Mary D. Naylor, PhD, RNMary D. Naylor, PhD, RNMarian S. Ware Professor in GerontologyMarian S. Ware Professor in GerontologyDirector, NewCourtland Center for Transitions and HealthDirector, NewCourtland Center for Transitions and HealthUniversity of Pennsylvania, School of NursingUniversity of Pennsylvania, School of Nursing

The Transitional Care Model:The Transitional Care Model:Translating Research into PracticeTranslating Research into PracticeDevelopment and Translation of the Transitional Care Model for Older Adults

January 28, 2009

Transitional Care Transitional Care

Transitional careTransitional care – range of time – range of time limited services and environments limited services and environments designed to ensure health care designed to ensure health care continuity and avoid preventable poor continuity and avoid preventable poor outcomes among at risk populations outcomes among at risk populations as they move from one level of care to as they move from one level of care to another, among multiple providers another, among multiple providers and/or across settings. and/or across settings.

Context for Transitional CareContext for Transitional CareAcute Care Episode: Acute Care Episode:

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

The Case for Transitional CareThe Case for Transitional Care

High rates of medical errors High rates of medical errors

Serious unmet needsSerious unmet needs

Poor satisfaction with carePoor satisfaction with care

High rates of preventable High rates of preventable readmissionsreadmissions

Tremendous human and cost burdenTremendous human and cost burden

Different Goals of Different Goals of Evidence-Based InterventionsEvidence-Based Interventions

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

Address “root causes” of poor Address “root causes” of poor outcomes with focus on longer-term, outcomes with focus on longer-term, positive outcomespositive outcomes

Quality Cost Quality Cost Transitional Care Model (TCM)Transitional Care Model (TCM)

Engaging Elder/Caregiver

Managing Symptoms

Educating/Promoting

Self-Management

Assuring Continuity

CoordinatingCare

MaintainingRelationship

ScreeningScreening

CollaboratingCollaborating

Unique Features Unique Features

Care is delivered and Care is delivered and coordinatedcoordinated

……by same nurseby same nurse

……across settingsacross settings

……7 days per week 7 days per week

……using evidence-based protocolusing evidence-based protocol

……with focus on long term outcomeswith focus on long term outcomes

Findings from Randomized Findings from Randomized Clinical TrialsClinical Trials

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

Transitional Transitional Care ModelCare ModelProtocol OverviewProtocol Overview

Across RCTs, TCM has Across RCTs, TCM has consistently…consistently…

Increased time to first rehospitalizationIncreased time to first rehospitalization Decreased total all-cause rehospitalizationsDecreased total all-cause rehospitalizations Increased patient satisfactionIncreased patient satisfaction Improved physical function and quality of Improved physical function and quality of

lifelife** Decreased total health care costsDecreased total health care costs

*Most recently completed RCT only*Most recently completed RCT only

Barriers to Adoption Barriers to Adoption

Organization of current system of careOrganization of current system of care

Lack of quality and financial incentivesLack of quality and financial incentives

Culture of careCulture of care

Translating TCM into PracticeTranslating TCM into Practice

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

Project Goals (Aetna)Project Goals (Aetna)

Test TCM in defined marketTest TCM in defined market Document facilitators and barriersDocument facilitators and barriers Provide for ongoing NAC inputProvide for ongoing NAC input Present findings to Aetna decision Present findings to Aetna decision

makersmakers Widely disseminate findingsWidely disseminate findings

Tools of TranslationTools of Translation

Patient screening and recruitmentPatient screening and recruitment

Orientation of TCNs Orientation of TCNs (web-based modules)

Documentation and Quality Monitoring Documentation and Quality Monitoring (clinical information system - CIS) 

Quality improvement Quality improvement (case conferences and CIS)

EvaluationEvaluation

Integrating TCM within Aetna

Project teamProject team Key decisionsKey decisions

Link to geriatric case management Link to geriatric case management programprogram

Partner with home care agencyPartner with home care agency Target 200 members in mid-Atlantic Target 200 members in mid-Atlantic

regionregion Clearly define roles and work flow Clearly define roles and work flow

processesprocesses

Key Indicators of SuccessKey Indicators of Success

Decisions by Aetna re: adoptionDecisions by other insurers and

providers to implement model Use of findings by CMS and insurers to

reimburse evidence-based transitional care

ValueValue ==Health Resource Health Resource

Utilization (Costs)Utilization (Costs)

Environment: Extant comprehensive system of telephonic care management

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

Quality/Satisfaction

Quality (N=172)Quality (N=172)

Significant improvements pre- and post-Significant improvements pre- and post-TCM in the following outcomes:TCM in the following outcomes:

self-reported health status (1 item)self-reported health status (1 item) symptom status (Symptom Bother Scale)*symptom status (Symptom Bother Scale)* depression (Geriatric Depression Scale)depression (Geriatric Depression Scale) functional status (SF-12) functional status (SF-12) quality of life (one item)quality of life (one item)

*improvements in 10/13 symptoms at p <0.05*improvements in 10/13 symptoms at p <0.05

SatisfactionSatisfaction

Members (N=171)Members (N=171) Overall high satisfaction - Mean of 3.0 on Overall high satisfaction - Mean of 3.0 on

each of the 15 survey items (1 low - 4 high)each of the 15 survey items (1 low - 4 high)

Physicians (N=25)*Physicians (N=25)* Overall high satisfaction with APN Overall high satisfaction with APN

involvement in members’ care – Mean of 3.5 involvement in members’ care – Mean of 3.5 on each of 10 survey items* (1 strongly on each of 10 survey items* (1 strongly disagree – 4 strongly agreedisagree – 4 strongly agree

** Satisfaction data from MDs with at least 3 TCM patients ** Satisfaction data from MDs with at least 3 TCM patients

Health Resource UtilizationHealth Resource Utilization

Quasi-experimental design simulating RCTQuasi-experimental design simulating RCT Each elder in TCM matched with “control”Each elder in TCM matched with “control” 155 pairs using stringent criteria (e.g., # of 155 pairs using stringent criteria (e.g., # of

comorbid conditions) were available for final comorbid conditions) were available for final HR analysesHR analyses

HR data obtained from Aetna’s claims’ HR data obtained from Aetna’s claims’ datasetdataset

Rehospitalization Rates*Rehospitalization Rates*

Significant reductions in readmission rates Significant reductions in readmission rates and hospital days through 3 monthsand hospital days through 3 months

0-3 months, 45 TCM vs. 60 controls (25% 0-3 months, 45 TCM vs. 60 controls (25% decrease; 99 fewer hospital days)decrease; 99 fewer hospital days)

0-6 months, 104 TCM vs. 112 controls0-6 months, 104 TCM vs. 112 controls 0-12 months, 184 TCM vs. 203 controls0-12 months, 184 TCM vs. 203 controls

**ED rates similar (85 TCM vs. 81 controls at 12 mos.)ED rates similar (85 TCM vs. 81 controls at 12 mos.)

Skilled Nursing Facility RatesSkilled Nursing Facility Rates

Trend toward reduced SNF admissions Trend toward reduced SNF admissions between TCM vs. controlsbetween TCM vs. controls

0-3 months, 5 TCM vs. 11 controls0-3 months, 5 TCM vs. 11 controls 0-6 months, 14 TCM vs. 22 controls0-6 months, 14 TCM vs. 22 controls 0-12 months, 26 TCM vs. 38 controls 0-12 months, 26 TCM vs. 38 controls

Skilled Home Care VisitsSkilled Home Care Visits

Trend toward decreased use of home Trend toward decreased use of home visits for TCM vs. controlsvisits for TCM vs. controls

0-3 months, 252 TCM vs. 436 controls0-3 months, 252 TCM vs. 436 controls 0-6 months, 393 TCM vs. 728 controls0-6 months, 393 TCM vs. 728 controls 0-12 months, 658 TCM vs. 1153 controls0-12 months, 658 TCM vs. 1153 controls

TCN Visits TCN Visits

Mean # of home visits = 7.26 (2-19); mean Mean # of home visits = 7.26 (2-19); mean length = 50 minuteslength = 50 minutes

Mean # of MD office visits = 0.7 (0-3); Mean # of MD office visits = 0.7 (0-3); mean length = 62 minutesmean length = 62 minutes

Mean # of patient phone calls = 7.82; Mean # of patient phone calls = 7.82; mean length = 8 minutesmean length = 8 minutes

Costs

Significant reductions in total health Significant reductions in total health care costs through 3 months; care costs through 3 months; savings continue thru 12 monthssavings continue thru 12 months

$439 PMPM savings at 3 months$439 PMPM savings at 3 months $181 PMPM savings at 12 months $181 PMPM savings at 12 months

Factors Considered in Factors Considered in Interpreting FindingsInterpreting Findings

Hospital component of TCM was not Hospital component of TCM was not implemented in applying model with implemented in applying model with Aetna’s membersAetna’s members

Regional variations in service useRegional variations in service use Comparison group obtained from Comparison group obtained from

region with 20% region with 20% lowerlower utilization rate utilization rate than mid-Atlantic regionthan mid-Atlantic region

TCM as High TCM as High Value Value

Proposition Proposition for Aetnafor Aetna

High Quality High Quality + +

SatisfactionSatisfaction

Reductions Reductions in Acute in Acute

Readmissions Readmissions (Costs)(Costs)

==

Progress to DateProgress to Date

TCM proposed for expansion as part of TCM proposed for expansion as part of

Aetna’s 2009 Strategic PlanAetna’s 2009 Strategic Plan Kaiser enrollment complete; data Kaiser enrollment complete; data

analyses ongoinganalyses ongoing University of Pennsylvania Health University of Pennsylvania Health

System has adopted TCM; Blue Cross System has adopted TCM; Blue Cross

plans to reimburse for its membersplans to reimburse for its members

Next Steps for Penn TeamNext Steps for Penn Team

Continue efforts to promote Continue efforts to promote widespread adoption of TCM widespread adoption of TCM

Use findings to promote needed policy Use findings to promote needed policy changeschanges

Continue to build the scienceContinue to build the science

How can we improve post-How can we improve post-discharge outcomes for discharge outcomes for hospitalized cognitively hospitalized cognitively

impaired elders?impaired elders?

Funding: Marian S. Ware Alzheimer Program, and Funding: Marian S. Ware Alzheimer Program, and National Institute on Aging (2005-2010)National Institute on Aging (2005-2010)

How can we improve How can we improve transitions of elders in transitions of elders in

LTC to and from LTC to and from hospitals?hospitals?

Funding: Rand-Hartford Center for Interdisciplinary Funding: Rand-Hartford Center for Interdisciplinary Geriatric Health Care Research (2005-2008); Geriatric Health Care Research (2005-2008); National Institute on Aging, National Institute of National Institute on Aging, National Institute of Nursing Research (2006-2011)Nursing Research (2006-2011)

AcknowledgementsAcknowledgements

Research team, nurses and staffResearch team, nurses and staff NewCourtland Center for Transitions NewCourtland Center for Transitions

and Healthand Health Translation PartnersTranslation Partners FundersFunders

www.transitionalcare.infowww.transitionalcare.info

Thank You!Thank You!