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1 Transitional Care Programme Evaluation – The Singapore Experience 12 th April 2013 Dr Patsy Chow Dr Loong Mun Wong Dr Jason Cheah.

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Presentation on theme: "1 Transitional Care Programme Evaluation – The Singapore Experience 12 th April 2013 Dr Patsy Chow Dr Loong Mun Wong Dr Jason Cheah."— Presentation transcript:

1 1 Transitional Care Programme Evaluation – The Singapore Experience 12 th April 2013 Dr Patsy Chow Dr Loong Mun Wong Dr Jason Cheah Agency for Integrated Care

2 2 2 What is Transitional Care? “Care transitions” refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. In its position statement in 2003, the American Geriatrics Society defined transitional care as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location”. Source: Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society. 2003;51(4):

3 3 3 Transitional Care – Innovation Abounds There are many innovative models of transitional care delivery; some more well established than others. Some examples in the US  The Care Transitions Intervention ®  The Transitional Care Model (TCM)  Project RED  Project BOOST Australia  No single standard model as long as programme satisfies the legislative guidelines linked to The Aged Care Act 1997: “A form of flexible care provided to an older person at the end of an inpatient hospital episode in the form of a package of services that includes at least low intensity therapy and either nursing support or personal care”  Emphasises on transitions between acute and community care Reference: The Australian Government. National Evaluation of the Transition Care Program. Final Evaluation Report

4 4 The Care Transitions Intervention® spearheaded by Dr Eric A. Coleman Aims to empower patients/care-givers to assume greater and active role in self management as they transit across settings 4-week programme led by Transitions Coach ® The Four Pillars ®  Medication self management  Dynamic patient-centric health record  Timely primary care/specialist care follow-up  Knowledge of ‘red flags’ and appropriate responses The Transitional Care Model (TCM) by Dr Mary D. Naylor week programme directed by Advanced Practice Nurses  Patient assessment and development of care plan begin within 24 hours of hospital admission  Regular home visits with telephonic support (7 days a week) after discharge  First post discharge visit with the physician accompanied by the Transitional Care Nurse  Interdisciplinary approach; close collaboration with physician 4 Some Classical Models

5 5 Transitional care initiatives are nascent in Singapore; most are in pilot phase. Transitional care (TC) in our local context is defined as care and/or services to support patients’ transfer from the acute care to community setting. Objectives  To support post discharge patients to transit from hospital to community by streamlining and coordinating care services.  To optimise patients’ outcomes following an episode of illness.  To minimise hospital utilisation by facilitating timely discharge and reducing unnecessary hospital readmissions and/or ED visits. Key features  Time-limited  Coordinates services according to individualised care plans  Handover to community based partners for follow-up care 5 Defining Transitional Care in Singapore

6 6 Existing programmes can be broadly classified into two categories: 6 Transitional Care Initiatives in Singapore Predominantly Care Coordination Predominantly Skilled Care Interventions Caters to patients with complex social care needs and those at risk of functional decline Targets at patients with higher level of acuity in terms of physical care needs Emphasis rests on care coordination and patient/caregiver empowerment Focuses on direct intervention or care provision (e.g. medical, nursing, functional, pharmaceutical) Minimal provision of direct skilled care Less emphasis on care coordination activities FOCFees for service All are hospital-led at present (3 in total) E.g. Aged Care Transition Team The first transitional care pilot in Singapore inspired by The Care Transitions Intervention® The most mature programme by far Demonstrates positive results E.g. Post Acute Care at Home Slightly more advanced in development compared to the other hospital-led TC programmes

7 7 ACTION is a government funded project started in Aged Care Transition (ACTION) Teams Aim: To help patients make a safe and smooth transition from hospitals into their homes or community, by streamlining and coordinating care services to optimise patients’ outcomes throughout and after an episode of illness. Scale:  81 care coordinators in 6 Restructured Hospitals (RHs), 1 Tertiary Centre & 5 Community Hospitals.  More than 28,731 patients recruited since 2008.

8 8 8 Patient Screening Criteria of ACTION Elderly above the age of 65 yrs Multiple co-morbidities Polypharmacy Impaired mobility or significant functional decline Impaired self care skills Poor cognitive status Lives alone or has poor social support Catastrophic/Chronic illness and injury with anticipated long term health care needs Multiple admissions / ED visits over the last 6 months Note: Provision of 80/20 rule for exceptions (e.g. young patients)

9 9 HospitalCommunity AdmissionDischarge About 1-3 months post discharge Screening high-risk patients Assessment of needs Referral to appropriate ILTC services Develop and implement care plan Goal setting and evaluation of care plans ACTION Team Care Coordinators Nurses, Social workers, Allied health professionals High-risk hospital inpatients Residential Facility e.g. community hospital Home with supporting services Day rehabilitation services Home Medical & Home nursing services Social support services Discharge Telephone follow up, home visit and assessment Optimize a patient’s self-care capabilities at home Caregiver education and support Monitoring of high risk clients Hand-off to other services ACTION Process 9

10 10 Mixed-Method Evaluation Approach Administrative data analysis

11 11 ACTION Clients are Elderly and Frail 77% above 70 years old 38% are main carer of themselves 65% taking > 5 medications 72% have 3 or more co-morbidities Patient profile is heterogeneous across sites Based on 2009Q1 to 2011 Q2 administrative database (N=14,025) Source: RHIME Administrative Data Analysis 27% with history of >1 fall

12 12 Does ACTION Reduce Hospital Utilisation? Retrospective case-control study to compare the number of readmissions and ED visits within 6 months after index hospitalisation Cases from ACTION cohort (Feb 09 - Jul 10) Controls were selected from MOH Casemix and Subvention Database Inclusion criteria – at least 1 of the following  ≥3 diagnoses  At least 1 of these diseases: diabetes, hypertension, hyperlipidemia, dementia, COPD, stroke and schizophrenia  ≥1 hospitalisation or ED visit in past 6 months prior to index hospitalisation Exclusion criteria  Social over-stayer / absconder  Age <65y  Non-subsidised patients

13 13 Statistical Analysis Propensity score weighting was done to adjust for selection bias based on these covariates:  Age  Gender  Length of initial hospital stay  Charlson Co-Morbidity Index  No. of hospitalisation in the 180 days preceding index hospital admission and ED attendance  No. of ED attendance in the 180 days preceding index hospital admission Propensity score-weighted logistic regression was done to obtain respective adjusted outcomes.

14 14 Baseline Characteristics of Clients (after weighting by propensity score) Source: RHIME-MOH Comparison with Comparator Group ACTION (N=4132)Control (N=4132)P-value Age (years) Mean (SD)79.2 (7.7) - Gender Male1795 (43.5%)1797 (43.5%)- Female2335 (56.5%)2333 (56.5%)- Charlson Index Mean (SD)1.6 (1.8)1.5 (1.8)0.37 Length of stay (days) Mean (SD)11.6 (13.0)11.1 (15.4)0.25 Past Hospitalisation history No. of admissions within 180 days before index hospitalisation Mean (SD)0.79 (1.4)0.81 (1.4)0.51 Patients with ≥ 1 admission within 180 days before index hospitalisation n (%)1731 (41.9%)1847 (44.7%)0.014 No. of 180-day ED attendances within 180 days before index hospitalisation Mean (SD)1.9 (2.0)1.9 (3.1)0.89 Patients with ≥ 1 attendance within 180 days before index hospitalisation n (%)4004 (96.9%)3781 (91.5%)<0.001 Propensity score used to adjust for Age, Gender, Charlson’s index, Length of Stay, Number of admissions in 180 days prior to index admission, Number of ED attendances in 180 days prior to index admission

15 15 Comparison Results – Readmission (Unplanned) Propensity score used to adjust for Age, Gender, Charlson’s index, Length of Stay, Number of admissions in 180 days prior to index admission, Number of ED attendances in 180 days prior to index admission Source: RHIME-MOH Comparison with Comparator Group ACTION (N= 4132)Control (N=4132)P-value Unplanned readmission after hospital discharge Readmission within 15 days n411879<0.001 Patients with ≥ 1 readmission within 15 days n (%)413 (10.0)880 (21.3)<0.001 Readmission within 30 days n <0.001 Patients with ≥ 1 readmission within 30 days n (%)644 (15.6)1148 (27.8)<0.001 Readmission within 180 days n <0.001 Patients with ≥ 1 readmission within 180 days n (%)1843 (37.9)2074 (51.6)<0.001

16 16 Comparison Results - ED Attendance Propensity score used to adjust for Age, Gender, Charlson’s index, Length of Stay, Number of admissions in 180 days prior to index admission, Number of ED attendances in 180 days prior to index admission Source: RHIME-MOH Comparison with Comparator Group ACTION (N= 4132)Control (N=4132)P-value ED attendance after hospital discharge ED attendance within 30 days n Mean (SD)0.24 (0.62)0.30 (0.73)0.002 Patients with ≥ 1 ED attendance within 30 days n (%)797 (19.3)950 (23.0)<0.001 ED attendance within 180 days n Mean (SD)0.92 (2.0)1.1 (3.1)0.052 Patients with ≥ 1 ED attendance within 180 days n (%)1913 (46.3)2021 (48.9)0.027

17 17 Comparison Results Propensity score used to adjust for Age, Gender, Charlson’s index, Length of Stay, Number of admissions in 180 days prior to index admission, Number of ED attendances in 180 days prior to index admission Odds ratios of hospital readmission and ED attendance - ACTION vs. Controls (after weighting by propensity score) ACTION patients significantly less likely to be readmitted, and less likely to visit ED. The odds of unplanned readmission within 15, 30 and 180 days for ACTION patients are lower than the odds for control patients. The odds of ED attendance of ACTION clients within 30 days are lower than that of controls. Source: RHIME-MOH Comparison with Comparator Group OutcomeAdjusted Odds Ratio (95% CI)P-value Readmission within 15 days0.5 (0.4, 0.5)<0.001 within 30 days0.5 (0.5, 0.6)<0.001 within 180 days0.6 (0.6, 0.7)<0.001 ED attendance within 30 days0.81 (0.72, 0.90)<0.001 within 180 days0.90 (0.82, 0.99)0.027

18 18 Hazard ratio (95% CI) = 1.3 ( ), P<0.001 ACTION Clients are More Likely to be Readmission-Free Source: RHIME-MOH Comparison with Comparator Group

19 19 Estimated Cost Savings Estimating cost savings from the difference in reduced hospital days and programme implementation costs ACTION saved 6283 bed days of unplanned admissions over 6 months  Estimated S$5.3m saved from these reduced bed days Operational cost of ACTION programme over six months (Apr to Sep 2010) was S$1.94m (>95% the care coordinators’ salary) Hence overall cost savings = S$3.4m over 6 months Assumes no net additional healthcare cost used by ACTION care recipients compared to the control group **.

20 20 ACTION clients/ caregivers were surveyed in Feb/ Mar 2011 after discharge from service Exclusion Those who lodged a hospital complaint Social overstayer Cognitively impaired without a caregiver Those transferred to community hospital/ inpatient in rehabilitation ward/ sub-acute ward/ sheltered home/ nursing home 1 st interview: 1 week post-discharge Health-Related QoL (EQ-5D) 2 nd interview: 4-6 weeks post-discharge Care Transitions Measure (CTM-15), Health-Related QoL (EQ-5D), satisfaction ratings 451 completed both surveys 70% of responses by caregiver proxy More Evaluation of ACTION Source: RHIME-IMH Survey

21 21 Quality of Care Transition CTM-15 measures four domains Information transfer Patient and caregiver preparation Self-management support Empowerment to assert preferences Total score ranges from 0 to100 Higher scores indicate better transition Overall mean CTM-15 score of surveyed clients/ caregivers was Source: RHIME-IMH Survey

22 22 Perception in Health-Related QoL (EQ-5D) Analysed for surveys completed by same person (n=296) Higher proportion reported having ‘no problems’ at 4-6 weeks for all 5 dimensions (P<0.05) Interview 1Interview 2 ‘Self’-rated health (0=worst health, 100=best health) P<0.05 Source: RHIME-IMH Survey

23 23 Majority were Satisfied with ACTION 70% rated ACTION service overall as good or excellent. 68% rated care and concern shown by ACTION care coordinators as good or excellent. 63% rated knowledge of care coordinators as good or excellent (N=451) Source: RHIME-IMH Survey

24 24 The ACTION, a hospital-based transitional care program, significantly reduced acute care utilization for up to 6 months post discharge. Improved care recipient well-being, and positive responses to quality of care transition and service satisfaction ratings Findings confirmed the effectiveness of the Care Transition Intervention in Singapore’s public health system. 24 Conclusion of ACTION Analysis

25 25 A tertiary hospital pilot programme that delivers transitional care to patients that requires multi disciplinary team interventions post discharge Key objective include:  Reducing unnecessary ED attendance and readmissions and hence burden on hospital resources Services provided are time limited with an average duration of 3 months Encourages handover of patient management to the community whenever possible The hospital had conducted the first phase of its evaluation to assess the effectiveness of the programme 25 Post Acute Care at Home (PACH)

26 26 Based on the analysis of administrative database of PACH client cohort (Apr 11 – Dec 11), 2.9 bed-days can potentially be saved per patient, from  ED visits and readmission averted through timely response by team to urgent calls made by clients  Management of certain conditions at home (which in the absence of PACH would have led to hospital admissions), e.g.  Behavioural problems from persons with dementia staying at home  Facilitation of timely discharge from acute hospital through the provision of post discharge support AIC and Ministry of Health will work with the hospital on the second phase of the evaluation in acquiring mortality and health service utilisation data to facilitate further analysis. 26 Initial Results: Bed Days Saved Source: PACH Administrative Data Analysis

27 27 There are currently 3 hospital-led transitional care programmes that provide multidisciplinary interventions to help patients transit from hospitals to community. Common challenges faced by this category of TC programmes Patients were not keen to be enrolled into such community programmes due to high out-of-pocket charges Difficulties in recovering cost from patients and hence services were highly subsidised by hospitals Problems in discharging patients to community partners who are not well-equipped Limitations in performing robust evaluation by hospitals due to lack of access to comprehensive data 27 Challenges of Current TC Programmes

28 28 Expansion of ACTION service in other segments such as specialist outpatient clinics and ED ACTION teams will collaborate and align more closely with other local projects within respective hospitals Revision of funding model for hospital-led TC programmes to ensure affordability and sustainability A unified evaluation will be conducted under the oversight of AIC and Ministry of Health to assess programme outcomes in-depth. Emergence of new hybrid models taking reference from, for instance Project BOOST and UK Virtual Ward 28 Moving Forward

29 29 ACTION Managers, ACTION Care Coordinators, ACTION Clinical Champions and ACTION Heads of AH, CGH, NUH, KTPH, TTSH, SGH, NHC, RCCH, SLH, AMKCH, SACH and BVH Colleagues from Health Services Research and Health Information Department, Ministry of Health Colleagues from Research Division, Institute of Mental Health Dr Ian Leong, PACH Programme Director, TTSH Dr Wong LM, Chief, CID, AIC Ms Polly Cheung, Deputy Chief, CID, AIC Dr Wee Shiou Liang, Head (RHIME), AIC Colleagues from Regional Integration Office, AIC MOH and AIC Management 29 Acknowledgement

30 30 Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4): The Australian Government. National Evaluation of the Transition Care Program. Final Evaluation Report The Care Transitions Program [Internet]. [Cited 2013 Feb 18]. Available from: Health Workforce Solutions LLC and Robert Wood Johnson Foundation. Transitional Care Model [Internet] [cited 2013 Feb 18]. Available from: Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomised controlled trial. Arch of Int Med. 2006;166: Coleman EA. The care transitions intervention [Internet]. [Cited 2013 Feb 20]. Available at: %20CFMC.pdf Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalised with heart failure: a randomised, controlled trial. JAGS. 2004;65: References

31 31 Thank you


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