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Care Transitions Intervention. Model Concepts and Implementation through Lehigh Valley Home Health Services. Vickie Cunningham, Tracey Wilds and Karen Panik. "Sometimes the questions are complicated and the answers are simple." -Dr. Seuss. What is the Care Transitions Intervention (CTI)?. - PowerPoint PPT Presentation
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Care Transitions InterventionCare Transitions Intervention
Model Concepts and Implementation through Lehigh Valley Home Health Services
Model Concepts and Implementation through Lehigh Valley Home Health Services
Vickie Cunningham, Tracey Wilds and Karen Panik
"Sometimes the questions are complicated and the answers are simple."
-Dr. Seuss
What is the Care Transitions Intervention (CTI)?
What is the Care Transitions Intervention (CTI)?
■ 4-week program■ Patients with complex care needs and
family caregivers ■ Specific tools ■ Transition Coach ■ Self-management skills
■ 4-week program■ Patients with complex care needs and
family caregivers ■ Specific tools ■ Transition Coach ■ Self-management skills
Why The Care Transitions Intervention?
Why The Care Transitions Intervention?
■ Patients who received this program were significantly less likely to be readmitted to the hospital, and the benefits were sustained for five months after the end of the one-month intervention.
■ Anticipated cost savings for 350 chronically ill adults with an initial hospitalization over 12 months is $295,594.
■ Patients who received this program were also more likely to achieve self-identified personal goals around symptom management and functional recovery.
■ Patients who received this program were significantly less likely to be readmitted to the hospital, and the benefits were sustained for five months after the end of the one-month intervention.
■ Anticipated cost savings for 350 chronically ill adults with an initial hospitalization over 12 months is $295,594.
■ Patients who received this program were also more likely to achieve self-identified personal goals around symptom management and functional recovery.
CTI Model Pillars CTI Model Pillars
■ Medication self-management ■ Use of a dynamic patient-centered
record, the Personal Health Record ■ Timely primary care/specialty care
follow up ■ Knowledge of red flags that indicate a
worsening in their condition and how to respond
■ Medication self-management ■ Use of a dynamic patient-centered
record, the Personal Health Record ■ Timely primary care/specialty care
follow up ■ Knowledge of red flags that indicate a
worsening in their condition and how to respond
CTI Model Encounters CTI Model Encounters
■ Hospital Visit■ Home Visit■ 2-3 phone contacts
■ Hospital Visit■ Home Visit■ 2-3 phone contacts
Key Attributes of a CoachKey Attributes of a Coach
■ Ability to shift from a “doing” role to a
coaching role■ Comfort with medication review ■ Understands the difference between
being persistent vs. pesty
■ Ability to shift from a “doing” role to a
coaching role■ Comfort with medication review ■ Understands the difference between
being persistent vs. pesty
Outcomes Obtained in Initial study
Outcomes Obtained in Initial study
■ Re-hospitalized 180 days – 26 % Intervention 31 % control
■ Re-hospitalized 90 days– 17 %Intervention 23 % control
■ Re-hospitalized 30 days – 8 % Intervention 12 % control
■ Re-hospitalized 180 days – 26 % Intervention 31 % control
■ Re-hospitalized 90 days– 17 %Intervention 23 % control
■ Re-hospitalized 30 days – 8 % Intervention 12 % control
Coleman, E.A., Parry, C, Chalmers, S., & Min, S. (2006). The care transitions intervention results of a randomized control trial. Archives of Internal Medicine 166 1822-1828.
Care Transitions Intervention Implementation at Lehigh Valley
Health Network
Care Transitions Intervention Implementation at Lehigh Valley
Health Network
Market AnalysisMarket AnalysisStrengths
• CTI has been researched and was touted by Medicare Innovations Collaborative (Med-IC) as one mechanism to enhance older adult patient care while decreasing rehospitalization (Medicare Innovations Collaborative, 2011).
• Patient transition to home from acute setting can be fragmented and difficult to navigate
• If patient does not require traditional home based services the patient may feel insecure about the transition to home and return to the hospital creating avoidable readmission
Strengths• CTI has been researched and was touted by Medicare
Innovations Collaborative (Med-IC) as one mechanism to enhance older adult patient care while decreasing rehospitalization (Medicare Innovations Collaborative, 2011).
• Patient transition to home from acute setting can be fragmented and difficult to navigate
• If patient does not require traditional home based services the patient may feel insecure about the transition to home and return to the hospital creating avoidable readmission
Medicare Innovations Collaborative (2011). Models of Care – Medicare Innovations Collaborative (2011). Models of Care – Transitional care. Retrieved from Transitional care. Retrieved from http://www.med-ic.org/pages/care.html
Market Analysis ContinuedMarket Analysis Continued
Weaknesses– Need for
systematic culture change within healthcare delivery system
– Research has not been duplicated by anyone other than originator
Weaknesses– Need for
systematic culture change within healthcare delivery system
– Research has not been duplicated by anyone other than originator
Market Analysis ContinuedMarket Analysis ContinuedOpportunities
• No current transitions program to assist patients that do not receive traditional home based services within Lehigh Valley Health Network
• No current transitional care delivery programs within geographic area (Lehigh, Carbon, Northampton County)
Opportunities• No current transitions
program to assist patients that do not receive traditional home based services within Lehigh Valley Health Network
• No current transitional care delivery programs within geographic area (Lehigh, Carbon, Northampton County)
Market Analysis ContinuedMarket Analysis Continued
Threats– Lack of patient
interest– Lack of direct
revenue which could impact sustainability
Threats– Lack of patient
interest– Lack of direct
revenue which could impact sustainability
Market Analysis continuedMarket Analysis continued
Stakeholders– Acute care hospitals who wish to decrease
uncompensated care– Home health agencies who wish to enhance
home and community based services– Third party payers who wish to decrease care
delivery costs– Patients and caregivers who wish to improve
patient self management– Physicians who wish to boost patient
compliance with treatment plans
Stakeholders– Acute care hospitals who wish to decrease
uncompensated care– Home health agencies who wish to enhance
home and community based services– Third party payers who wish to decrease care
delivery costs– Patients and caregivers who wish to improve
patient self management– Physicians who wish to boost patient
compliance with treatment plans
GoalsGoals
■ Ease transition from other levels of care to home based services
■ Enhance collaboration and transitions between home based service programs.
■ Improve continuity of care to patients with chronic disease.
■ Decrease number and length of hospitalizations for patients with chronic disease
■ Ease transition from other levels of care to home based services
■ Enhance collaboration and transitions between home based service programs.
■ Improve continuity of care to patients with chronic disease.
■ Decrease number and length of hospitalizations for patients with chronic disease
Setting the StageSetting the Stage■ Evaluate all transitions program
evidence ■ Training for care transitions coaching ■ Development of patient materials
including admission packet, Policies, consent, documentation and patient education
■ Spoke with Members of the MED- IC initiative for guidance on roll out
■ Evaluate all transitions program evidence
■ Training for care transitions coaching ■ Development of patient materials
including admission packet, Policies, consent, documentation and patient education
■ Spoke with Members of the MED- IC initiative for guidance on roll out
Setting the Stage Cont.Setting the Stage Cont.
■ Small test of change using Coleman model ■ Evaluation of pilot and obtained grant funding
for Transitions Coach position ■ Developed job description ■ Coach hired■ Developed referral mechanism using
Allscripts system■ Developed home health mechanism for
referrals■ Identified Inclusion Criteria
■ Small test of change using Coleman model ■ Evaluation of pilot and obtained grant funding
for Transitions Coach position ■ Developed job description ■ Coach hired■ Developed referral mechanism using
Allscripts system■ Developed home health mechanism for
referrals■ Identified Inclusion Criteria
Inclusion CriteriaInclusion Criteria
■ Lehigh and Northampton Co■ Hospitalized ■ Telephone■ English Speaking■ Adult■ Alert and Oriented■ At least 1 chronic condition
■ Lehigh and Northampton Co■ Hospitalized ■ Telephone■ English Speaking■ Adult■ Alert and Oriented■ At least 1 chronic condition
Service Delivery PlanService Delivery PlanFollow criteria outlined by the
CTI to reduce rehospitalization
– 4-week program– Patients with complex
care needs and family caregivers
– Specific tools (Personal Health record)
– Transition Coach – Self-management skills
Follow criteria outlined by the CTI to reduce rehospitalization
– 4-week program– Patients with complex
care needs and family caregivers
– Specific tools (Personal Health record)
– Transition Coach – Self-management skills
Care Transitions Program (2007). Care Transitions Program (2007). Business plan. Retrieved from Business plan. Retrieved from Colorado_Business_Plan_2009.pdf
Service Delivery Plan Continued
Service Delivery Plan Continued
■ 1 FTE Transitions coach per 25 patient caseload (RN or MSW preferred)
■ 0.25 FTE Clerical /office support per 25 patient caseload
■ 1 FTE Transitions coach per 25 patient caseload (RN or MSW preferred)
■ 0.25 FTE Clerical /office support per 25 patient caseload
OutcomesOutcomes
CTI Outcomes 1/12/2011 – 3/2012CTI Outcomes 1/12/2011 – 3/2012
■ Total referrals: 219 ■ 93 Refusals■ 46 Referral Inappropriate■ 75 Enrolled (signed a consent of
willingness to CTI participation) ■ 30 day readmission 10.6% overall
– 0% of those who completed intervention admitted 30 days post completion
■ Total referrals: 219 ■ 93 Refusals■ 46 Referral Inappropriate■ 75 Enrolled (signed a consent of
willingness to CTI participation) ■ 30 day readmission 10.6% overall
– 0% of those who completed intervention admitted 30 days post completion
Cost Benefit AnalysisCost Benefit Analysis
$265 per day to maintain program
average cost of heart failure readmission = $5497 (Whelan, Greiner, Schulman & Curtis, 2010, p.37)
Prevention of 18 hospitalizations for HF per year will recoup cost of program
$265 per day to maintain program
average cost of heart failure readmission = $5497 (Whelan, Greiner, Schulman & Curtis, 2010, p.37)
Prevention of 18 hospitalizations for HF per year will recoup cost of program
Cost Benefit Analysis Continued
Cost Benefit Analysis Continued
• 30 day readmission projection• 365 patients per year at 12 % rehospitalization rate = 44
patients rehospitalized• 365 patients at 8% rehospitalization rate = 29 patients
rehospitalized• 16 patient decrease = $87,952 annualized savings
• 90 day readmission projection• 365 patients per year at 23% rehospitalization rate = 84
patients rehospitalized• 365 patients at 18% rehospitalization rate = 62• 22 patient decrease = $120,934 annualized savings
• 30 day readmission projection• 365 patients per year at 12 % rehospitalization rate = 44
patients rehospitalized• 365 patients at 8% rehospitalization rate = 29 patients
rehospitalized• 16 patient decrease = $87,952 annualized savings
• 90 day readmission projection• 365 patients per year at 23% rehospitalization rate = 84
patients rehospitalized• 365 patients at 18% rehospitalization rate = 62• 22 patient decrease = $120,934 annualized savings
Coleman, E.A., Parry, C, Chalmers, S., & Min, S. (2006). The care transitions intervention results of a randomized control trial. Archives of Internal Medicine 166 1822-1828.
BarriersBarriers
■ Difficult to get patients to accept program
– Overwhelmed
– Don’t need
– Have support
■ Difficult to get patients to accept program
– Overwhelmed
– Don’t need
– Have support
Lessons LearnedLessons Learned
■ Identify as a component of delivery system ■ Enhanced visibility in community■ If developing other models that are similar
keep CTI data separate■ Work with care providers in other arenas to
enhance program■ Work with PCP and hospitalists together and
separate to enhance buy – in
■ Identify as a component of delivery system ■ Enhanced visibility in community■ If developing other models that are similar
keep CTI data separate■ Work with care providers in other arenas to
enhance program■ Work with PCP and hospitalists together and
separate to enhance buy – in
Patient PerceptionPatient Perception
“Thank you for visiting me in my home…this is a good, helpful program“
“Thank you for visiting me in my home…this is a good, helpful program“
"It's so nice to have all this support to keep me in the comfort of my home"
"Thank you so much for your time, concern and patience…I've never had this kind of support"
“Really helps me understand what my medications are and if I need to talk to the Doctor about them”
“Thanks for helping me feel more confident in making my doctor appts”
ConclusionsConclusions
■ CTI increases patient self management■ CTI decreases hospital readmissions■ CTI cost effective and simple to
implement
■ CTI increases patient self management■ CTI decreases hospital readmissions■ CTI cost effective and simple to
implement
ReferencesReferences■ Boling, P.A., (2009). Care transitions and home health care. Clinical Geriatric Medicine 25 135-148.■ Care Transitions Program (2007). Business plan. Retrieved from Colorado_Business_Plan_2009.pdf■ Care Transitions Program (2007). CTI Evidence and Adoptions. Retrieved from
http://www.caretransitions.org/documents/Evidence_and_Adoptions_2.pdf■ Coleman, E.A., Parry, C, Chalmers, S., & Min, S. (2006). The care transitions intervention results of a
randomized control trial. Archives of Internal Medicine 166 1822-1828.■ Coleman, E.A., Smith, J.D., Frank, J.C., Min, S. Parry, C. & Kramer, A.M. (2004). Preparing patients
and caregivers to participate in care delivered across settings the care transitions intervention. Journal American Geriatric Association 52 1817-1825.
■ Colorado Foundation for Medical Care (2010). About the theme: opportunities for improving care transitions. Retrieved from http://www.cfmc.org/caretransitions/about.html
■ Jencks, S.F., Williams, M.V. & Coleman, E.A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. The New England Journal of Medicine 360(14) 1418-1428.
■ Medicare Innovations Collaborative (2011). Models of Care – Transitional care. Retrieved from http://www.med-ic.org/pages/care.html
■ Parrish, M.M, O’Malley, K., Adams, R.I., Adams, S.R. & Coleman, E.A. (2009). Implementation of the care transitions intervention sustainability and lessons learned. Professional Case Management 14(6) 282-293.
■ Whelan, D.J., Greiner, M.A., Schulman, K.A., & Curtis, L.H. (2010) Costs of inpatient care among Medicare beneficiaries with heart failure, 2001 to 2004. Circ Cardiovasc Qual Outcomes 3 33-40.
■ Boling, P.A., (2009). Care transitions and home health care. Clinical Geriatric Medicine 25 135-148.■ Care Transitions Program (2007). Business plan. Retrieved from Colorado_Business_Plan_2009.pdf■ Care Transitions Program (2007). CTI Evidence and Adoptions. Retrieved from
http://www.caretransitions.org/documents/Evidence_and_Adoptions_2.pdf■ Coleman, E.A., Parry, C, Chalmers, S., & Min, S. (2006). The care transitions intervention results of a
randomized control trial. Archives of Internal Medicine 166 1822-1828.■ Coleman, E.A., Smith, J.D., Frank, J.C., Min, S. Parry, C. & Kramer, A.M. (2004). Preparing patients
and caregivers to participate in care delivered across settings the care transitions intervention. Journal American Geriatric Association 52 1817-1825.
■ Colorado Foundation for Medical Care (2010). About the theme: opportunities for improving care transitions. Retrieved from http://www.cfmc.org/caretransitions/about.html
■ Jencks, S.F., Williams, M.V. & Coleman, E.A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. The New England Journal of Medicine 360(14) 1418-1428.
■ Medicare Innovations Collaborative (2011). Models of Care – Transitional care. Retrieved from http://www.med-ic.org/pages/care.html
■ Parrish, M.M, O’Malley, K., Adams, R.I., Adams, S.R. & Coleman, E.A. (2009). Implementation of the care transitions intervention sustainability and lessons learned. Professional Case Management 14(6) 282-293.
■ Whelan, D.J., Greiner, M.A., Schulman, K.A., & Curtis, L.H. (2010) Costs of inpatient care among Medicare beneficiaries with heart failure, 2001 to 2004. Circ Cardiovasc Qual Outcomes 3 33-40.
Questions?Questions?
