1. Managing Care and Care Transitions Across the Long-Term Care Spectrum 1 Darryl Wieland, Christine S. Ritchie University of South Carolina/Palmetto Health Richland, University of Alabama at Birmingham (UAB) Birmingham/Atlanta VA GRECC 1 VA Geriatrics and Extended Care State-of-the Art Conference, “The Changing Face of Geriatrics and Extended Care: Meeting Veterans Needs in the Next Decade,” Washington DC, March 2008

2. Long-Term Care/Transitions Management: Which Patients, Program Models, Systems? “Rubenstein categories” JAGS 1984;32:503-12. “Rehabilitation” “Medical” “Geriatric” e.g. VA RMS Disease Management “Guided Care” } CCM in Managed Care, Medicare Advantage Palliative and Advanced Illness Care Models Care Transitions Intervention GEM and Other CGA/MGA Models PACE/AIC Models/HBPC Long-Term Community-Based LTC/NH Short-term LTC

3. Common Objectives in Managing Care and Care Transitions From hospital base, e.g.: –APN dc planning w home follow-up (Transitional Care Model); –Care Transitions Intervention GOALS: placement in community @ lowest sustainable level of care [LOC]; prevention of avoidable rehospitalization Managing Care and Care Transitions

4. Common Objectives in Managing Care and Care Transitions From community base, e.g.: –Geriatric care management team [e.g., GRACE, Guided Care, CARE]; –Day hospital, –Hospital-at-home, –PACE GOALS: preventing inpatient hospitalizations, rehospitalization, placement to higher LOC Managing Care and Care Transitions

5. Cochrane Review of Hospital-to-Home DC Planning (Shepperd 2004) –System, program & pt heterogeneity; uncertain impact on index LOS, rehospitalization, health, payments or margins/costs –Excluded GEM and some enhanced DC support team models U Penn Center for Evidence-Based Practice (draft—ms. in prep). –Most up-to-date & comprehensive; most evidence low-to-moderate quality; some support for electronic DC communications; daily ID team rounds pre-DC; pt educ.; inpt. intervention w HV/phone f-u Hospital-Based Program Models Managing Care and Care Transitions

6. Transitional Care Model (RCT) (Naylor 1999) –APN DC Planning with In-Home APN Follow-up –Targeted (at risk) elderly med-surg inpatients in 2 Medicare FFS hospitals –@ 24 wks: ↓ readmissions, multiple readmissions, hosp days/pt; ↑ time to readmission –Health outcomes not impacted; Medicare reimbursement reduced $0.6 million (50%). Transitional Care Model (RCT) (Naylor 2004) –Targeted 239 heart older failure pts in 6 hospitals; f-u to 52 wks. –Longer time to 1 st readm. or death; 1-yr readm rate lower; mean total costs 35%↓; short-term improvements in QoL, function, & satisfaction. Hospital-Based Program Models Managing Care and Care Transitions

7. Care Transitions Intervention (CCT, RCT)(Coleman 2004, 2006) –CTI includes cross-site comm. tools, pt. “activation,” “transition coach” –Older Medicare pts (>65) w target dxes, complex care needs, managed care system –↓ readmissions @ 30/60/90 days, ↑ pt confidence in info rec’d, comm. w team, understanding meds, hosp. costs lower at 180 days, net cost savings to plan Hospital-Based Program Models Managing Care and Care Transitions

8. Coordination and Advocacy for Rural Elderly [CARE] (pilot, descriptive) (Ritchie 2002) –VISN 7 G&EC demo – RN/SW teams performed in- home asmt on elderly at-risk (PRA+) rural vets; Laptop-based MDS-HC  problem list, plan, progress note –Care advocacy & referral/coordination/linkage to VA & non-VA svcs, pt/caregiver monitoring, education, support; follow-up visits x 6 mos. –Eight problems/pt identified; ⅔ referred to services; ½ to medical care; issues were coord. w 1º care and linkage w VA services, CARE discontinued due failure to earn workload credit Community-Based Models Managing Care and Care Transitions

9. Geriatric Resources for Assessment and Care of Elders [GRACE] (RCT)(Counsell 2007) –LT geri care management for multimorbid low income elderly in 1º care @ 6 FQHCs; –annual CGA by GRACE Support Team (APN/SW); –annual plan w larger interdisciplinary care team incl geriatrician, PharmD, PT, mental health SW, comm. svc liaison; team mtgs w 1º care MDs – plan implemented by support team & 1º care –Protocols for 12 targeted geriatric conditions: advance care plng, health maintenance, med mgmt, mobility imp/falls, pain, UI, depression, hearing & vision, malnutrition/wt loss, dementia, caregiver burden –Weekly interdisciplinary team meetings to review progress; ongoing support team home-based CM (>1/mo) w EMR, web- tracking Community-Based Models Managing Care and Care Transitions

10. GRACE (RCT)(Counsell 2007) OUTCOMES –@ 24 mos, improvements in 4/8 SF-36 subscales (general health, vitality, social fnct, MH) and Mental Component Sum. –↓ ED visits; ↓ ED visits & hospitalizations in 2 nd year for pre- defined “high risk” subgroup Community-Based Models Managing Care and Care Transitions

11. Guided Care (cluster RCT) (Boyd 2005, Boult 2008) –1º care + package of innovations for elderly patients w multiple chronic dxes @ high utilization risk (HCC model); pts in PCP groups were in Medicare A/B, MA, or TriCare plans –Specially trained RNs assigned to PCP pods provide comprehensive chronic care to panels of 50-60 pts. –Using web-accessible EMR, RN, with PCP collaboration, implements 8 key processes: in-home pt/caregiver multidimensional asmt, evidence-based care plan, promotes pt self-mgmt, monthly health monitoring, coaching healthy behaviors, managing care transitions, caregiver ed./support, coordinating access to comm. resources Community-Based Models

12. Guided Care (Boyd 2005, Boult 2008) OUTCOMES –@ 6 mos., GC pts twice as likely to rate their care “high-quality.” viz., ↑ satisf. ratings for Goal Setting, Coordination of Care, and Decision Support; n.s. trend to score higher Problem Solving performance [on Patient Asmt of Chronic Illness Care measure] –On Primary Care Assessment Tool, GC PCPs more satisfied w pt comm., family/caregiver comm., caregiver ed., motivating pts, and community resource referrals; improved also on knowledge of pt med taking. Community-Based Models Managing Care and Care Transitions

13. Program of All-Inclusive Care for the Elderly [PACE] / VA All-Inclusive Care Demo (pilot, descriptive) ( Weaver 2008) –PACE is federally-cap’d program for dual eligibles (Medicare/ Medicaid) aged >55 state-certified as requiring NH; –provides LT day-center based team mngt & 1º care, transport svcs, in-home care, hospitalization and NH care + under its cap’d rate; –multiple studies found PACE to improve sat., health outcomes, reduce hospitalizations, LT NH placement, & reduce Medic. payments. Community-Based Models Managing Care and Care Transitions

14. VA All-Inclusive Care Demo ( Weaver 2008) –AIC demonstrated 3 variants of PACE in VA for vets qualified using PACE criteria: (1) All VA svcs; (2) Blended “barter” model between VAMC & PACE site; (3) Full contract w PACE –Pilots demonstrated feasibility; pt. characteristics and utilization patterns varied by Model; all models improved access to particular svcs (reduced wait- times) and provided svcs otherwise unavailable; distribution of svcs & costs varied by model (3). Community-Based Models Managing Care and Care Transitions

15. Wrap Up Decades’ experience: how concern for care transitions arose from LT care coordination efforts. Patient-centered care hindered by care organization and financing in most care systems (US and elsewhere) AGS Position Statement on Transitional Care (5 positions) can be generalized to apply also to GCM ↑ role of assistive and information technologies Managing Care and Care Transitions

16. Wrap Up AGS Position Statement on Transitional Care (Coleman, Boult 2003) can be generalized to apply also to GCM: –…professionals must prepare clients…for care across settings, [involving them in] decisions related to all LT and boundary-crossing care. –Multidirectional comm. among clinicians is essential to high quality TC/GCM. –Develop policies to promote quality TC/GCM. –Education to all involved clinicians re: TC/GCM (would add increase workforce) –↑ research to improve TC/GCM processes

17. Evaluation of new consumer & healthcare technologies Smart houses Personal devices (PDA, cells etc.) Broadband & wireless comm. Digital video etc. Sensors & remote monitoring Personal MRs/EMRs ePrescribing/DM/Clin Trials Tele-health/medicine Improvement of medical devices Call centers and web technologies Managing Care and Care Transitions

18. References Rubenstein L, Wieland D, English P, et al. The Sepulveda VA GEU: Data on four-year outcomes and predictors of improved patients outcomes. JAGS 1984;32:503-12. Shepperd S, Parkes J, McClaren J et al. Discharge planning from hospital to home. Cochrane Data Syst Rev 2004;(1):CD000313. Naylor M, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA 1999;281:613-20. Naylor M, Brooten D, Campbell R et al. Transitional care of older adults hospitalized with heart failure. JAGS 2004;52:675-684. Coleman E, Smith J, Frank J, et al. Preparing patients and caregivers to participate in care delivered across settings: The Care Transitions Intervention. JAGS 2004;52:1817-25. Coleman E, Parry C, Chalmers S, et al. The Care Transitions Intervention: Results of a randomized controlled trial. Arch Intern Med 2006;166:1822-8. Managing Care and Care Transitions

19. References II Ritchie C, Wieland D, Tully C, et al. Coordination and Advocacy for Rural Elders [CARE]: A model of rural case management with veterans. Gerontologist 2002;42:399-405. Counsell S, Callahan C, Clark D, et al. Geriatric care management for low- income seniors: A randomized controlled trial. JAMA 2007;298:2623-33. Boyd C, Shadmi E, Conwell L, et al. The effect of Guided Care on quality of care. JAGS 2005;53:S205. Boult C, Reider L, Frey K, et al. The early effects of “Guided Care” on the quality of health care for multi-morbid older persons: A cluster-randomized controlled trial. J Gerontol A Biol Sci Med Sci 2008;63(3). Weaver F, Hickey E, Hughes S, et al. Providing all-inclusive care for frail elderly veterans: Evaluation of three models of care. JAGS 2008;56:345-53. Coleman E, Boult C, AGS Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs (AGS Position Statement). JAGS 2003;51:556-7. Managing Care and Care Transitions