Presentation on theme: "Transitional Care Programme Evaluation – The Singapore Experience"— Presentation transcript:
1 Transitional Care Programme Evaluation – The Singapore Experience 12th April 2013Dr Patsy ChowDr Loong Mun WongDr Jason CheahAgency for Integrated Care
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 Transitional Care – Innovation Abounds There are many innovative models of transitional care delivery; some more well established than others.Some examples in the USThe Care Transitions Intervention®The Transitional Care Model (TCM)Project REDProject BOOSTAustraliaNo 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 careReference: The Australian Government. National Evaluation of the Transition Care Program. Final Evaluation Report
4 Some Classical ModelsThe Care Transitions Intervention® spearheaded by Dr Eric A. ColemanAims to empower patients/care-givers to assume greater and active role in self management as they transit across settings4-week programme led by Transitions Coach®The Four Pillars®Medication self managementDynamic patient-centric health recordTimely primary care/specialist care follow-upKnowledge of ‘red flags’ and appropriate responsesThe Transitional Care Model (TCM) by Dr Mary D. Naylor8 -12 week programme directed by Advanced Practice NursesPatient assessment and development of care plan begin within 24 hours of hospital admissionRegular home visits with telephonic support (7 days a week) after dischargeFirst post discharge visit with the physician accompanied by the Transitional Care NurseInterdisciplinary approach; close collaboration with physician
5 Defining Transitional Care in Singapore 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.ObjectivesTo 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 featuresTime-limitedCoordinates services according to individualised care plansHandover to community based partners for follow-up care
6 Transitional Care Initiatives in Singapore Existing programmes can be broadly classified into two categories:Predominantly Care CoordinationPredominantly Skilled Care InterventionsCaters to patients with complex social care needs and those at risk of functional declineTargets at patients with higher level of acuity in terms of physical care needsEmphasis rests on care coordination and patient/caregiver empowermentFocuses on direct intervention or care provision (e.g. medical, nursing, functional, pharmaceutical)Minimal provision of direct skilled careLess emphasis on care coordination activitiesFOCFees for serviceAll are hospital-led at present (3 in total)E.g. Aged Care Transition TeamThe first transitional care pilot in Singapore inspired by The Care Transitions Intervention®The most mature programme by farDemonstrates positive resultsE.g. Post Acute Care at HomeSlightly more advanced in development compared to the other hospital-led TC programmesTC feesDoctor: $75 (subsidised) or $160 (full paying) Nurse: $40 (subsidised) or $85 (full paying) Therapist: $50 (subsidised) or $110 (full paying)hospital
7 Aged Care Transition (ACTION) Teams ACTION is a government funded project started in 2008.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 Patient Screening Criteria of ACTION Elderly above the age of 65 yrsMultiple co-morbiditiesPolypharmacyImpaired mobility or significant functional declineImpaired self care skillsPoor cognitive statusLives alone or has poor social supportCatastrophic/Chronic illness and injury with anticipated long term health care needsMultiple admissions / ED visits over the last 6 monthsNote: Provision of 80/20 rule for exceptions (e.g. young patients)
9 ACTION Process Hospital Community High-risk hospital inpatients AdmissionDischargeAbout 1-3 months post dischargeScreening high-risk patientsAssessment of needsReferral to appropriate ILTC servicesDevelop and implement care planGoal setting and evaluation of care plansACTION TeamCare CoordinatorsNurses, Social workers, Allied health professionalsHigh-risk hospital inpatientsResidential Facility e.g. community hospitalHome with supporting servicesDay rehabilitation servicesHome Medical & Home nursing servicesSocial support servicesTelephone follow up, home visit and assessmentOptimize a patient’s self-care capabilities at homeCaregiver education and supportMonitoring of high risk clientsHand-off to other services
10 Mixed-Method Evaluation Approach Administrative data analysis
11 ACTION Clients are Elderly and Frail Based on 2009Q1 to 2011 Q2 administrative database (N=14,025)Patient profile is heterogeneous across sites77% above 70 years old38% are main carer of themselves65% taking > 5 medications72% have 3 or more co-morbidities27% with history of >1 fallSource: RHIME Administrative Data Analysis
12 Does ACTION Reduce Hospital Utilisation? Retrospective case-control study to compare the number of readmissions and ED visits within 6 months after index hospitalisationCases from ACTION cohort (Feb 09 - Jul 10)Controls were selected from MOH Casemix and Subvention DatabaseInclusion criteria – at least 1 of the following≥3 diagnosesAt 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 hospitalisationExclusion criteriaSocial over-stayer / absconderAge <65yNon-subsidised patientsData fields extracted from the Casemix database include-age, gender, date of index hospital admission, primary diagnosis, length of stay, Charlson Co-Morbidity Index, no. and dates of hospitalizations and ED visits within 6 month.Data was extracted in a de-identified form and analysed in MOH’s Microdata Lab
13 Statistical AnalysisPropensity score weighting was done to adjust for selection bias based on these covariates:AgeGenderLength of initial hospital stayCharlson Co-Morbidity IndexNo. of hospitalisation in the 180 days preceding index hospital admission and ED attendanceNo. of ED attendance in the 180 days preceding index hospital admissionPropensity score-weighted logistic regression was done to obtain respective adjusted outcomes.Propensity score = predicted probability that a given patient will be enrolled into ACTION program conditional on covariates.
14 Baseline Characteristics of Clients (after weighting by propensity score) ACTION (N=4132)Control (N=4132)P-valueAge (years)Mean (SD)79.2 (7.7)-GenderMale1795 (43.5%)1797 (43.5%)Female2335 (56.5%)2333 (56.5%)Charlson Index1.6 (1.8)1.5 (1.8)0.37Length of stay (days)11.6 (13.0)11.1 (15.4)0.25Past Hospitalisation historyNo. of admissions within 180 days before index hospitalisation0.79 (1.4)0.81 (1.4)0.51Patients with ≥ 1 admission within 180 days before index hospitalisationn (%)1731 (41.9%)1847 (44.7%)0.014No. of 180-day ED attendances within 180 days before index hospitalisation1.9 (2.0)1.9 (3.1)0.89Patients with ≥ 1 attendance within 180 days before index hospitalisation4004 (96.9%)3781 (91.5%)<0.001Based on results as at 19th Jan 2012ACTION patients-were old (mean age 79.2y),-had relatively long hospital stay (mean 11.6 days)After propensity adjustment, the characteristics (demographic, length of the index hospital stay, comorbidity burden, and pre-index hospitalization admissions) of ACTION and control group are similar except the proportion of patients with prior ED visits (ACTION 96.9% vs Controls 91.5%).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 admissionSource: RHIME-MOH Comparison with Comparator Group
15 Comparison Results – Readmission (Unplanned) ACTION (N= 4132)Control (N=4132)P-valueUnplanned readmission after hospital dischargeReadmission within 15 daysn411879<0.001Patients with ≥ 1 readmission within 15 daysn (%)413 (10.0)880 (21.3)Readmission within 30 days6461148Patients with ≥ 1 readmission within 30 days644 (15.6)1148 (27.8)Readmission within 180 days15642130Patients with ≥ 1 readmission within 180 days1843 (37.9)2074 (51.6)Solely unplanned readmissions10.0% of ACTION clients were readmitted at least once within 15 days post discharge, 15.6% within 30 days and 37.9% within 180 days.Comparing ACTION clients and controls(i) The total number of unplanned readmissions for ACTION clients are significantly lower than that of the control group within 15 days, 30 days and 180 days after discharge.(ii) A (statistically) significantly lower proportion of ACTION clients were readmitted within 15 days, 30 days and 180 days after discharge compared to the control grp.-15-days readmission (ACTION 10.0% vs. Controls 21.3%)-30-days readmission (ACTION 15.6% vs. Controls 27.8%)-180-days readmission (ACTION 37.9% vs. Controls 51.6%)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 admissionSource: RHIME-MOH Comparison with Comparator Group
16 Comparison Results - ED Attendance ACTION (N= 4132)Control (N=4132)P-valueED attendance after hospital dischargeED attendance within 30 daysn9921240Mean (SD)0.24 (0.62)0.30 (0.73)0.002Patients with ≥ 1 ED attendance within 30 daysn (%)797 (19.3)950 (23.0)<0.001ED attendance within 180 days380145450.92 (2.0)1.1 (3.1)0.052Patients with ≥ 1 ED attendance within 180 days1913 (46.3)2021 (48.9)0.027Based on results as at 19th Jan 201219.3% of ACTION clients visited ED at least once within 30 days post discharge and 46.3% within 180 days.The mean number of ED visits were however very small (0.24 within 30 days and 0.92 within 180 days)Comparing ACTION clients and controls(i) A (statistically) significantly lower proportion of ACTION clients visited ED within 30 days after discharge compared to the control grp.-ED visit within 30-days (ACTION 19.3% vs. Controls 23.0%)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 admissionSource: RHIME-MOH Comparison with Comparator Group
17 Adjusted Odds Ratio (95% CI) Comparison ResultsACTION 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.Odds ratios of hospital readmission and ED attendance - ACTION vs. Controls (after weighting by propensity score)OutcomeAdjusted Odds Ratio (95% CI)P-valueReadmissionwithin 15 days0.5 (0.4, 0.5)<0.001within 30 days0.5 (0.5, 0.6)within 180 days0.6 (0.6, 0.7)ED attendance0.81 (0.72, 0.90)0.90 (0.82, 0.99)0.027Unplanned re-admPropensity 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 admissionSource: RHIME-MOH Comparison with Comparator Group
18 ACTION Clients are More Likely to be Readmission-Free Hazard ratio (95% CI) = 1.3 ( ), P<0.001Hazard ratio of 1.3 means that an ACTION client who has not yet been readmitted by a certain time (within the 180 days time frame) has 1.3 times the chance of remaining admission-free and staying in the community at the next point in time compared to someone in the control group.Within 180d post-discharge, 889 (21.5%) deaths in ACTION and 670 (13.6%) deaths in Control grp.Source: RHIME-MOH Comparison with Comparator Group
19 Estimated Cost Savings Estimating cost savings from the difference in reduced hospital days and programme implementation costsACTION saved 6283 bed days of unplanned admissions over 6 monthsEstimated S$5.3m saved from these reduced bed daysOperational 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 monthsAssumes no net additional healthcare cost used by ACTION care recipients compared to the control group**.While we did not obtain actual expenditures in this evaluation, cost savings from public health system’s perspective could be estimated from the difference in hospital day and incremental program costs.Beds days saved = reduced unplanned hospitalizations 6mths x average length of stay* =6283 daysCost savings = 6283 x average cost for C-class bed per day (2009 figure) = 6283 x 842=$5.3m*assume same LOS in index admission (propensity adjusted)**Assumes no net additional healthcare cost by ACTION care recipients compared to the control group.We think assumption is reasonable given that we did not consider savings from reduced ED visits for ACTION care recipients, that ACTION care recipients did not receive any residential care, were not on any other hospital programs, and were not likely to incur additional primary care and community care costs compared to a control group of similar conditions.The only likely addition cost to ACTION care recipients and their family would be additional equipment and home modifications as well as set up cost (only CCIT as minimal capita cost set at hospital)Notwithstanding a careful cost effectiveness analyses, our demonstration program appeared to deliver good value for money.
20 More Evaluation of ACTION ACTION clients/ caregivers were surveyed in Feb/ Mar 2011 after discharge from serviceExclusionThose who lodged a hospital complaintSocial overstayerCognitively impaired without a caregiverThose transferred to community hospital/ inpatient in rehabilitation ward/ sub-acute ward/ sheltered home/ nursing home1st interview: 1 week post-dischargeHealth-Related QoL (EQ-5D)2nd interview: 4-6 weeks post-dischargeCare Transitions Measure (CTM-15), Health-Related QoL (EQ-5D), satisfaction ratings451 completed both surveys70% of responses by caregiver proxySource: RHIME-IMH Survey
21 Quality of Care Transition CTM-15 measures four domainsInformation transferPatient and caregiver preparationSelf-management supportEmpowerment to assert preferencesTotal score ranges from 0 to100Higher scores indicate better transitionOverall mean CTM-15 score of surveyed clients/ caregivers was 63.8.Source: RHIME-IMH Survey
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)5 dimensions – MOBILITY, SELF-CARE, USUAL ACTIVITIES , PAIN / DISCOMFORT and ANXIETY / DEPRESSIONI have no problem.. I have slight problem.. I have moderate problem.. I have severe problem.. I have extreme problem … Interview 1Interview 2‘Self’-rated health(0=worst health, 100=best health)60.464.1P<0.05Source: RHIME-IMH Survey
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 excellentSource: RHIME-IMH Survey
24 Conclusion of ACTION Analysis 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 ratingsFindings confirmed the effectiveness of the Care Transition Intervention in Singapore’s public health system.
25 Post Acute Care at Home (PACH) A tertiary hospital pilot programme that delivers transitional care to patients that requires multi disciplinary team interventions post dischargeKey objective include:Reducing unnecessary ED attendance and readmissions and hence burden on hospital resourcesServices provided are time limited with an average duration of3 monthsEncourages handover of patient management to the community whenever possibleThe hospital had conducted the first phase of its evaluation to assess the effectiveness of the programme
26 Initial Results: Bed Days Saved 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, fromED visits and readmission averted through timely response by team to urgent calls made by clientsManagement 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 homeFacilitation of timely discharge from acute hospital through the provision of post discharge supportAIC 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.Source: PACH Administrative Data Analysis
27 Challenges of Current TC Programmes 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 programmesPatients were not keen to be enrolled into such community programmes due to high out-of-pocket chargesDifficulties in recovering cost from patients and hence services were highly subsidised by hospitalsProblems in discharging patients to community partners who are not well-equippedLimitations in performing robust evaluation by hospitals due to lack of access to comprehensive data
28 Moving ForwardExpansion of ACTION service in other segments such as specialist outpatient clinics and EDACTION teams will collaborate and align more closely with other local projects within respective hospitalsRevision of funding model for hospital-led TC programmes to ensure affordability and sustainabilityA 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
29 AcknowledgementACTION Managers, ACTION Care Coordinators, ACTION Clinical Champions and ACTION Heads of AH, CGH, NUH, KTPH, TTSH, SGH, NHC, RCCH, SLH, AMKCH, SACH and BVHColleagues from Health Services Research and Health Information Department, Ministry of HealthColleagues from Research Division, Institute of Mental HealthDr Ian Leong, PACH Programme Director, TTSHDr Wong LM, Chief, CID, AICMs Polly Cheung, Deputy Chief, CID, AICDr Wee Shiou Liang, Head (RHIME), AICColleagues from Regional Integration Office, AICMOH and AIC Management
30 ReferencesColeman 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 ReportThe 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: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:
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