TCM010 – Unit 1 March 19, 2013

Translating Research Into Practice

Mary D. Naylor, PhD, RN, FAANMarian S. Ware Professor in GerontologyDirector, NewCourtland Center for Transitions and HealthUniversity of Pennsylvania School of Nursing

The Transitional Care Model

www.transitionalcare.info

Perspectives on Chronic Illness

Care in the US Older Adults Family Caregivers Health Care Clinicians Society

Range of time limited services and environments that complement primary care and are designed to ensure health care continuity and avoid preventable poor outcomes among at risk populations as they move from one level of care to another, among multiple providers and across settings.

Transitional Care

The 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

Major Affordable Care Act Provisions

Center for Medicare and Medicaid Innovation• Community-Based Care Transitions

Program• Multi-Payer Patient-Centered Medical

Home• Shared Savings Program (ACOs)• Payment Innovation (e.g., Bundled

Payments) Transitional Care Payment Codes Federal Coordinated Health Care

Office

Medicare Transitional Care Act of 2012*

Amends title XVIII (Medicare) of the Social Security Act to cover transitional care services for qualified individuals provided by a transitional care clinician acting as an employee of a qualified transitional care entity, such as a hospital (or a critical care hospital), a home health agency, a primary care practice, a federally qualified health center, a long-term care facility, a medical home, an appropriate community-based organization, an assisted living center, or an accountable care organization. (* Re-Introduced by Reps. Earl Blumenauer (D-Ore.), Thomas Petri (R-

Wis.), Allyson Schwartz (D-Pa.) and Jan Schakowsky (D-Ill.) in September, 2012)

Context: Acute Care Episode

Adapted from the National Quality Forum (NQF) steering committee on Measurement Framework: Evaluating Efficiency Across Patient-Focused Episodes of Care. The committee’s report presents the NQF-endorsed measurement framework for assessing efficiency, and ultimately value, associated with the care over the course of an episode of illness and sets forth a vision to guide ongoing and future efforts.

Trajectory 1 (T1)Relatively healthy adult with onset of new chronic illness

Trajectory 2 (T2)Adult with multiple chronic conditions

Trajectory 3 (T3)Adults at end of life

PopulationAt Risk

Acute Phase

Post Acute/ Rehab Phase

Secondary Prevention

Different Goals of Evidence-Based Interventions

Address gaps in care and promote effective “hand-offs”

Address “root causes” of poor outcomes with focus on longer-term value

Recommended 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

Transitional Care Model (TCM)

SCREENING

ENGAGING OLDER ADULT & CAREGIVER

MANAGING SYMPTOMS

EDUCATING/ PROMOTING SELF-MGMT

COLLABORATING

ASSURING CONTINUIT

Y

COORDINATING CARE

MAINTAINING RELATIONSHI

P

Care is delivered and coordinated……by same APN supported by team…in hospitals, SNFs, and homes…seven days per week …using evidence-based protocol…supported by tool box

Unique Features

Core Components

Holistic, person/family centered approach

Nurse-coordinated, team model Protocol guided, streamlined care Single “point person” across

episode of care Information/decision support

systems that span settings Focus on increasing value over

long term

Hospital to Home Findings*

Better Care

Better Health

Reduced

Costs• Enhance

d access• Reduced

errors• Increase

d satisfaction

• Decreased symptoms

• Improved function

• Enhanced quality of life

• Decreased all-cause rehospitalizations

• Reduced ED visits

• Total cost savings

(* Based on 3 NIH funded RCTs: Ann Intern Med, 1994,120:999-1006; JAMA, 1999, 281:613-620; J Am Geriatr Soc, 2004, 52:675-684)

Translating Evidence Into Practice

Penn research team formed partnerships with Aetna Corporation and Kaiser Permanente to test “real world” applications of research-based model of care among 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)

Tools of Translation Patient screening and recruitment Preparation of TCM nurses and

teams (e.g., online course) Documentation and quality

monitoring (clinical information system) 

Quality improvement (case conferences grounded in root cause analysis)

Evaluation

Findings (Aetna)

Improvements in all quality measures

Increased patient and physician satisfaction

Reductions in rehospitalizations through 3 months

Cost savings through one year All significant at p < 0.05 (Naylor et al., 2011. J Evaluation in Clinical Practice. doi: 10.1111/j.1365-2753.2011.01659.x.)

Would cognitively impaired hospitalized

older adults and their caregivers benefit

from TCM? Funding: Marian S. Ware Alzheimer Program, and National Institute on Aging, R01AG023116, (2005-

2011)

www.transitionalcare.info

Comparative Effectiveness Study

Compared three evidence-based innovations among hospitalized cognitively impaired older adults and family caregivers, each designed to:• Improve patients’ and family caregivers’

outcomes• Reduce preventable rehospitalizations• Decrease total health care costs

Enrolled 407 older adults and 407 family caregivers in prospective clinical trial conducted over 2 phases

Cognitive Deficits at Baseline

Orien-tationRecall

deficits, 43.2%

Executive Function deficits(clock task), 37.6%

Diagnosis of De-

mentia, 19.2%

24.9% also had delirium (+ Confusion Assessment Method)

TCM

ASC/RNC

93.4%

79.8%

67.9%78.6%

63.7%

53.1%

0%

25%

75%

50%

100%

0 30 60 90 120 150 180Days

TCM ASC/RNC

Time to First Readmission

P=0.0005

Mean Number of All-Cause Rehospitalizations Through Six Months

30 60 90 120 150 18000.020.040.060.080.1

0.120.140.160.180.2

APNASC/RNC

Days

Mea

n N

o Re

hosp

ital

izat

ions

P=.0049

Next Steps

Analyses re: patient, family caregiver and cost outcomes ongoing

About 30% of sample transitioned from hospitals thru post-acute SNFs to home

Findings contributed to ongoing work (+ recent NIH submission) to assess effects of learning collaborative with SNFs (hospitals and post-SNF providers) in implementation of evidence-based transitional care

What do we know about effects of

transitions among elderly long-term care recipients over time?

Funding: National Institute on Aging, National Institute of Nursing Research, R01AG025524,

(2006-2011)

www.transitionalcare.info

Prospective Observational Study

Examine the trajectory of changes in each of multiple HRQoL domains

Explore relationships between and among the multiple domains and health + long-term service use

Compare the patterns of change among similar older adults supported by three options (i.e., HCBS, ALF, NH)

Methods

Enrolled 470 English- and Spanish-speaking older adults from 50 sites, who were new recipients of long-term services and supports

Included older adults with mild- and moderate- cognitive impairment

Conducted quarterly interviews with adults and abstracted chart data; conducted organizational surveys

Conceptual HRQoL Model

(Zubritzky et al., 2012, The Gerontologist. doi: 10.1093/geront/gns093)

Bothersome Physical Symptoms

Present at Baseline*

Aching Shortness of Breath

Pain

64%56%

41%

(* Symptom Bother Scale)

Through Year One…

Overall rates of bothersome symptoms decreased and general health perceptions increased (p<0.001)

Further declines in bothersome symptoms were associated with increased depression (p<0.001) and increased hospitalization use (p=0.02)

Reported rates of bothersome symptoms were lower for non-white LTSS recipients (p=0.003)

Depressive Symptoms* Through One Year

0m 3m 6m 9m 12m

63% 61% 63% 65% 63%

26% 32% 30% 28% 32%11% 7% 6% 6% 5%

Categorized Depression Score Distri-bution Over Time(0-4) (5-9) (10+)

(* GDS-SF)

Preliminary Findings Suggest…

Opportunity to capture the “voice” of elderly LTSS recipients over time

Potential for interventions designed to recognize and manage physical and emotional symptoms

Potential for policies that enhance earlier access to symptom management

Does the TCM add value to the Patient Centered Medical

Home?Funding: Gordon and Betty Moore Foundation, Rita and Alex Hillman Foundation and the Jonas

Center for Excellence (2011-2013)

www.transitionalcare.info

Quasi-Experimental Study

Compare the health and cost outcomes demonstrated by community-based older adults coping with multiple chronic conditions who receive the PCMH+TCM to a similar group of older adults who receive the PCMH only

Modifications to TCM

Collaboration (co-management) with PCMH

Focus on patient (and family caregiver) goals – Goal Attainment Scaling

Emphasis on prevention of acute resource use (ED visit, index hospitalization) and continuity of care when acute event occurs

Preliminary Findings (PCMH+TCM only, N= 50)

Diagnoses: 12 (4-24) Medications: 11 (1-23) Major Risk Factors: 4 (2-7) Average PCMH+TCM intervention: 63 days (n=29)N Time to

hospitalization

PCMH+TCM

National Avg.*

ED visits (no hospitalization)

Acute office visits

34 0-30 days 3% 20% 0% 0%34 0-60 days 15% 28% 0% 0%33 0-90 days 15% 34% 6% 0%

(* Based on Jenks et al., 2009, N Engl J Med. 360:1418-1428)

The TCM… Focuses on transitions of high-risk

cognitively intact and impaired older adults across all settings

Has been “successfully” translated into practice

Has been recognized by the Coalition for Evidence-Based Policy as an innovation meeting “top-tier” evidence standards

Key Components for Success Champions Shared goals Multi-stakeholder

involvement Communication Data monitoring and

reporting Culture of continuous

learning

Implementation Progress

Aetna – expansion of TCM proposed as part of Aetna’s Strategic Plan

University of Pennsylvania Health System – adopted TCM (Aetna and Blue Cross reimbursing)

Other health care systems & communities – adopting/adopting

Informing ACA implementation

TCM Locations

International Locations: Canada, Germany, Ireland, New Zealand, Scotland, Singapore

Areas in the U.S. implementing TCM

Key Lessons Solving complex problems will

require multidimensional solutions Evidence is necessary but not

sufficient Change is needed in structures,

care processes, and health professionals’ roles and relationships to each other and people they support

Carpe Diem!

www.transitionalcare.info