Bridging Hospital to Home: An Innovative Social Work Approach to Transitional Care

The Bridge Model

An Innovative Social Work Approach to Transitional CareBridging Hospital to HomeAmerican Society On AgingThursday April 28th, 2011San Francisco, CA

1

Kristen Pavle, Health & Medicine Policy Research GroupGood Morning!

AgendaITCC, Transitional Care

The Bridge Model

Building Relationships: Hospital & Community Based OrganizationsAging Resource CentersBusiness agreements/contracts

Cultural Competency

Research, Evaluation, and Data

Q & A

3K

Who we are the Illinois Transitional Care ConsortiumITCC was formed to more effectively address needs of older adults transitioning from the hospital to the community by linking hospital based services with the aging network through intensive care coordination.

ITCC is a result of collective experience in the field of aging, and visionary leadership

4

ITCC membersCommunity-based organizationsAging Care ConnectionsShawnee Alliance for SeniorsSolutions for Care

HospitalsRush University Medical CenterMacNeal HospitalAdventist LaGrange Memorial HospitalHerrin HospitalMemorial Hospital of Carbonda;e

Research, Evaluation & PolicyUniversity of Illinois at Chicago, School of Public HealthHealth & Medicine Policy Research Group

The Illinois Transitional Care Consortium, or ITCC, is a diverse group comprised of:Community-based providersHospitalsResearch, Evaluation and Policy groups

Talk about the idea of Consortium members representing different populations: rural, urban, suburban, medically under-served, hispanic, etc.

So, why transitional care?19.6% of Medicare beneficiaries are readmitted in 30 days

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

76% of 30 day readmissions are highly preventable

Kristen Ive mentioning this a lot on presentations when you get to the 40-50% make it clear that it does not imply that social workers can only prevent 40-50% of readmissions because social workers can intervene on numerous medical issues by connecting the right silos of care together. Things like medication regimen or discharge instruction confusion, etc.6

Older Adults and Care TransitionsOlder adults are particularly vulnerable to poor transition outcomesMultiple medical conditions, medications, and care providersPhysical and cognitive limitationsHealth literacyBurdened caregivers

Photo courtesy of auntjojo on Flickr.com

The United States Health Care SystemMedicareMedicare Advantage PlansPrivate InsuranceCo-PaysDeductiblesIn-Network ProvidersRehabilitationSkilled Nursing FacilitiesIn-Patient Hospital StaysCommunity-based OrganizationsPrimary Care Physicians

Specialist doctorsNursesSocial WorkersPreventive CareLong-term careFamily CaregiversMedicaidHome care physiciansMedical homesAccountable care organizationsDirect-care workers: home health, home care

Take homes: complex, silos of care, no connection

A lot of great systems are already in place. Lets not reinvent the wheel but learn how to connect them.

Perfect StormIncreasingly aged populationGreater functionality with chronic conditionsLiving longer, yet sickerBottom Line: people need better care and we need to offer high quality care while containing costs

Photo courtesy of striking_photography on Flickr.com

9As the countrys demographics change, care coordination and transitional care have become increasingly important in the U.S. health care delivery system. We are entering an era of an increasingly aged population, longer life-spans and improved medical technology, giving individuals with chronic conditions of all ages greater functionality. People are now living longer but often living sicker. An estimated 130 million Americans live with at least one chronic disease [Lipson & Au, 2010], and at least 65 million older adults experience multiple chronic conditions [Boult, Karm & Groves, 2008]. The implications for health care costs are significant; currently, older adults with more than four chronic conditions, 25% of the Medicare population, are responsible for at least 80% of Medicare spending [Boult et al., 2008].

If we do not address the increasing complexity and larger population of people in need, we are going to see health outcomes decrease!

WR: i like this slide. as opposed to other presentations i've been to where this is brought up (which is every other presentation), i'd like to really let this soak in in order for the audience to understand what this means for the community. perhaps bring up urban case loads now and then.

Transitional CareCoordinating care from one care setting to anotherHospital to homeHospital to nursing homeNursing home to homeHome to nursing homeWithin hospital or nursing homeInsurance transitionsPCP transitionCaregiver moving in or out

Since were the transitional care consortium, we need to address what IS transitional care? Lets run through some examples.

Examples from ALMH

Advisory BoardJean Bohnhoff - Executive Director, Effingham County Committee on AgingThomas Cornwell - Medical Director, HomeCare PhysiciansBob Clapp - Senior Vice President, Hospital Affairs, Rush University Medical CenterJim Durkan - President/CEO, Community Memorial FoundationKaren Freda - Executive Director, Illinois Council of Case Coordination UnitsMichael Gelder - Senior Health Policy Advisory to Illinois Governor Pat QuinnMichael Koronkowski Pharmacist and Geriatrics Professor, University of Illinois at ChicagoPatricia Merryweather - Vice President, Illinois Hospital AssociationJonathan Lavin - Executive Director, Age Options, Suburban Cook County Area Agency on AgingMarta Pereyra - Coalition of Limited English-Speaking ElderlyCheryl Schraeder - Director of Policy & Practice Initiatives, Institute for Healthcare Innovation, University of Illinois at Chicago College of NursingPatricia Volland - Senior Vice President, Strategy & Business Development, The New York Academy of MedicineRebecca Zuber - President, Rebecca Zuber, Inc.

Benefits of an advisory board= various stake holders outside of the consortium are represented including national perspective: government, policy, limited English speaking, academic, hospital, rural

Our connection through the Advisory Board with the Illinois Hospital Association has been invaluable. Pat Merryweather a Sr. VP for IHA has been a champion of our Bridge Model and supportive of us in helping to explain to hospitals the merit of our Model

Meeting format

Walter Rosenberg, Rush University Medical CenterThe Bridge Model

A Case ExampleMrs. HarrisonWidowed75 years oldHas diabetes and COPDAdmitted through the ED after a fallHospitalized for 5 daysDischarged with home health care10 medications prescribed

2-3 min

Mrs. Harrisons two children cant agree how to best manage their mothers medical needs.Mrs. Harrison at HomeCommunity PCP doesnt know Mrs. Harrison was admitted to the hospital.Mrs. Harrisons primary caregiver is overwhelmed and has to return to work.The Home Health Care Agency doesnt arrive on time.Mrs. Harrison has no transportation to her follow-up medical appointments.Mrs. Harrison doesnt know which medications to resume and which to stop taking at home.Mrs. Harrisons Community Services are delayedMrs. Harrison has questions about her medical bill and doesnt know what her insurance will cover.Mrs. Harrison cant afford her medications anyway.Mrs. Harrison is having difficulty coping with her mobility changes.Mrs. Harrison is feeling depressed because she cant get around anymore like she used to.Mrs. Harrison is feeling isolated now that shes homebound.Mrs. Harrison is afraid she will fall again and have to return to the hospital.Is this the worst case scenario, or is it a typical transition?

Walter

Take your time here, gauge the audience for credibility response. Double check that these sound right to them.

The Bridge Model

http://blog.reflexstock.com/2009/12/a-selection-of-stunning-images/

ilana15

The Bridge ModelOverview of ComponentsSocial-worker Based: Bridge Care CoordinatorInterdisciplinary TeamsHospital HomePatient Focused, Community-Specific The Aging Resource CenterUrban, Suburban, and Rural applicability

ilana

Go into detail about the symbolic meaning of the aging resource center (e.g. The ARC is essentially a symbol of the partnership between the hospital and the community. It is a physica

The Bridge Model

The participant enters the hospital with more than an illness.

CaregiverFamilySESRaceGenderEthnicityReligionMental HealthPersonal Values and Beliefs

Referrals can originate from an electronic medical record, a discharge planner, the patient or a family member.

Risk screen built in to the EMRIf non-hospital staff, requires access to the EMR

Review of the electronic medical record, meeting with an interdisciplinary pre-discharge and fast tracking community services.

Pre-discharge: referrals in one of a few ways (emr, walk-ins, d/c planners), assessment in one of a few ways (emr, interdisciplinary team, d/c-planner, family/patient)

17

The Bridge Model ProcessThe Bridge Care Coordinator builds relationships with the community service providers.

Services get fast-tracked to aid in a seamless transition upon discharge

The Bridge Care Coordinator conducts a comprehensive assessment and intervention to identify needs unrealized prior to discharge.

Medication complianceTransportation to doctors appointmentsCommunity resources neededScheduled doctors appointmentSafety at home At 30 days, the participant/caregiver gets contacted and the transitional process gets assessed.

Warm handoff made to appropriate agenciesDoctors visit completedMedication regimen understood Safety at homeAny additional unmet needs

Post-discharge: 48 hr. assessment and intervention (in-depth piece, follow up on important non-resource issues like pcp f/u, regimen understanding, caregiver burden, unmet needs, home health, etc. )

18

Building off of Aging NetworkConducting Choices for Care Assessments and CCC Assessments Setting up CCP Interim Services and Interim Home Delivered Meals

Providing and referring families for Caregiver Support Services and Respite

Conducting Benefits Check-Ups

Providing Information & Assistance to Patients and their families on site (i.e. Medicaid, Food Stamps, Circuit Breaker, Tax Freezes, Medicare Part D, Home Modification, FSS)

These are services that are already available, BUT we do the in-depth assessment, etc., etc.

Bridge Care Coordinators

http://commons.wikimedia.org/wiki/File:Provence_Winds_Compass_Rose.jpg

20

Bridge Care CoordinatorsWhy Social Workers?Systems TheoryBiopsychosocial framework Psychosocial determinants of health

http://early-childhood-resources.com/2010/05/reflection

40-50%

Health disparities

The Post-Discharge Environment

http://amandabauer.blogspot.com/2010/03/romantic-circles-by-kandinsky.html

Key word: advocacy

22

Psychosocial Issues

Social isolationDepressionDifficulty coping with changeFinancial stressorsLanguage barriersHealth literacy barriersOlder generations taught to be good patients40-50% of readmissions linked to psychosocial issues and lack of community resources

Bring up own experience when possible (tell them a little story)

good patient is a big reason why the situation changes post discharge. Were all taught to respect doctors and we nod and say yes, but do we really understand?

So even with good coaching, however (coleman, naylor), things will go wrong at d/c23

Calculating the CostWhat is the REAL cost?Staff allocationOverheadTrainingCase load efficiency

http://www.boston.com/ae/theater_arts/exhibitionist/2007/06/salaries_of_sym.html

SustainabilityCant do good without doing wellWhos money are you saving? Who is your audience?Business case optionsReadmissionsHigher yield patientsPatient SatisfactionThe 3026 RFPGrants

http://www.thinkgeek.com/gadgets/tools/a396/

Ilana Shure, Aging Care ConnectionsEsther Izaguirre, Solutions for CareBuilding Relationships

Aging Resource Center

The Role of the ARCSymbol of hospital-community collaboration

Greater ability to interface with the community

Promotes the notion of systems approach to discharge planning.

Maximizes the opportunity for a servable moment.

Community-Hospital PartnershipsAging Care Connections (CCU - Suburban Chicago) Adventist LaGrange Memorial Hospital

Shawnee Alliance for Seniors (CCU Rural, downstate Illinois)Memorial Hospital of CarbondaleHerrin Hospital

Solutions for Care (CCU Suburban Chicago)Mac Neal Hospital

Central West (CMU Chicago)Rush University Medical Center

31

Aging Network: National State

Walter

Per the Older Americans Act the Administration on Aging created an Aging Network. The Aging Network includes State Units on Aging. In Illinois the State Unit on Aging is the Illinois Department on Aging (or IDoA for short), a stand alone State Department.

Illinois Aging Services Network

33Walter to comment about Hospitals, where do they come in? Fragmentation! (Which is interesting considering what weve been talking about: older adults have a lot of chronic conditions, require a lot of care, are frequently rehospitalized. WHY wouldnt the aging network include hospitals??)

In Illinois, the state is divided in to 13 Planning and Service Areas (PSAs). Each PSA is managed by an Area Agency on Aging. AAAs plan and coordinate services and programs for older adults, and do not typically provide direct services for older adults, but contract with Care Coordination Units to do so.

Care Coordination Units (CCUs) -central access points for older adults and their caregivers. May be located in a senior center or other social service agencyConnection to public, private and volunteer based community services and resources including:-housekeeping assistance, -home-delivered meals, -personal care, -respite services-caregiver support-benefits assistance-transportation-and other important resources and services

A care coordinator can perform a home visit to comprehensively assesses the person's needs, determine eligibility for various programs, develop a plan of care and arrange for services.

Establishing a Connection to the Aging NetworkMany older adults seen at the hospital by Bridge Care Coordinators have yet to get connected to resources available through their community

54% of ARC clients had no previous interaction with their local Care Coordination Unit (N=399)

Bridge Care Coordinators connect older adults to the aging network

49% of ARC clients utilized services offered through their local Care Coordination Unit for the first time after their encounter with a Bridge Care Coordinator (N=399)

Note that not all participants live in areathis is just a snapshot from one CCU34

Establishing an ARCTime frames for developing the ARCOutreach to hospitalThrough existing programs or contracts already established

Begin contacting individuals at the hospital who are supportive of the model.

35Establishing an ARC in our model involves integrating an onsite presence by a community based organization with an acute care hospital.

This is a new concept for both organizations. The start up time is easily 6-9 monthsWork from your strengths. Many CBOs are referral sources for discharge planners already, the federal OBRA requirements for nursing home screening, etc. place many care coordinators onsite at hospitals

Members of ITCC used our current contacts such as the Social Service Director, Executive Director of External Relations, Head of Gerontology Department, Physicians, CFO, CEO, etc. Focus on who is the decision maker of the hospital system or of the CBO if it is hospital seeking to partner and network with others to reach the targeted decision maker

Bring up solutions for care

Establishing a PartnershipEvaluate Potential Partners

Make the ASKIdentify what you are asking the partner to contribute

Establish the basic structure of the partnership prior to launching the projectKeep parameters loose enough to allow for growth development

An MoU at a minimum should be in place prior to the start date of the project

Establishing a Partnership Cont. Legal agreements should be created broadly defining the service provision, the recipient of the service and duties of each partner in the relationship including:Purpose of the programResponsibilities of both partiesIndividual responsibilities of the partnersFinancial liabilitiesConfidentiality and data sharingTermination

Annually review agreement!

http://www.fortklock.com/signatures.htm

Lessons Learned Integrate at all levels of the hospital systemFront desk reception to Regional Director

Be patient and persistentGuest versus Team Member

Troubleshoot challenges before they become barriers

Learn both cultures and languagesNetwork, network, network

Cultural Competency SFC services a Diverse Population40% Hispanic 37% Limited English Speaking or only speak SpanishBilingual and Bicultural Bridge Care Coordinators

Cultural Competency Continued Assess clients and caregivers in their language and coordinate and link them to servicesBCC are able to participate in the important aspects of culture, value and belief systems All printed material are in Spanish including Consent forms

Cultural Competency ContinuedSupport Groups for Spanish Speaking CaregiversChronic Disease Self Management Classes taught in Spanish -Take Charge of your Health Outreach Program to target cultural linguistically isolated individuals in the communities

Susan Altfeld, University of Illinois at Chicago School of Public HealthResearch & Evaluation

42

The Bridge Model Evidence BaseThe Bridge Model is an adaptation of the Enhanced Discharge Planning Program (EDPP)EDPP is an evidence-based model developed and evaluated with a randomized-controlled trial at Rush University Medical Center (ITCC partner)

Bridge implements the evidence based components of EDPP and best practices developed by ITCC partner sitesBridge is a hospital and community partnership

Building on what we have learned43

Rush University Medical Center Study Randomized controlled trial of 720 patientsAll patients older than 65 with multiple medical conditionsHalf received follow-up intervention, half were in the usual care group

Qualitative study Interviews with intervention social workers

44

What did we learn from the Rush study?83% of the patients in the intervention group had problems identified by the social worker during the assessment at 2 days post-dischargeFor of these individuals, problems did not emerge until after discharge surprises

Not a discharge planning issue but UNANTICIPATED SURPRISES!45

Needs Identified at 2 day post discharge contact* - Rush studyManagement of post-d/c care25%Obtaining community services24%Understanding discharge plan17%Caregiver stress35%Patient stress/coping35%Social support10%

*select variables

What were those needs?

Randomized Controlled Trial Outcomes at 30 day follow up patient follow up/adherenceInterventionUsual carePhysician communicationYES90.3%81.9%0.002Made appointment with physicianYES92.5%81.4%