The Transitional Care Model for Older Adults Transitional Care Model for Older Adults Mary D. Naylor,

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  • The Transitional Care Model for Older AdultsMary D. Naylor, PhD, RNMarian S. Ware Professor in GerontologyDirector, NEWCOURTLAND CENTER FOR TRANSITIONS AND HEALTHUniversity of Pennsylvania, School of Nursing

    National Health Policy ForumWashington, DC April 3, 2009

  • Transitional Care Transitional care range of time limited

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

  • Context for Transitional Care:Acute Care Episode

    Adapted from the National Quality Forum committee on Measurement Framework: Evaluating Efficiency across Episodes of Care

  • Quality Cost Transitional Care Model (TCM)

    Engaging Elder/Caregiver

    Managing Symptoms

    Educating/Promoting

    Self-Management

    Assuring Continuity

    CoordinatingCare

    MaintainingRelationship

    Screening

    Collaborating

  • 5

    Unique Features

    Care is delivered and coordinatedby same TC nurse

    in hospitals, SNFs, and homes

    7 days per week/mean of 2 months

    using evidence-based protocol

    with focus on long term outcomes

  • Core ComponentsHolistic, person/family centered approachProtocol guided, streamlined care Team model; shared accountabilitySingle point person across episode of careInformation/communication systems that span settings

  • 7

    Findings from Randomized Clinical Trials To Date

    Funding: National Institutes of Health, National Institute of Nursing Research, National Institute on Aging (1990-2010)

  • 8

    Across all RCTs, TCM has

    Increased time to first readmission or deathImproved physical function and quality of life*Increased patient satisfactionDecreased total all-cause readmissionsDecreased total health care costs

    *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.

  • 10

    * 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 2

    6

    w

    eeks

    **at

    52

    wee

    ks**

    *

    Dollars (US)

    TCM's Impact on Total Health Care Costs*

    TCM Group

    Control Group

  • Translating TCM into Practice

    Penn research team formed partnerships with Aetna Corporation and Kaiser Permanente to test real world applications of research-based model of care for high risk elders.

    Funded by The Commonwealth Fund and the following Foundations: Jacob and Valeria Langeloth, The John A. Hartford, Inc., Gordon & Betty Moore, and California HealthCare; guided by National Advisory Committee (NAC)

  • National Advisory Committee

    VHA

    Penn Home Care & Hospice Services

    http://www.aarp.org/http://www.cms.hhs.gov/http://www.ncqa.org/http://www.medicarerights.org/index.htmlhttp://www.pacificare.com/commonPortal/application;JSESSIONID_CP=LGCNcnyTV5FRdr29hk0r366Qz0SjkTJhdJGzfJLGzJCcdSkvMP7k!781660123!-549409331?namespace=pacificareGateway&origin=pacificareHeader.jsp&event=link.starthttp://pennhealth.com/

  • Tools of Translation

    Patient screening and recruitment Web-based modules to orient nurses

    Documentation and quality monitoring via clinical information system (CIS)

    Quality improvement (case conferences and CIS)

    Evaluation

  • Value =Health Resource Utilization/Costs

    Environment: Ongoing chronic care management programs.

    Question: Does the Transitional Care Model offer greater value in this environment?

    Quality/Satisfaction

  • 15

    Progress to Date Aetna identified as high value proposition; expansion proposed as part of Aetnas 2009 Strategic PlanKaiser data collection/analyses ongoingUniversity of Pennsylvania Health System adopted TCM (Blue Cross reimbursing)QIOs working w/States to implement TCM

  • 16

    Barriers to Wide Scale AdoptionOrganization of current care system

    Regulatory issues

    Lack of quality and financial incentives

    Challenges current practice culture

  • Acknowledgements

    Research team, nurses and staffNewCourtland Center for Transitions and HealthTranslation PartnersFunders

    www.transitionalcare.info

  • Thank You!

    Slide Number 1Transitional Care Context for Transitional Care:Acute Care Episode Quality Cost Transitional Care Model (TCM)Slide Number 5Core ComponentsFindings from Randomized Clinical Trials To DateAcross all RCTs, TCM hasSlide Number 9Slide Number 10Translating TCM into PracticeSlide Number 12Tools of TranslationValue =Progress to Date Barriers to Wide Scale AdoptionSlide Number 17Slide Number 18AcknowledgementsThank You!