The Carol Hogue Lectureship May 5, 2010
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Transcript of The Carol Hogue Lectureship May 5, 2010
The Carol Hogue Lectureship May 5, 2010Duke University School of Nursing & University of North Carolina Chapel Hill
Mary D. Naylor, PhD, RN, FAANMary D. Naylor, PhD, RN, FAANMarian S. Ware Professor in GerontologyMarian S. Ware Professor in GerontologyDirector, NewCourtland Center for Transitions Director, NewCourtland Center for Transitions and Healthand HealthUniversity of Pennsylvania School of NursingUniversity of Pennsylvania School of Nursing
Perspectives on Chronic Illness Perspectives on Chronic Illness Care in the USCare in the US
Older Adult
Family Caregiver
Society
Transitional CareTransitional Care
Transitional care – range of time time limited limited services and environments that complement primary complement primary care and are designed to ensure health care continuity and avoid preventable poor outcomes among at riskat risk populations as they move from one level of care to another, among multiple providers and across settings.
The Case for Transitional CareThe Case for Transitional Care
High rates of medical errors
Serious unmet needs
Poor satisfaction with care
High rates of preventable readmissions
Tremendous human and cost burden
Context for Transitional CareContext for Transitional Care: : Acute Care EpisodeAcute Care Episode
Adapted from the National Quality Forum committee on Measurement Framework: Evaluating Efficiency across Episodes of Care Adapted from the National Quality Forum committee on Measurement Framework: Evaluating Efficiency across Episodes of Care
Different Goals of Different Goals of Evidence-Based InterventionsEvidence-Based Interventions
Address gaps in care and promote effective “hand-offs”
Address “root causes” of poor outcomes with focus on longer-term, positive outcomes
Recommended ApproachRecommended Approach
Stratify population based on needs/risk & apply EB interventions• Lower risk groups (T1) – improve “hand-offs”
• Higher risk groups (T2) – interrupt current trajectory/focus on long-term outcomes
• Adults at end of life (T3) – transition to palliative care/hospice
Unique FeaturesUnique Features
Care is delivered and coordinatedCare is delivered and coordinated
…by same advanced practice nurse
…in hospitals, SNFs, and homes
…seven days per week
…using evidence-based protocol
…with focus on long termlong term outcomes
Naylor MD, Brooten D, Jones R, Lavizzo-Mourey R, Mezey MD, & Pauly M. Comprehensive discharge planning for the hospitalized elderly. Ann Intern Med. 1994; 120:999-1006.
Could we improve Could we improve outcomes for older outcomes for older
adults and their adults and their caregivers by caregivers by
enhancing the quality enhancing the quality of hospital discharge of hospital discharge
planning? planning?
National Institute of Nursing ResearchR01NR02095, (1989-1992)
What if we targeted high-risk patients What if we targeted high-risk patients and and
added a home care component?added a home care component?National Institute of Nursing ResearchR01NR02095, (1992-1997)
Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, & Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-620.
Would a comprehensive Would a comprehensive intervention targeting intervention targeting their complex needs, their complex needs, improve outcomes for improve outcomes for
elders elders hospitalized with heart hospitalized with heart
failure? failure? National Institute of Nursing Research R01NR04315, (1997-
2001)
Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, & Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684.
Core Components Core Components
Holistic, person/family centered approach
Nurse-led, team model Protocol guided, streamlined care Single “point person” across episode
of care Information/communication systems
that span settings
Across RCTs, TCM has…Across RCTs, TCM has…
Increased time to first readmission or death
Improved physical function and quality of life*
Increased patient satisfaction Decreased total all-cause readmissions Decreased total health care costs
*Most recently completed RCT only*Most recently completed RCT only
1 Naylor MD, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, & Pauly MV. Comprehensive discharge planning for the hospitalized elderly. Ann Intern Med. 1994;120:999-1006.2 Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, & Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-620.3 Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, & Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684.
* Total costs were calculated using average Medicare reimbursements for hospital readmissions, ED visits, physician visits, and care provided by visiting nurses and other healthcare personnel. Costs for TCM care is included in the intervention group total. ** Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, & Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-620.*** Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, & Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684.
$6,661
$12,481
$3,630
$7,636
at 26
weeks**
at 52
weeks**
*
Dollars (US)
TCM's Impact on Total Health Care Costs*
TCM Group
Control Group
Barriers to Widespread Barriers to Widespread Adoption Adoption
Organization of current system of care
Regulatory barriers Lack of quality and financial incentives
Culture of care
Translating TCM into PracticeTranslating TCM into Practice
Penn research team formed Penn research team formed partnerships with Aetna partnerships with Aetna Corporation and Kaiser Permanente Corporation and Kaiser Permanente to test “real world” applications of to test “real world” applications of research-based model of care research-based model of care among at risk elders. among at risk elders.
Funded by The Commonwealth Fund and the following foundations: Funded by The Commonwealth Fund and the following foundations: Jacob and Valeria Langeloth, The John A. Hartford, Gordon & Betty Jacob and Valeria Langeloth, The John A. Hartford, Gordon & Betty Moore, and California HealthCare; guided by National Advisory Moore, and California HealthCare; guided by National Advisory Committee (NAC)Committee (NAC)
Project Goals (Aetna)Project Goals (Aetna)
Test TCM in defined market Document facilitators and barriers
Provide for ongoing NAC input Present findings to Aetna decision makers
Widely disseminate findings
Tools of TranslationTools of Translation
Patient screening and recruitment
Orientation of nurses (web-based modules)
Documentation and quality monitoring (clinical information system)
Quality improvement (case conferences grounded in root cause analysis)
Evaluation
Key Indicators of SuccessKey Indicators of Success
Decisions by Aetna re: adoption Decisions by other insurers and providers to implement model
Use of findings by CMS and insurers to reimburse evidence-based transitional care
ValueValue ==Health Resource Health Resource Utilization (Costs)Utilization (Costs)
Environment: Extant comprehensive system of geriatric telephonic care management
Question: Does the Transitional Care Model offer greater value in this environment?
Quality/SatisfactionQuality/Satisfaction
FindingsFindings
Improvements in all quality measures
Increased patient and physician satisfaction
Reductions in rehospitalizations through 3 months
Cost savings of $2170 per member per month thru one year
All significant at p <.05
TCM as TCM as High Value High Value Proposition Proposition for Aetnafor Aetna
High Quality High Quality
+ Satisfaction+ Satisfaction
Reductions Reductions in Acute in Acute
ReadmissionReadmissions (Costs)s (Costs)
==
Building a Translational Building a Translational RoadmapRoadmap
Semi-structured, interviews by independent consultant following start-up and roll-out phases
Analysis of transcripts to identify common facilitators, barriers and lessons learned
Key LessonsKey Lessons
Strong champions Fit of the innovation Importance of the business case Responsiveness to external climate Total engagement Flexibility Clearly defined role/work processes Excellent communication
Progress to Date Progress to Date
AetnaAetna – expansion proposed as part of Aetna’s Strategic Plan
KaiserKaiser – data collection/analyses ongoing
University of Pennsylvania Health University of Pennsylvania Health SystemSystem – adopted TCM (Blue Cross reimbursing)
QIOsQIOs – working with NJ and NY Other health care providers
Ongoing EffortsOngoing Efforts
Advancing the scienceAdvancing the science Promoting widespread Promoting widespread
adoption of TCM adoption of TCM Using findings to promote Using findings to promote
policy changespolicy changes
Would cognitively impaired Would cognitively impaired hospitalized older adults and hospitalized older adults and
their caregivers benefit their caregivers benefit from TCM? from TCM?
Funding: Marian S. Ware Alzheimer Program, and National Institute on Aging, R01AG023116, (2005-2010)
What do we know about What do we know about effects effects
of transitions in health among of transitions in health among
elderly long-term care elderly long-term care
recipients over time? recipients over time?
Funding: Rand-Hartford Center for Interdisciplinary Geriatric Health Care Research (2005-2008); National Institute on Aging, National Institute of Nursing Research, R01AG025524, (2006-2011)
Promoting AdoptionPromoting Adoption
Sample strategiesSample strategies: : national and international collaborations and consultations, website, media efforts
Selected outcomesSelected outcomes: : endowed center; featured in Wall Street Journal, Washington Post, PBS, NPR; AAN Edge Runner, AHRQ Health Care Innovations, RWJF Innovative Care Models, NQF Best Practice
Influencing Health PolicyInfluencing Health Policy
Sample strategiesSample strategies: : Policy briefs, Congressional testimony, Hill and MedPAC briefings
Selected outcomesSelected outcomes:: Medicare Transitional Care Act
(S.1295, and H.R. 2773) Provisions re: transitional care in
current health care bill
National Institute of Nursing ResearchNational Institute of Nursing Research National Institute on AgingNational Institute on Aging Presbyterian Foundation for PhiladelphiaPresbyterian Foundation for Philadelphia Marian S. Ware Alzheimer’s Program, PennMarian S. Ware Alzheimer’s Program, Penn National Alzheimer’s AssociationNational Alzheimer’s Association The Commonwealth FundThe Commonwealth Fund Jacob & Valeria Langeloth FoundationJacob & Valeria Langeloth Foundation The John A. Hartford Foundation, Inc.The John A. Hartford Foundation, Inc. Gordon & Betty Moore FoundationGordon & Betty Moore Foundation California HealthCare FoundationCalifornia HealthCare Foundation
Univ. of Pennsylvania Health SystemUniv. of Pennsylvania Health SystemIndependence Blue Cross of PhiladelphiaIndependence Blue Cross of PhiladelphiaAetna CorporationAetna CorporationKaiser PermanenteKaiser PermanenteCMS QIOsCMS QIOs
MarMark k PaulPaulyy
KathryKathryn n BowleBowless KathleeKathlee
n n McCauleMcCauleyy
Ellen Ellen KurtzmaKurtzmann
SandySandySchwarSchwartztz
Greg Greg MaisliMaislinn
With Gratitude and With Gratitude and ThanksThanks
It does take a village…
Katherine AbbottLucinda Bertsinger
M. Brian BixbyLaura DiGiovanni
Janice FoustBinh Ha
Karen HirschmanDavid Jiang
Heidi KaputskaJoAnne Konick-McMahan
Laura LechtenbergJessica MacLeodEllen McPartland
SarahLena PanzerJanet Prvu BettgerJonathan SnyderJanet Van CleaveMichelle Whetzel
Christina WhitehouseTamora Williams