transitional care workgroup

Transitional Care Workgroup Meeting July 12, 2013

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Welcome and Introductions Chad Boult, MD, MPH, MBA Program Director, Improving Healthcare Systems

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Housekeeping: Providing Input

Today’s webinar participants can provide input via e-mail ([email protected]); via Twitter (#PCORI); or the webinar “chat” feature.

Please submit questions today, as they occur to you. We will collect and synthesize these for discussion at 12:45 p.m. (ET).

We welcome additional input through July 19, 2013, at 5:00 p.m. (ET) via e-mail [email protected].

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mailto:[email protected]


What Research Questions Are Within PCORI’s Mandate?

PCORI funds studies that compare the benefits and harms of two or more approaches to care. Cost effectiveness: PCORI will consider the measurement of factors that may differentially affect patients’ adherence to the alternatives, such as out-of-pocket costs, but it cannot fund studies related to cost-effectiveness or the costs of treatments or interventions. Disease processes and causes: PCORI cannot fund studies that focus on risk factors, origins, or mechanisms of disease.

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How PCORI Manages the Potential for Conflict of Interest

The researchers, patients, and stakeholders who have been invited to this workgroup will be involved in the process of determining the specific subject areas that we should address in a PCORI Funding Announcement (PFA).

The broader community of researchers, patients, and other stakeholders who are participating by web, Twitter, and chat can be involved as well.

Participants in this workgroup are eligible to apply for funding if PCORI decides to produce a funding announcement studying models of transitional care. The Moderators of this workgroup will not be eligible to apply for funding under this PFA. Input received during the workgroup deliberations will be broadcast via webinar, and the webinar will be archived and made available to other researchers, patients, and stakeholders via the PCORI website.

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Introductions: Moderators

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Trent Haywood, MD, JD

Chief Medical Officer, Blue Cross and Blue Shield

Doris Lotz, MD, MPH

Medicaid Medical Director, State of New Hampshire

Introductions: Workgroup Members

Leah Binder, MA, MGA – Purchasers

Tara A. Cortes RN, Ph.D. – Home Healthcare

Jeffrey Delafuente, MS, FCCP, FASCP – Pharmacists

Gretchen Dickson, MD, MBA – Family Practitioners

Eric E. Howell, MD – Hospitalists

Elizabeth (Libby) Hoy – Patients

James E. Lett II, MD, CMD – Patient Advocacy

Mary D. Naylor, PhD, FAAN, RN – Researchers

Shelley Price, MS, FHIMSS – Healthcare Information Technology

Erin Rand-Giovannetti, PhD, MPH – Researchers

John Schall, MPP – Caregivers

David Schulke – Hospitals/Health Systems

Sara J. Singer, PhD, MBA – Researchers

Nancy Skinner, RN-BC, CCM – Case Managers

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Background on Transitional Care Workgroup Lynn Disney, PhD, JD, MPH Senior Program Officer, Improving Healthcare Systems

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How We Select Targeted Research Topics

Evolution of the Topic

1,000+ research topics collected

841 accepted 308 assigned to Improving Healthcare Systems (IHS) program

Program director screened, consolidated, and rated topics

89 resulted from program director screening and were scored

15 scored highest and selected for advisory panel consideration Topic briefs commissioned for all 15 topics Reviewed and ranked by IHS Advisory Panel—April 19-20, 2013

10 Link to PCORI Website—Full Description

http://www.pcori.org/funding-opportunities/funding-announcements/from-research-questions-to-research-funding-about-our-topic-generation-and-research-prioritization-process/

PCORI Advisory Panel on IHS Prioritized Five Research Topics

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TOP TWO • Models of Transitional Care

• Models of Patient-Empowering Care Management NEXT THREE • Features of Health Insurance Coverage

• Co-location of Mental Health and Primary Health Care

• Models of Perinatal Care Management

Setting the Stage— Current State of Evidence Mary D. Naylor, PhD, FAAN, RN Marian S. Ware Professor in Gerontology and Director of the NewCourtland Center for Transitions and Health, University of Pennsylvania, School of Nursing

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Transitional Care: Meaning of Concept

Transitional care – range of time limited services and environments that 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 health care team members and across settings such as hospitals to homes.

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The Case for Transitional Care

Patients’ poor ratings of experiences with healthcare system Serious unmet needs reported by patients and family caregivers High rates of preventable medical errors and associated poor outcomes Tremendous human burden

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Transitional Care: Published Evidence

21 clinical trials of diverse innovations focused on chronically ill older adults 9 of 21 studies reported positive impact on health outcomes and reductions in preventable rehospitalizations Effective interventions: Extended from hospital to home Offered multiple solutions Relied on teams (including patients) with nurses as

“coordinator” Naylor MD, Aiken LH, Kurtzman ET, Olds DM, & Hirschman KB. (2011). THE CARE SPAN -- The Importance of Transitional Care in Achieving Health Reform. Health Affairs, 30(4):746-754.

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Core Components of Effective Interventions

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Citation

Comprehensive assessment, care

planning

Interactions with post acute, community

clinicians

Coordination/ referrals for

community services

Care Transitions Program Coleman et al., 2006 Parry et al., 2009

— —

+ +

— —

Chronically Critically Ill Daly et al., 2005

+ + +

Project RED Jack et al., 2009

+ + —

Transitional Care Model Naylor et al., 1994 Naylor et al., 1999 Naylor et al., 2004

+ + +

+ + +

+ + +

Congestive Heart Failure Rich et al., 1995

+ — +

Telehealth (with HF) Wakefield et al., 2008

— — —

Core Components of Effective Interventions

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Citation Self management

support

Comprehensive medication

management

Use of Information Technology


+ +

+ +

— —


— + —


+ +


+ + +

+ + +

+ + +


— + —

Telehealth (with Heart Failure) Wakefield et al., 2008

+ — —

Effects on Health, Quality of Life and Patients’ Care Experience

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Citation Health Quality of life

Patients’ Care Experiences


— NS

— —

— —


NS — —


+ — —


NS NS NS

— — +

+

NS +


NS

+

—


NS

+

—

Effects on Healthcare Resource Use

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Citation Total readmissions,

all cause (no. of months)

Time to first readmission

(no. of months)

Length of readmission stay (no. of months)

Other resource

use


+ (3 mo) + (3 mo)

— —

— —

— —


NS NS + (2 mo) —


+(1 mo) — — +


+ (1.5 mo) + (6 mo)

+ (12 mo)

NS

+ (6 mo) + (12 mo)

+ (1.5 mo) + (6 mo)

NS

NS NS +


+ (3 mo)

—

+ (3 mo)

—


+ (12 mo)

+ (12 mo)

NS

NS

Examples of Unanswered Questions That Could Build Upon This Evidence

What are common triggers of major health transitions? (e.g., decline in function, death of spouse) What transitional care outcomes matter most to patients (e.g., trust, achieving their health goals, functional status, quality of life)? To their family caregivers? How do we consistently measure them? What risk stratification strategies are effective at identifying who will benefit most from transitional care approaches of different intensities?

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Unanswered Questions

How can behavioral health be more effectively incorporated into transitional care? How can transitions between hospitals and homes be better aligned with primary care and community organizations? What components of effective transitional care interventions are most valuable? Which models are most effective? Which tools/technologies are most helpful? What is the impact potential on various patient or community subgroups? (e.g., people with low health literacy or advanced illness, communities with fewer resources)

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Unanswered Questions

How can transitional care approaches more effectively engage patients and family caregivers and promote shared decision making? What are the unique transitional care needs of family caregivers? How can their needs be best addressed? Can transitional care evidence be extended to improve palliative care outcomes? What are the facilitators and barriers to successful implementation of effective transitional care?

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Measuring Patient-Centered Outcomes Sara J. Singer, PhD, MBA Assistant Professor, Harvard University, School of Public Health Erin Rand-Giovannetti, PhD, MPH Research Scientist, National Committee for Quality Assurance

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How a Question Becomes a Measure

Identify what

matters Develop a framework

Draft measures

Test the measures

Use the measures

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Refine

Refine

What Matters?

Scan the literature Talk to stakeholders Identify gaps Gap 1: Just because structures and services are

integrated doesn’t mean that patients receive integrated care.

Gap 2: Patients and loved ones deliver care too. Their needs, preferences, and responsibilities are part of needs to be integrated.

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Develop a Framework That Describes What Matters

Aim to be comprehensive and mutually exclusive

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Things that matter Coordination within your provider’s office

Coordination across your providers / with your hospital

Coordination by your provider of care at home

Familiarity over time

Help with care before, after, and outside of office visits

Patient-centered care

Support for patient’s role in caregiving

--Singer et al., Patient Perception of Integrated Care (PPIC) Survey

Develop Specific Questions to Measure What Matters

Borrow or craft items that address your framework Check that questions are attributable and actionable Balance number and type

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Things that matter Coordination within your provider’s office

Coordination across your providers / with your hospital

Coordination by your provider of care at home

Familiarity over time

Help with care before, after, and outside of office visits

Patient-centered care

Support for patient’s shared-responsibility

Questions that measure them After your most recent hospital stay, did anyone from your provider’s office contact you to ask about the condition you were in the hospital for?

--Singer et al., Patient Perception of Integrated Care (PPIC) Survey

Test, Refine and Use the Survey

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In the last 6 months, how often did this provider discuss whether the care you were receiving matched your

values and preferences?

In the last 6 months, how often did this provider discuss whether you were getting the health care you wanted?


Before using a survey Do patients understand intended meaning of the questions? Is the survey too long? Refine

Pilot-test the survey with a small group of patients Do groups of questions represent coherent concepts? Are the concepts distinct from each other? Do measures differentiate providers? Is there room for improvement?

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Do measures relate to things that should be related? Refine

Retest repeat

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Clinical and financial

outcomes

Patient perceptions of integrated

care

Integrated organizations and activities

Provide rapid feedback of results Teach/learn Act/refine Repeat


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0%

20%

40%

60%

80%

100%

% A

lway

s

How often did you get a timely answer to your medical question

after hours?

Importance and Evidence for Outcomes

Importance Importance to individual Importance to health of population

Evidence Evidence that outcome leads to well-being for individuals Logic for how the outcome can be influenced by the

intervention Ex: Person-centered goal achievement – Percent of individuals who make progress towards a self-defined goal?

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Scientific Soundness of Measure

Scientific Soundness Reliability: Measure results are repeatable Validity: Measure results are correct Meaningful difference

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Feasibility and Usability - Reality Check

Feasibility How do we actually capture the information we are

measuring? How do we capture the information for populations with

communication or cognitive limitations?

Usability Will the information gathered from the measure be useable

and worth the cost of measurement?

Ex: Person-centered goal achievement – Percent of individuals who make progress towards a self-defined goal?

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BREAK

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• Visit us at www.pcori.org • Follow @PCORI on Twitter • Watch our YouTube channel PCORINews

http://www.pcori.org/

Vignette

It is March 5, 2018, and Jane Smith is about to be discharged from Center Hospital, where she was diagnosed with several chronic conditions, which have left her unable to fully take care of herself. She will be leaving with several new medications and the hospitalist’s recommendation to “change your diet and activity level.” A new transitional care program has just been implemented at Center Hospital and is available to patients and caregivers, at their request.

Question for Workgroup Participants: From your current perspective (patient, caregiver, clinician, payer, etc.), what are three or four questions that you would want answered before deciding whether to participate in this transitional care program?

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Collaborative Workgroup Discussion

Focus: Provide targeted input without scientific jargon

Honor Timelines: Provide brief and concise presentations and comments

Participate: Encourage exchange of ideas among diverse perspectives that are present today: Researchers Patients Other stakeholders

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Workgroup Objectives: Narrowing the Broad Topic

Transitional care is a very broad concept The process today is to take this broad concept and: Understand it Determine which questions/issues are the most

important to all stakeholders Create a concise list of these high-priority

questions

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Questions from Patient and Stakeholder Perspectives

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LUNCH

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Comments Submitted by Others E-mail ([email protected]) Twitter (#PCORI) The webinar “chat” feature

Lauren Holuj, MHA Program Associate, Improving Healthcare Systems

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Discussion of Proposed Research Questions

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BREAK

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Refinement of Research Questions to be Addressed

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Recap and Next Steps

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We Still Want to Hear from You

We welcome your input on today’s discussions

We are accepting comments and questions for consideration on this topic through July 19, 5:00 p.m. (ET) via e-mail ([email protected])

We will take all feedback into consideration

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Thank You for Your Participation

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transitional care workgroup

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