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Mary D. Naylor, PhD, RNMary D. Naylor, PhD, RNMarian S. Ware Professor in GerontologyMarian S. Ware Professor in GerontologyDirector, NewCourtland Center for Transitions and HealthDirector, NewCourtland Center for Transitions and HealthUniversity of Pennsylvania, School of NursingUniversity of Pennsylvania, School of Nursing
The Transitional Care Model:The Transitional Care Model:Translating Research into PracticeTranslating Research into PracticeDevelopment and Translation of the Transitional Care Model for Older Adults
January 28, 2009
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Transitional Care Transitional Care
Transitional careTransitional care – range of time – range of time limited services and environments limited services and environments designed to ensure health care designed to ensure health care continuity and avoid preventable poor continuity and avoid preventable poor outcomes among at risk populations outcomes among at risk populations as they move from one level of care to as they move from one level of care to another, among multiple providers another, among multiple providers and/or across settings. and/or across settings.
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Context for Transitional CareContext for Transitional CareAcute Care Episode: Acute Care Episode:
Adapted from the National Quality Forum committee on Measurement Framework: Evaluating Efficiency across Episodes of Care
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The Case for Transitional CareThe Case for Transitional Care
High rates of medical errors High rates of medical errors
Serious unmet needsSerious unmet needs
Poor satisfaction with carePoor satisfaction with care
High rates of preventable High rates of preventable readmissionsreadmissions
Tremendous human and cost burdenTremendous human and cost burden
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Different Goals of Different Goals of Evidence-Based InterventionsEvidence-Based Interventions
Address gaps in care and promote Address gaps in care and promote effective “hand-offs”effective “hand-offs”
Address “root causes” of poor Address “root causes” of poor outcomes with focus on longer-term, outcomes with focus on longer-term, positive outcomespositive outcomes
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Quality Cost Quality Cost Transitional Care Model (TCM)Transitional Care Model (TCM)
Engaging Elder/Caregiver
Managing Symptoms
Educating/Promoting
Self-Management
Assuring Continuity
CoordinatingCare
MaintainingRelationship
ScreeningScreening
CollaboratingCollaborating
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Unique Features Unique Features
Care is delivered and Care is delivered and coordinatedcoordinated
……by same nurseby same nurse
……across settingsacross settings
……7 days per week 7 days per week
……using evidence-based protocolusing evidence-based protocol
……with focus on long term outcomeswith focus on long term outcomes
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Findings from Randomized Findings from Randomized Clinical TrialsClinical Trials
Funding: National Institutes of Health, National Institute of Nursing Funding: National Institutes of Health, National Institute of Nursing Research, National Institute on Aging (1990-2010)Research, National Institute on Aging (1990-2010)
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Transitional Transitional Care ModelCare ModelProtocol OverviewProtocol Overview
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Across RCTs, TCM has Across RCTs, TCM has consistently…consistently…
Increased time to first rehospitalizationIncreased time to first rehospitalization Decreased total all-cause rehospitalizationsDecreased total all-cause rehospitalizations Increased patient satisfactionIncreased patient satisfaction Improved physical function and quality of Improved physical function and quality of
lifelife** Decreased total health care costsDecreased total health care costs
*Most recently completed RCT only*Most recently completed RCT only
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Barriers to Adoption Barriers to Adoption
Organization of current system of careOrganization of current system of care
Lack of quality and financial incentivesLack of quality and financial incentives
Culture of careCulture of care
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Translating TCM into PracticeTranslating TCM into Practice
Penn research team formed Penn research team formed partnerships with Aetna Corporation partnerships with Aetna Corporation and Kaiser Permanente to test “real and Kaiser Permanente to test “real world” applications of research-based world” applications of research-based model of care for high risk elders. model of care for high risk elders.
Funded by The Commonwealth Fund and the following Foundations: Jacob and Valeria Langeloth, The John A. Hartford, Gordon & Betty Moore, and California HealthCare; guided by National Advisory Committee (NAC)
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Project Goals (Aetna)Project Goals (Aetna)
Test TCM in defined marketTest TCM in defined market Document facilitators and barriersDocument facilitators and barriers Provide for ongoing NAC inputProvide for ongoing NAC input Present findings to Aetna decision Present findings to Aetna decision
makersmakers Widely disseminate findingsWidely disseminate findings
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Tools of TranslationTools of Translation
Patient screening and recruitmentPatient screening and recruitment
Orientation of TCNs Orientation of TCNs (web-based modules)
Documentation and Quality Monitoring Documentation and Quality Monitoring (clinical information system - CIS)
Quality improvement Quality improvement (case conferences and CIS)
EvaluationEvaluation
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Integrating TCM within Aetna
Project teamProject team Key decisionsKey decisions
Link to geriatric case management Link to geriatric case management programprogram
Partner with home care agencyPartner with home care agency Target 200 members in mid-Atlantic Target 200 members in mid-Atlantic
regionregion Clearly define roles and work flow Clearly define roles and work flow
processesprocesses
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Key Indicators of SuccessKey Indicators of Success
Decisions by Aetna re: adoptionDecisions by other insurers and
providers to implement model Use of findings by CMS and insurers to
reimburse evidence-based transitional care
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ValueValue ==Health Resource Health Resource
Utilization (Costs)Utilization (Costs)
Environment: Extant comprehensive system of telephonic care management
Question: Does the Transitional Care Model offer greater value in this environment?
Quality/Satisfaction
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Quality (N=172)Quality (N=172)
Significant improvements pre- and post-Significant improvements pre- and post-TCM in the following outcomes:TCM in the following outcomes:
self-reported health status (1 item)self-reported health status (1 item) symptom status (Symptom Bother Scale)*symptom status (Symptom Bother Scale)* depression (Geriatric Depression Scale)depression (Geriatric Depression Scale) functional status (SF-12) functional status (SF-12) quality of life (one item)quality of life (one item)
*improvements in 10/13 symptoms at p <0.05*improvements in 10/13 symptoms at p <0.05
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SatisfactionSatisfaction
Members (N=171)Members (N=171) Overall high satisfaction - Mean of 3.0 on Overall high satisfaction - Mean of 3.0 on
each of the 15 survey items (1 low - 4 high)each of the 15 survey items (1 low - 4 high)
Physicians (N=25)*Physicians (N=25)* Overall high satisfaction with APN Overall high satisfaction with APN
involvement in members’ care – Mean of 3.5 involvement in members’ care – Mean of 3.5 on each of 10 survey items* (1 strongly on each of 10 survey items* (1 strongly disagree – 4 strongly agreedisagree – 4 strongly agree
** Satisfaction data from MDs with at least 3 TCM patients ** Satisfaction data from MDs with at least 3 TCM patients
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Health Resource UtilizationHealth Resource Utilization
Quasi-experimental design simulating RCTQuasi-experimental design simulating RCT Each elder in TCM matched with “control”Each elder in TCM matched with “control” 155 pairs using stringent criteria (e.g., # of 155 pairs using stringent criteria (e.g., # of
comorbid conditions) were available for final comorbid conditions) were available for final HR analysesHR analyses
HR data obtained from Aetna’s claims’ HR data obtained from Aetna’s claims’ datasetdataset
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Rehospitalization Rates*Rehospitalization Rates*
Significant reductions in readmission rates Significant reductions in readmission rates and hospital days through 3 monthsand hospital days through 3 months
0-3 months, 45 TCM vs. 60 controls (25% 0-3 months, 45 TCM vs. 60 controls (25% decrease; 99 fewer hospital days)decrease; 99 fewer hospital days)
0-6 months, 104 TCM vs. 112 controls0-6 months, 104 TCM vs. 112 controls 0-12 months, 184 TCM vs. 203 controls0-12 months, 184 TCM vs. 203 controls
**ED rates similar (85 TCM vs. 81 controls at 12 mos.)ED rates similar (85 TCM vs. 81 controls at 12 mos.)
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Skilled Nursing Facility RatesSkilled Nursing Facility Rates
Trend toward reduced SNF admissions Trend toward reduced SNF admissions between TCM vs. controlsbetween TCM vs. controls
0-3 months, 5 TCM vs. 11 controls0-3 months, 5 TCM vs. 11 controls 0-6 months, 14 TCM vs. 22 controls0-6 months, 14 TCM vs. 22 controls 0-12 months, 26 TCM vs. 38 controls 0-12 months, 26 TCM vs. 38 controls
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Skilled Home Care VisitsSkilled Home Care Visits
Trend toward decreased use of home Trend toward decreased use of home visits for TCM vs. controlsvisits for TCM vs. controls
0-3 months, 252 TCM vs. 436 controls0-3 months, 252 TCM vs. 436 controls 0-6 months, 393 TCM vs. 728 controls0-6 months, 393 TCM vs. 728 controls 0-12 months, 658 TCM vs. 1153 controls0-12 months, 658 TCM vs. 1153 controls
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TCN Visits TCN Visits
Mean # of home visits = 7.26 (2-19); mean Mean # of home visits = 7.26 (2-19); mean length = 50 minuteslength = 50 minutes
Mean # of MD office visits = 0.7 (0-3); Mean # of MD office visits = 0.7 (0-3); mean length = 62 minutesmean length = 62 minutes
Mean # of patient phone calls = 7.82; Mean # of patient phone calls = 7.82; mean length = 8 minutesmean length = 8 minutes
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Costs
Significant reductions in total health Significant reductions in total health care costs through 3 months; care costs through 3 months; savings continue thru 12 monthssavings continue thru 12 months
$439 PMPM savings at 3 months$439 PMPM savings at 3 months $181 PMPM savings at 12 months $181 PMPM savings at 12 months
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Factors Considered in Factors Considered in Interpreting FindingsInterpreting Findings
Hospital component of TCM was not Hospital component of TCM was not implemented in applying model with implemented in applying model with Aetna’s membersAetna’s members
Regional variations in service useRegional variations in service use Comparison group obtained from Comparison group obtained from
region with 20% region with 20% lowerlower utilization rate utilization rate than mid-Atlantic regionthan mid-Atlantic region
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TCM as High TCM as High Value Value
Proposition Proposition for Aetnafor Aetna
High Quality High Quality + +
SatisfactionSatisfaction
Reductions Reductions in Acute in Acute
Readmissions Readmissions (Costs)(Costs)
==
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Progress to DateProgress to Date
TCM proposed for expansion as part of TCM proposed for expansion as part of
Aetna’s 2009 Strategic PlanAetna’s 2009 Strategic Plan Kaiser enrollment complete; data Kaiser enrollment complete; data
analyses ongoinganalyses ongoing University of Pennsylvania Health University of Pennsylvania Health
System has adopted TCM; Blue Cross System has adopted TCM; Blue Cross
plans to reimburse for its membersplans to reimburse for its members
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Next Steps for Penn TeamNext Steps for Penn Team
Continue efforts to promote Continue efforts to promote widespread adoption of TCM widespread adoption of TCM
Use findings to promote needed policy Use findings to promote needed policy changeschanges
Continue to build the scienceContinue to build the science
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How can we improve post-How can we improve post-discharge outcomes for discharge outcomes for hospitalized cognitively hospitalized cognitively
impaired elders?impaired elders?
Funding: Marian S. Ware Alzheimer Program, and Funding: Marian S. Ware Alzheimer Program, and National Institute on Aging (2005-2010)National Institute on Aging (2005-2010)
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How can we improve How can we improve transitions of elders in transitions of elders in
LTC to and from LTC to and from hospitals?hospitals?
Funding: Rand-Hartford Center for Interdisciplinary Funding: Rand-Hartford Center for Interdisciplinary Geriatric Health Care Research (2005-2008); Geriatric Health Care Research (2005-2008); National Institute on Aging, National Institute of National Institute on Aging, National Institute of Nursing Research (2006-2011)Nursing Research (2006-2011)
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AcknowledgementsAcknowledgements
Research team, nurses and staffResearch team, nurses and staff NewCourtland Center for Transitions NewCourtland Center for Transitions
and Healthand Health Translation PartnersTranslation Partners FundersFunders
www.transitionalcare.infowww.transitionalcare.info
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Thank You!Thank You!