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Translating Research Into Practice. The Transitional Care Model. Mary D. Naylor, PhD, RN, FAAN Marian S. Ware Professor in Gerontology Director, NewCourtland Center for Transitions and Health University of Pennsylvania School of Nursing. TCM010 – Unit 1March 19, 2013. - PowerPoint PPT Presentation
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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