Managing Care and Care Managing Care and Care Transitions Across the Transitions Across the Long-Term Care SpectrumLong-Term Care Spectrum11

Darryl Wieland, Christine S. Ritchie Darryl Wieland, Christine S. Ritchie University of South University of South

Carolina/Palmetto Health Richland, University of Carolina/Palmetto Health Richland, University of Alabama at Birmingham (UAB) Birmingham/Atlanta VA Alabama at Birmingham (UAB) Birmingham/Atlanta VA

GRECCGRECC

1VA Geriatrics and Extended Care State-of-the Art Conference, “The Changing Face of Geriatrics and Extended Care: Meeting Veterans Needs in the Next Decade,” Washington DC, March 2008

Long-Term Care/Transitions Management:Long-Term Care/Transitions Management: Which Patients, Program Models, Systems?Which Patients, Program Models, Systems?

“Rubenstein categories” JAGS 1984;32:503-12.

“Rehabilitation” “Medical”

“Geriatric”

e.g. VA RMSDisease Management

“Guided Care” }CCM in Managed Care, Medicare Advantage

Palliative and Advanced Illness Care Models

Care Transitions Intervention

GEM and Other CGA/MGA Models

PACE/AIC Models/HBPC

Long-Term Community-Based LTC/NH

Short-term LTC

Common Objectives in Managing Care Common Objectives in Managing Care and Care Transitionsand Care Transitions

From hospital base, e.g.:From hospital base, e.g.:– APN dc planning w home follow-up APN dc planning w home follow-up

(Transitional Care Model);(Transitional Care Model);– Care Transitions InterventionCare Transitions Intervention

GOALS: placement in community @ lowest GOALS: placement in community @ lowest sustainable level of care [LOC]; prevention of sustainable level of care [LOC]; prevention of avoidable rehospitalizationavoidable rehospitalization

Managing Care and Care Transitions

Common Objectives in Managing Care Common Objectives in Managing Care and Care Transitionsand Care Transitions

From community base, e.g.: From community base, e.g.: – Geriatric care management team [e.g., Geriatric care management team [e.g.,

GRACE, Guided Care, CARE]; GRACE, Guided Care, CARE]; – Day hospital, Day hospital, – Hospital-at-home, Hospital-at-home, – PACEPACEGOALS: preventing inpatient hospitalizations, GOALS: preventing inpatient hospitalizations,

rehospitalization, placement to higher LOCrehospitalization, placement to higher LOC

Managing Care and Care Transitions

Cochrane Review of Hospital-to-Home DC Cochrane Review of Hospital-to-Home DC Planning (Shepperd 2004)Planning (Shepperd 2004)– System, program & pt heterogeneity; System, program & pt heterogeneity; uncertain impact uncertain impact

on index LOS, rehospitalization, health, payments or on index LOS, rehospitalization, health, payments or margins/costsmargins/costs

– Excluded GEM and some enhanced DC support team Excluded GEM and some enhanced DC support team modelsmodels

U Penn Center for Evidence-Based Practice U Penn Center for Evidence-Based Practice ((draftdraft—ms. in prep).—ms. in prep).– Most up-to-date & comprehensive; most evidence Most up-to-date & comprehensive; most evidence

low-to-moderate quality; low-to-moderate quality; some support for electronic some support for electronic DC communications; daily ID team rounds pre-DC; pt DC communications; daily ID team rounds pre-DC; pt educ.; inpt. intervention w HV/phone f-ueduc.; inpt. intervention w HV/phone f-u

Hospital-Based Program Models Hospital-Based Program Models

Managing Care and Care Transitions

Transitional Care Model (RCT) (Naylor 1999)Transitional Care Model (RCT) (Naylor 1999)– APN DC Planning with In-Home APN Follow-upAPN DC Planning with In-Home APN Follow-up– Targeted (at risk) elderly med-surg inpatients in 2 Medicare FFS Targeted (at risk) elderly med-surg inpatients in 2 Medicare FFS

hospitalshospitals– @ 24 wks: @ 24 wks: ↓↓ readmissions, multiple readmissions, hosp days/pt; readmissions, multiple readmissions, hosp days/pt;

↑↑ time to readmission time to readmission– Health outcomes not impacted; Medicare reimbursement Health outcomes not impacted; Medicare reimbursement

reduced $0.6 million (50%).reduced $0.6 million (50%).

Transitional Care Model (RCT) (Naylor 2004)Transitional Care Model (RCT) (Naylor 2004)– Targeted 239 heart older failure pts in 6 hospitals; f-u to 52 wks.Targeted 239 heart older failure pts in 6 hospitals; f-u to 52 wks.– Longer time to 1Longer time to 1stst readm. or death; 1-yr readm rate lower; mean readm. or death; 1-yr readm rate lower; mean

total costs 35%total costs 35%↓; short-term improvements in QoL, function, & ↓; short-term improvements in QoL, function, & satisfaction.satisfaction.

Hospital-Based Program Models Hospital-Based Program Models

Managing Care and Care Transitions

Care Transitions Intervention (CCT, RCT)Care Transitions Intervention (CCT, RCT)(Coleman 2004, 2006)(Coleman 2004, 2006)– CTI includes cross-site comm. tools, pt. CTI includes cross-site comm. tools, pt.

“activation,” “transition coach”“activation,” “transition coach”– Older Medicare pts (Older Medicare pts (>>65) w target dxes, 65) w target dxes,

complex care needs, managed care systemcomplex care needs, managed care system

– ↓↓ readmissions @ 30/60/90 days, readmissions @ 30/60/90 days, ↑↑ pt pt confidence in info rec’d, comm. w team, confidence in info rec’d, comm. w team, understanding meds, hosp. costs lower at 180 understanding meds, hosp. costs lower at 180 days, net cost savings to plandays, net cost savings to plan

Hospital-Based Program ModelsHospital-Based Program Models

Managing Care and Care Transitions

Coordination and Advocacy for Rural Elderly [CARE] Coordination and Advocacy for Rural Elderly [CARE] (pilot, descriptive) (Ritchie 2002)(pilot, descriptive) (Ritchie 2002)

– VISN 7 G&EC demo – RN/SW teams performed in-VISN 7 G&EC demo – RN/SW teams performed in-home asmt on elderly at-risk (PRA+) rural vets; home asmt on elderly at-risk (PRA+) rural vets; Laptop-based MDS-HC Laptop-based MDS-HC problem list, plan, progress problem list, plan, progress notenote

– Care advocacy & referral/coordination/linkage to VA & Care advocacy & referral/coordination/linkage to VA & non-VA svcs, pt/caregiver monitoring, education, non-VA svcs, pt/caregiver monitoring, education, support; follow-up visits x 6 mos.support; follow-up visits x 6 mos.

– Eight problems/pt identified; Eight problems/pt identified; ⅔ ⅔ referred to services; referred to services; ½ to medical care; issues were coord. w 1½ to medical care; issues were coord. w 1º care and º care and linkage w VA services, CARE linkage w VA services, CARE discontinued due failure discontinued due failure to earn workload creditto earn workload credit

Community-Based Models Community-Based Models

Managing Care and Care Transitions

Geriatric Resources for Assessment and Care of Elders Geriatric Resources for Assessment and Care of Elders [GRACE] (RCT)(Counsell 2007[GRACE] (RCT)(Counsell 2007))

– LT geri care management for multimorbid low income elderly in LT geri care management for multimorbid low income elderly in

11º careº care @ 6 FQHCs; @ 6 FQHCs; – annual CGA by GRACE Support Team (APN/SW); annual CGA by GRACE Support Team (APN/SW); – annual plan w larger interdisciplinary care team incl geriatrician, annual plan w larger interdisciplinary care team incl geriatrician,

PharmD, PT, mental health SW, comm. svc liaison; team mtgs w PharmD, PT, mental health SW, comm. svc liaison; team mtgs w 11º careº care MDs – plan implemented by support team & MDs – plan implemented by support team & 11º careº care

– Protocols for 12 targeted geriatric conditions: advance care plng, Protocols for 12 targeted geriatric conditions: advance care plng, health maintenance, med mgmt, mobility imp/falls, pain, UI, health maintenance, med mgmt, mobility imp/falls, pain, UI, depression, hearing & vision, malnutrition/wt loss, dementia, depression, hearing & vision, malnutrition/wt loss, dementia, caregiver burdencaregiver burden

– Weekly interdisciplinary team meetings to review progress; Weekly interdisciplinary team meetings to review progress; ongoing support team home-based CM (ongoing support team home-based CM (>>1/mo) w EMR, web-1/mo) w EMR, web-trackingtracking

Community-Based ModelsCommunity-Based Models

Managing Care and Care Transitions

GRACE (RCT)(Counsell 2007)GRACE (RCT)(Counsell 2007)

OUTCOMESOUTCOMES

– @ 24 mos, improvements in 4/8 SF-36 @ 24 mos, improvements in 4/8 SF-36 subscales (general health, vitality, social fnct, subscales (general health, vitality, social fnct, MH) and Mental Component Sum.MH) and Mental Component Sum.

– ↓↓ ED visits; ED visits; ↓↓ ED visits & hospitalizations in 2 ED visits & hospitalizations in 2ndnd year for pre- defined “high risk” subgroupyear for pre- defined “high risk” subgroup

Community-Based ModelsCommunity-Based Models

Managing Care and Care Transitions

Guided Care (cluster RCT) (Boyd 2005, Boult 2008)Guided Care (cluster RCT) (Boyd 2005, Boult 2008)– 11º care + package of innovations for elderly patients w multiple º care + package of innovations for elderly patients w multiple

chronic dxes @ high utilization risk (HCC model); pts in PCP chronic dxes @ high utilization risk (HCC model); pts in PCP groups were in Medicare A/B, MA, or TriCare plans groups were in Medicare A/B, MA, or TriCare plans

– Specially trained RNs assigned to PCP pods provide Specially trained RNs assigned to PCP pods provide comprehensive chronic care to panels of 50-60 pts. comprehensive chronic care to panels of 50-60 pts.

– Using web-accessible EMR, RN, with PCP collaboration, Using web-accessible EMR, RN, with PCP collaboration, implements 8 key processes: implements 8 key processes:

in-home pt/caregiver multidimensional asmt, in-home pt/caregiver multidimensional asmt, evidence-based care plan, evidence-based care plan, promotes pt self-mgmt, promotes pt self-mgmt, monthly health monitoring, monthly health monitoring, coaching healthy behaviors, coaching healthy behaviors, managing care transitions, managing care transitions, caregiver ed./support, caregiver ed./support, coordinating access to comm. resources coordinating access to comm. resources

Community-Based ModelsCommunity-Based Models

Guided Care (Boyd 2005, Boult 2008)Guided Care (Boyd 2005, Boult 2008)OUTCOMESOUTCOMES– @ 6 mos., GC pts twice as likely to rate their care @ 6 mos., GC pts twice as likely to rate their care

“high-quality.” viz., “high-quality.” viz., ↑ satisf. ↑ satisf. ratings for Goal Setting, ratings for Goal Setting, Coordination of Care, and Decision Support; n.s. Coordination of Care, and Decision Support; n.s. trend to score higher Problem Solving performance trend to score higher Problem Solving performance [on Patient Asmt of Chronic Illness Care measure][on Patient Asmt of Chronic Illness Care measure]

– On Primary Care Assessment Tool, GC PCPs more On Primary Care Assessment Tool, GC PCPs more satisfied w pt comm., family/caregiver comm., satisfied w pt comm., family/caregiver comm., caregiver ed., motivating pts, and community caregiver ed., motivating pts, and community resource referrals; improved also on knowledge of pt resource referrals; improved also on knowledge of pt med taking. med taking.

Community-Based ModelsCommunity-Based Models

Managing Care and Care Transitions

Program of All-Inclusive Care for the Elderly Program of All-Inclusive Care for the Elderly [PACE] / VA All-Inclusive Care Demo [PACE] / VA All-Inclusive Care Demo (pilot, (pilot, descriptive) (descriptive) (Weaver 2008)Weaver 2008)– PACE isPACE is federally-cap’d program for dual eligibles federally-cap’d program for dual eligibles

(Medicare/ Medicaid) aged (Medicare/ Medicaid) aged >>55 state-certified as 55 state-certified as requiring NH; requiring NH;

– provides LT day-center based team mngt & 1provides LT day-center based team mngt & 1º care, º care, transport svcs, in-home care, hospitalization and NH transport svcs, in-home care, hospitalization and NH care + under its cap’d rate; care + under its cap’d rate;

– multiple studies found PACE to improve sat., health multiple studies found PACE to improve sat., health outcomes, reduce hospitalizations, LT NH placement, outcomes, reduce hospitalizations, LT NH placement, & reduce Medic. payments.& reduce Medic. payments.

Community-Based ModelsCommunity-Based Models

Managing Care and Care Transitions

VA All-Inclusive Care Demo VA All-Inclusive Care Demo ((Weaver 2008)Weaver 2008)– AIC demonstrated 3 variants of PACE in VA for vets AIC demonstrated 3 variants of PACE in VA for vets

qualified using PACE criteria: (1) All VA svcs; (2) qualified using PACE criteria: (1) All VA svcs; (2) Blended “barter” model between VAMC & PACE site; Blended “barter” model between VAMC & PACE site; (3) Full contract w PACE(3) Full contract w PACE

– Pilots demonstrated feasibility; pt. characteristics and Pilots demonstrated feasibility; pt. characteristics and utilization patterns varied by Model; all models utilization patterns varied by Model; all models improved access to particular svcs (reduced wait-improved access to particular svcs (reduced wait-times) and provided svcs otherwise unavailable; times) and provided svcs otherwise unavailable; distribution of svcs & costs varied by model (3). distribution of svcs & costs varied by model (3).

Community-Based ModelsCommunity-Based Models

Managing Care and Care Transitions

Wrap UpWrap Up

Decades’ experience: how concern for care Decades’ experience: how concern for care transitions arose from LT care coordination transitions arose from LT care coordination efforts.efforts.Patient-centered care hindered by care Patient-centered care hindered by care organization and financing in most care systems organization and financing in most care systems (US and elsewhere)(US and elsewhere)AGS Position Statement on Transitional Care (5 AGS Position Statement on Transitional Care (5 positions) can be generalized to apply also to positions) can be generalized to apply also to GCM GCM ↑ ↑ rrole of assistive and information technologiesole of assistive and information technologies

Managing Care and Care Transitions

Wrap Up

AGS Position Statement on Transitional Care AGS Position Statement on Transitional Care (Coleman, Boult 2003) can be generalized to (Coleman, Boult 2003) can be generalized to apply also to GCM:apply also to GCM:– ……professionals must prepare clients…for care professionals must prepare clients…for care acrossacross

settings, [involving them in] decisions related to settings, [involving them in] decisions related to all LT all LT and boundary-crossingand boundary-crossing care. care.

– MultiMultidirectional comm. directional comm. amongamong clinicians is essential to clinicians is essential to high quality TC/GCM. high quality TC/GCM.

– Develop policies to promote quality TC/GCM.Develop policies to promote quality TC/GCM.– Education to all involved clinicians re: TC/GCM Education to all involved clinicians re: TC/GCM

(would add increase workforce)(would add increase workforce)– ↑ ↑ research to improve TC/GCM processesresearch to improve TC/GCM processes

Evaluation of new consumer & healthcare technologies

Smart housesPersonal devices (PDA, cells etc.)Broadband & wireless comm.Digital video etc.

Sensors & remote monitoringPersonal MRs/EMRsePrescribing/DM/Clin TrialsTele-health/medicineImprovement of medical devicesCall centers and web technologies

Managing Care and Care Transitions

ReferencesReferences

Rubenstein L, Wieland D, English P, et al. Rubenstein L, Wieland D, English P, et al. The Sepulveda VA GEU: The Sepulveda VA GEU: Data on four-year outcomes and predictors of improved patients Data on four-year outcomes and predictors of improved patients outcomesoutcomes. . JAGSJAGS 1984;32:503-12. 1984;32:503-12.Shepperd S, Parkes J, McClaren J et al. Shepperd S, Parkes J, McClaren J et al. Discharge planning from Discharge planning from hospital to home.hospital to home. Cochrane Data Syst RevCochrane Data Syst Rev 2004;(1):CD000313. 2004;(1):CD000313.Naylor M, Brooten D, Campbell R, et al. Naylor M, Brooten D, Campbell R, et al. Comprehensive discharge Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized planning and home follow-up of hospitalized elders: A randomized clinical trial.clinical trial. JAMA JAMA 1999;281:613-20.1999;281:613-20.Naylor M, Brooten D, Campbell R et al. Naylor M, Brooten D, Campbell R et al. Transitional care of older Transitional care of older adults hospitalized with heart failure.adults hospitalized with heart failure. JAGSJAGS 2004;52:675-684. 2004;52:675-684.Coleman E, Smith J, Frank J, et al. Coleman E, Smith J, Frank J, et al. Preparing patients and Preparing patients and caregivers to participate in care delivered across settings: The Care caregivers to participate in care delivered across settings: The Care Transitions Intervention.Transitions Intervention. JAGSJAGS 2004;52:1817-25. 2004;52:1817-25.Coleman E, Parry C, Chalmers S, et al. Coleman E, Parry C, Chalmers S, et al. The Care Transitions The Care Transitions Intervention: Results of a randomized controlled trial.Intervention: Results of a randomized controlled trial. Arch Intern Arch Intern MedMed 2006;166:1822-8. 2006;166:1822-8.

Managing Care and Care Transitions

References IIReferences IIRitchie C, Wieland D, Tully C, et al. Ritchie C, Wieland D, Tully C, et al. Coordination and Advocacy for Rural Coordination and Advocacy for Rural Elders [CARE]: A model of rural case management with veterans.Elders [CARE]: A model of rural case management with veterans. GerontologistGerontologist 2002;42:399-405. 2002;42:399-405.Counsell S, Callahan C, Clark D, et al. Counsell S, Callahan C, Clark D, et al. Geriatric care management for low-Geriatric care management for low-income seniors: A randomized controlled trial.income seniors: A randomized controlled trial. JAMAJAMA 2007;298:2623-33. 2007;298:2623-33.Boyd C, Shadmi E, Conwell L, et al. Boyd C, Shadmi E, Conwell L, et al. The effect of Guided Care on quality of The effect of Guided Care on quality of care.care. JAGS JAGS 2005;53:S205.2005;53:S205.Boult C, Reider L, Frey K, et al. Boult C, Reider L, Frey K, et al. The early effects of “Guided Care” on the The early effects of “Guided Care” on the quality of health care for multi-morbid older persons: A cluster-randomized quality of health care for multi-morbid older persons: A cluster-randomized controlled trial.controlled trial. J Gerontol A Biol Sci Med Sci J Gerontol A Biol Sci Med Sci 2008;63(3).2008;63(3).Weaver F, Hickey E, Hughes S, et al. Weaver F, Hickey E, Hughes S, et al. Providing all-inclusive care for frail Providing all-inclusive care for frail elderly veterans: Evaluation of three models of care.elderly veterans: Evaluation of three models of care. JAGSJAGS 2008;56:345-53. 2008;56:345-53.Coleman E, Boult C, AGS Health Care Systems Committee. Coleman E, Boult C, AGS Health Care Systems Committee. Improving the Improving the quality of transitional care for persons with complex care needs (AGS quality of transitional care for persons with complex care needs (AGS Position Statement).Position Statement). JAGSJAGS 2003;51:556-7. 2003;51:556-7.

Managing Care and Care Transitions