the carol hogue lectureship may 5, 2010

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The Carol Hogue Lectureship May 5, 2010 Duke University School of Nursing & University of North Carolina Chapel Hill Mary D. Naylor, PhD, RN, FAAN Mary D. Naylor, PhD, RN, FAAN Marian S. Ware Professor in Marian S. Ware Professor in Gerontology Gerontology Director, NewCourtland Center for Director, NewCourtland Center for Transitions and Health Transitions and Health University of Pennsylvania School of University of Pennsylvania School of Nursing Nursing

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The Transitional Care Model:. Translating Research Into Practice and Policy. 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. - PowerPoint PPT Presentation

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The Carol Hogue Lectureship May 5, 2010Duke University School of Nursing & University of North Carolina Chapel Hill

Mary D. Naylor, PhD, RN, FAANMary D. Naylor, PhD, RN, FAANMarian S. Ware Professor in GerontologyMarian S. Ware Professor in GerontologyDirector, NewCourtland Center for Transitions Director, NewCourtland Center for Transitions and Healthand HealthUniversity of Pennsylvania School of NursingUniversity of Pennsylvania School of Nursing

Perspectives on Chronic Illness Perspectives on Chronic Illness Care in the USCare in the US

Older Adult

Family Caregiver

Society

Mr. Jenkins & his FamilyMr. Jenkins & his Family

Transitional CareTransitional Care

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

The Case for Transitional CareThe 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

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

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

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

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

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

Recommended ApproachRecommended 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

Quality Cost Transitional Care Model (TCM)

Unique FeaturesUnique Features

Care is delivered and coordinatedCare is delivered and coordinated

…by same advanced practice nurse

…in hospitals, SNFs, and homes

…seven days per week

…using evidence-based protocol

…with focus on long termlong term outcomes

Naylor MD, Brooten D, Jones R, Lavizzo-Mourey R, Mezey MD, & Pauly M. Comprehensive discharge planning for the hospitalized elderly. Ann Intern Med. 1994; 120:999-1006.

Could we improve Could we improve outcomes for older outcomes for older

adults and their adults and their caregivers by caregivers by

enhancing the quality enhancing the quality of hospital discharge of hospital discharge

planning? planning?

National Institute of Nursing ResearchR01NR02095, (1989-1992)

What if we targeted high-risk patients What if we targeted high-risk patients and and

added a home care component?added a home care component?National Institute of Nursing ResearchR01NR02095, (1992-1997)

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.

Would a comprehensive Would a comprehensive intervention targeting intervention targeting their complex needs, their complex needs, improve outcomes for improve outcomes for

elders elders hospitalized with heart hospitalized with heart

failure? failure? National Institute of Nursing Research R01NR04315, (1997-

2001)

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.

Applying the Model toApplying the Model to

Mr. Jenkins & his FamilyMr. Jenkins & his Family

Core Components Core Components

Holistic, person/family centered approach

Nurse-led, team model Protocol guided, streamlined care Single “point person” across episode

of care Information/communication systems

that span settings

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

Increased time to first readmission or death

Improved physical function and quality of life*

Increased patient satisfaction Decreased total all-cause readmissions Decreased total health care costs

*Most recently completed RCT only*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.

* 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 26

weeks**

at 52

weeks**

*

Dollars (US)

TCM's Impact on Total Health Care Costs*

TCM Group

Control Group

Barriers to Widespread Barriers to Widespread Adoption Adoption

Organization of current system of care

Regulatory barriers Lack of quality and financial incentives

Culture of care

Translating TCM into PracticeTranslating TCM into Practice

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

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

National Advisory CommitteeNational Advisory Committee

VHAVHA

Penn Home Care & Hospice Services

Project Goals (Aetna)Project Goals (Aetna)

Test TCM in defined market Document facilitators and barriers

Provide for ongoing NAC input Present findings to Aetna decision makers

Widely disseminate findings

Tools of TranslationTools of Translation

Patient screening and recruitment

Orientation of nurses (web-based modules)

Documentation and quality monitoring (clinical information system) 

Quality improvement (case conferences grounded in root cause analysis)

Evaluation

Key Indicators of SuccessKey Indicators of Success

Decisions by Aetna re: adoption Decisions 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 geriatric telephonic care management

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

Quality/SatisfactionQuality/Satisfaction

FindingsFindings

Improvements in all quality measures

Increased patient and physician satisfaction

Reductions in rehospitalizations through 3 months

Cost savings of $2170 per member per month thru one year

All significant at p <.05

TCM as TCM as High Value High Value Proposition Proposition for Aetnafor Aetna

High Quality High Quality

+ Satisfaction+ Satisfaction

Reductions Reductions in Acute in Acute

ReadmissionReadmissions (Costs)s (Costs)

==

Building a Translational Building a Translational RoadmapRoadmap

Semi-structured, interviews by independent consultant following start-up and roll-out phases

Analysis of transcripts to identify common facilitators, barriers and lessons learned

Key LessonsKey Lessons

Strong champions Fit of the innovation Importance of the business case Responsiveness to external climate Total engagement Flexibility Clearly defined role/work processes Excellent communication

Progress to Date Progress to Date

AetnaAetna – expansion proposed as part of Aetna’s Strategic Plan

KaiserKaiser – data collection/analyses ongoing

University of Pennsylvania Health University of Pennsylvania Health SystemSystem – adopted TCM (Blue Cross reimbursing)

QIOsQIOs – working with NJ and NY Other health care providers

Ongoing EffortsOngoing Efforts

Advancing the scienceAdvancing the science Promoting widespread Promoting widespread

adoption of TCM adoption of TCM Using findings to promote Using findings to promote

policy changespolicy changes

Would cognitively impaired Would cognitively impaired hospitalized older adults and hospitalized older adults and

their caregivers benefit their caregivers benefit from TCM? from TCM?

Funding: Marian S. Ware Alzheimer Program, and National Institute on Aging, R01AG023116, (2005-2010)

What do we know about What do we know about effects effects

of transitions in health among of transitions in health among

elderly long-term care elderly long-term care

recipients over time? recipients over time?

Funding: Rand-Hartford Center for Interdisciplinary Geriatric Health Care Research (2005-2008); National Institute on Aging, National Institute of Nursing Research, R01AG025524, (2006-2011)

Promoting AdoptionPromoting Adoption

Sample strategiesSample strategies: : national and international collaborations and consultations, website, media efforts

Selected outcomesSelected outcomes: : endowed center; featured in Wall Street Journal, Washington Post, PBS, NPR; AAN Edge Runner, AHRQ Health Care Innovations, RWJF Innovative Care Models, NQF Best Practice

Influencing Health PolicyInfluencing Health Policy

Sample strategiesSample strategies: : Policy briefs, Congressional testimony, Hill and MedPAC briefings

Selected outcomesSelected outcomes:: Medicare Transitional Care Act

(S.1295, and H.R. 2773) Provisions re: transitional care in

current health care bill

National Institute of Nursing ResearchNational Institute of Nursing Research National Institute on AgingNational Institute on Aging Presbyterian Foundation for PhiladelphiaPresbyterian Foundation for Philadelphia Marian S. Ware Alzheimer’s Program, PennMarian S. Ware Alzheimer’s Program, Penn National Alzheimer’s AssociationNational Alzheimer’s Association The Commonwealth FundThe Commonwealth Fund Jacob & Valeria Langeloth FoundationJacob & Valeria Langeloth Foundation The John A. Hartford Foundation, Inc.The John A. Hartford Foundation, Inc. Gordon & Betty Moore FoundationGordon & Betty Moore Foundation California HealthCare FoundationCalifornia HealthCare Foundation

Univ. of Pennsylvania Health SystemUniv. of Pennsylvania Health SystemIndependence Blue Cross of PhiladelphiaIndependence Blue Cross of PhiladelphiaAetna CorporationAetna CorporationKaiser PermanenteKaiser PermanenteCMS QIOsCMS QIOs

MarMark k PaulPaulyy

KathryKathryn n BowleBowless KathleeKathlee

n n McCauleMcCauleyy

Ellen Ellen KurtzmaKurtzmann

SandySandySchwarSchwartztz

Greg Greg MaisliMaislinn

With Gratitude and With Gratitude and ThanksThanks

It does take a village…

Katherine AbbottLucinda Bertsinger

M. Brian BixbyLaura DiGiovanni

Janice FoustBinh Ha

Karen HirschmanDavid Jiang

Heidi KaputskaJoAnne Konick-McMahan

Laura LechtenbergJessica MacLeodEllen McPartland

SarahLena PanzerJanet Prvu BettgerJonathan SnyderJanet Van CleaveMichelle Whetzel

Christina WhitehouseTamora Williams

www.transitionalcare.info