• Master’s level social workers • Bio psychosocial focus • Patient referrals based on electronic medical

record• Core intervention - 48 hour post discharge

telephone assessment

ENHANCED DISCHARGE PLANNING PROGRAM

• Randomized controlled trial of 720 patients• All patients older than 65 with medical and psychosocial

risk factors• Randomized to follow-up intervention or usual care

• Qualitative study • Interviews with intervention social workers

ENHANCED DISCHARGE PLANNING PROGRAM INTERVENTION

• The mean duration of the intervention was 5.8 days (s.d.=11.3) • Range 1 to 72 days.

• The mean number of contacts was 5.4 (s.d.= 6.3). • Range 1 to 44 days

LOGISTIC REGRESSION ANALYSES – ADHERENCE OUTCOMES

OUTCOME Odds ratio 95%CI Lower 95% CI UpperPhysician communication 2.04 1.28 3.24

Physician appointment 2.70 1.64 4.45

Physician appointment kept 2.09 1.51 2.89

Physician appointment made and kept 2.22 1.59 3.10 30 day mortality .38 0.16 0.88 Note: All models are adjusted for Admission type, prior admission in past year, coping, insurance except mortality which was adjusted for coping since other covariates not significant when included in the model

OUTCOMES – READMISSIONS AND ED USE

• Patient report re readmission/Emergency Department use not validated by hospital records• Primary issue: recall of specific admission dates/intervals

We are awaiting analysis of CMS data to explore readmissions and ED use

WHO WERE THESE PATIENTS?W H AT D I D T H E Y N E E D ?

W H AT D I D E D P P D O ?

PATIENT DEMOGRAPHICS

• Mean age=74.5 years• 49.2% Caucasian/45.6% African American• 59.4% Unmarried• 62.6% Urban• 91.1% Medicare• 22.6% Medicaid

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INTERVENTION GROUP

• 300 of 360 (83.3%) of patients had problems identified by an EDPP clinician upon assessment

• For 219 (73%) of these individuals, needs did not emerge until after discharge

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NEED FOR POST-ASSESSMENT INTERVENTION

• More than one call was needed for 254 of the 360 (70.6%) patients in this study. • These patients had issues that needed

intervention and could not be resolved in the initial contact.

NEEDS IDENTIFIEDTRANSITIONAL CARE/HEALTH

Delay in service – home health 36 10.0Issues with coordination between care providers 70 19.5Medication management issue 59 16.4Challenges with management of post-d/c care 102 28.4Challenges with management of new treatment/dx 63 17.6Difficulties obtaining community services 85 23.7Communication with service and medical providers 53 14.7Difficulty understanding discharge plan of care 60 16.7Transportation 36 10.0

NEEDS IDENTIFIED PSYCHOSOCIAL

Caregiver burden 126 35.0Coping with change 124 34.5Psychiatric illness 39 10.8Inadequate social support 35 9.8Insurance issues 25 7.0Bereavement and end of life concerns 15 4.2Suspected abuse and/or neglect; self-neglect 1 0.3

QUALITATIVE INTERVIEWS

• Clinical intervention themes• Broad view of the client system • Patient, caregiver, health

professionals/paraprofessionals• Need to transcend institutional roles to

resolve problems

QUALITATIVE INTERVIEWS

• Patient/caregiver themes• “surprises”• More stressful than anticipated• Fatigue

• Suggests that better discharge planning is not the answer

POST-INTERVENTION CONTACT

• Almost 1/3 of intervention patients (29.3%) contacted the EDPP clinician for additional services or information after the case was closed

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QUESTIONS AND COMMENTS

For more information, contact:Susan Altfeldsaltfeld@uic.edu312-355-1134

Thank you to the Rush EDPP clinical team---Madeleine Rooney, Debra Markovitz and Michele Packard--- for their dedication to patients and caregivers and their contributions to this research