transitional care workgroup

Download Transitional Care Workgroup

Post on 28-Nov-2014

394 views

Category:

Health & Medicine

0 download

Embed Size (px)

DESCRIPTION

July 12, 2013 slide presentation for the Transitional Care Workgroup Meeting.

TRANSCRIPT

  • 1. Transitional Care Workgroup Meeting July 12, 2013 1
  • 2. Welcome and Introductions Chad Boult, MD, MPH, MBA Program Director, Improving Healthcare Systems 2
  • 3. Housekeeping: Providing Input Todays webinar participants can provide input via e-mail (transitionalcare@pcori.org); 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 transitionalcare@pcori.org. 3
  • 4. What Research Questions Are Within PCORIs 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. 4
  • 5. 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. 5
  • 6. Introductions: Moderators 6 Trent Haywood, MD, JD Chief Medical Officer, Blue Cross and Blue Shield Doris Lotz, MD, MPH Medicaid Medical Director, State of New Hampshire
  • 7. 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 Managers7
  • 8. Background on Transitional Care Workgroup Lynn Disney, PhD, JD, MPH Senior Program Officer, Improving Healthcare Systems 8
  • 9. 9 How We Select Targeted Research Topics
  • 10. 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 PanelApril 19-20, 2013 10Link to PCORI WebsiteFull Description
  • 11. PCORI Advisory Panel on IHS Prioritized Five Research Topics 11 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
  • 12. 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 12
  • 13. 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. 13
  • 14. 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 14
  • 15. 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. 15
  • 16. Core Components of Effective Interventions 16 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
  • 17. Core Components of Effective Interventions 17 Citation Self management support Comprehensive medication management Use of Information Technology 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 Heart Failure) Wakefield et al., 2008 +
  • 18. Effects on Health, Quality of Life and Patients Care Experience 18 Citation Health Quality of life Patients Care Experiences Care Transitions Program Coleman et al., 2006 Parry et al., 2009 NS Chronically Critically Ill Daly et al., 2005 NS Project RED Jack et al., 2009 + Transitional Care Model Naylor et al., 1994 Naylor et al., 1999 Naylor et al., 2004 NS NS NS + + NS + Congestive Heart Failure Rich et al., 1995 NS + Telehealth (with HF) Wakefield et al., 2008 NS +
  • 19. Effects on Healthcare Resource Use 19 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 Care Transitions Program Coleman et al., 2006 Parry et al., 2009 + (3 mo) + (3 mo) Chronically Critically Ill Daly et al., 2005 NS NS + (2 mo) Project RED Jack et al., 2009 +(1 mo) + Transitional Care Model Naylor et al., 1994 Naylor et al., 1999 Naylor et al., 2004 + (1.5 mo) + (6 mo) + (12 mo) NS + (6 mo) + (12 mo) + (1.5 mo) + (6 mo) NS NS NS + Congestive Heart Fail

Recommended

View more >