Care Transitions Models and Key Technologies for Patients in the Home Lynn Redington, DrPH, MBA Senior Program Director Center for Technology and Aging Remington’s 9 th Annual Forecasting Think Tank Summit St. Pete, Florida March 13, 2011

Center for Technology and Aging  Established in 2009 with funding from The SCAN Foundation, located at the Public Health Institute  Mission: Expand the use of technologies that help older adults lead healthier lives and maintain independence  Independent, non-profit resource center on issues related to diffusion of technology for older adults  Technology Diffusion Grants Programs  e.g., Tech4Impact grant (Technologies for Improving Post-Acute Care Transitions “Tech4Impact”)

Post-Acute Care Transitions & Re-admissions Avoidable Readmissions:  Opportunity for better care, better health, lower costs  1 in 5 patients readmitted within 30 days of discharge  76% of readmissions are preventable  A $25 billion savings potential Call to action:  Improve care transitions (e.g., hospital to home)  Improve care coordination, outreach, patient engagement and support References: New England Journal of Medicine, Jencks S, et al “Rehospitalizations among patients in the Medicare fee-for-service program” N England Journal of Medicine 2009; 360: PricewaterhouseCoopers, The price of excess: Identifying waste in healthcare spending.

Many QI opportunities to reduce hospitalization...

Care Transitions Models Improve Processes, Information Flows, and Capacity Evidence-based models include: Care Transitions Intervention Transitional Care Model Guided Care GRACE Others

The Care Transitions Intervention (CTI) “The Coleman Model” Qualifications: CTI Coach can be layperson Length of intervention: 30 days Average cost: $196 per patient Steps: Four pillars--Medication management; Patient-centered record; Follow-up; Red flags Five encounters--Hospital/SNF Visit; Home Visit; 3 Follow-Up Calls

Transitional Care Model (TCM) “The Naylor Model” Qualifications: Transitional Care Nurses are advanced practice nurses (BA-prepared nurses under study) Length of intervention: 1 to 3 months Average cost: $982 per patient Steps: Visit patient in hospital, home visit w/24 hours, accompany patient to 1 st doctor visit, facilitate clinician collaboration and communications with patient/family, on call 7 days a week

Guided Care Developed at Johns Hopkins University since 2001 Qualifications: Guided Care Nurse must be an RN Length of intervention: For life Average cost: $1743 per patient per year Steps: Conduct comprehensive home assessment, create care guide and action plan for patient, provide monthly monitoring and self- management coaching, coordinate care, facilitate access to community services, engage/educate informal caregivers

GRACE: Geriatric Resources for Assessment and Care of Elders “The Counsell Model” Qualifications: Nurse practitioner and social worker Length of intervention: Long term/indefinite Average cost: $1432 per patient per year Steps: In-home assessment, home visit after any hospitalization, one phone or in-person follow-up per month, collaborate with PCP, hospital discharge planner and others in a team-based approach

How Technologies May Support Care Processes HomeMedication Management Management Video-BasedEducation Telemedicine Patient Health Records Remote Patient Monitoring Smart Sensors Wireless Broadband Networks

Technology Usage Examples: CTA Grantees that Aim to Reduce Hospitalizations Medication Optimization Technologies American Society of Consultant Pharmacists Foundation Caring Choices Connecticut Pharmacists Foundation VA Central California Health Care System Visiting Nurse Services of New York Remote Patient Monitoring Technologies AltaMed Health Services, Stamford Hospital California Association of Health Services at Home Centura Health at Home New England Healthcare Institute Sharp HealthCare Foundation HealthCare Partners Catholic Healthcare West Personal Health Records Technologies State Units on Aging and ADRCs in: California Rhode Island Washington Evidence-Based Care Transitions QI Evaluation Technologies State Units on Aging and ADRCs in: Indiana Texas ADRC = Aging and Disability Resource Center

Focus AreaMedication Adherence, Remote Patient Monitoring (RPM) PopulationVets with CHF, hospitalized within past 1-2 years Technology In-home RPM appliance using POTS, Med Adherence Algorithm, weight scale, BP cuff Expected Benefits Reduce hospital/ED visits; improve patient activation, QOL & satisfaction Workforce Issues Care coordinator (RN), MD oversight, Automated clinician alerts, enabled patients/informal caregivers Organizational Readiness VHA: world’s largest telehealth user, rural health = telehealth (see next 2 slides for background) Veterans Health Administration (Central CA) CTA Grant Project POTS = Plain Old Telephone Service

The Early Adopter Experience: Veterans Health Administration (1 of 2) VHA has evaluated, piloted, reevaluated, and deployed telehealth technologies in a continuing process of learning and improvement far beyond adoption in the private sector Largest national program--enables detailed analyses Home telehealth compared to traditional care models: –Studies conducted on patients enrolled in the VA’s Care Coordination/Home Telehealth program in 2006 and 2007 show: 25% reduction in bed days of care 20% reduction in numbers of admissions 86% mean satisfaction score rating

Net cost = $1,600 / patient / year vs. VHA’s home-based primary care services = $13,121 / patient / year Market nursing home care rates average = $77,745 / patient / year VHA takes “systems approach” to integrate the elements of the CC/HT program. This includes: Product selection Training Protocols for patient selection, management Data analytics Since VHA implemented CCHT in 2003, a total of 43,430 patients have been enrolled Age Distribution of all CCHT Patients The Early Adopter Experience: Veterans Health Administration (2 of 2)

Indiana State Unit on Aging CTA Grant Project Focus Area Implementing GRACE care transitions model and technologies into VAMC Indianapolis PopulationOlder Vets at high risk for hospitalization and institutional care Technology Technologies that support GRACE protocols (EHR, automated prompts, Web-access to protocols and other tools) Expected Benefits improved performance on Assessing Care of Vulnerable Elders (ACOVE) quality indicators, higher satisfaction, and decreased hospital readmissions and long-term institutionalization Workforce Issues Team-based approach coordinated by GRACE-trained nurse practitioner and social worker, increased engagement of patients and caregivers, local ADRC integrated into process Organizational Readiness VA validates new innovations before taking nationwide; GRACE intervention originated in Indiana; Counsell is leading project

Focus Area Improving communications, coordination, self-management during care transitions Population Patients recently discharged from hospital that are participating in the Care Transitions Intervention program Technology EHRs and PHRs (Electronic Health Records, Personal Health Records) Expected Benefits Reduce hospitalizations/re-hospitalizations, improve patient self- management, improve communications Workforce Issues CTI coach, connected clinicians, increased engagement of patients and caregivers Organizational Readiness An early adopter, Whatcom County, WA started project in 2001 Washington State Unit on Aging CTA Grant Project

Focus Area Remote Medication Therapy Management Population Older Cambodian-Americans w/ history of torture/trauma, high incidence of chronic illness and low literacy rate TechnologyVideo conferencing, spoken format technology, EMR Expected Benefits Reduce hospital/ED visits; improve meds use; improve access to culturally concordant providers Workforce Issues Remote pharmacist visit, patient is accompanied by community health worker. Few providers trained in special needs of this population. Organizational Readiness Connecticut partner, Khmer Health Advocates, is the only Cambodian health organization in the US Connecticut Pharmacists Foundation CTA Grant Project

Diffusion of Innovations Lessons Learned Stakeholder readiness to adopt Business model/payment model Technology/Intervention model Evidence base/relative advantage Compatibility Complexity Policy issues

Center for Technology and Aging