1. Common themes, lessons learned, and broader approaches for improving care Alicia I. Arbaje, M.D., M.P.H. Director of Transitional Care Research Division of Geriatric Medicine and Gerontology Australian Disease Management Association August, 2013

2.  Describe common themes of current approaches to improving care transitions in the United States  Discuss lessons learned from implementing care transitions initiatives  Present broader approaches for future interventions to improve care transitions 2

3. 79 year old widower Retired teacher, lives alone Income: small pension Daughter lives 10 miles away, has three teenagers Five chronic conditions Three physicians Eight medications

4. 6 community referrals 2 home care agencies 5 months homecare 2 nursing homes 6 weeks sub- acute care 3 hospital admissions 19 outpatient visits 8 meds 22 scripts

5. Walter Confused by care, meds Gets discouraged Adherence to care is poor Walter’s daughter Stressed Reduced work to half-time Considering rest homes

6. Fragmented Discontinuous Difficult to access Inefficient Unsafe Expensive “A nightmare to navigate”

7. 7 Emergency Department Inpatient Hospitalization Hospital Floor Critical Care Operating Room Skilled Nursing Facility Home +/- Home Health Care Long-Term Care Facility Primary Care Specialists

8.  1 in 4 transition annually  1 in 3 transition 2+ times after discharge  Half of transitions are to hospital and back  The rest are not easily predictable 8 Sato, Arbaje, et al., 2010; Coleman 2003

9.  Identification of at-risk patients and transitions  Screen for cognitive/functional impairment  Assess living situation and usual source of care  Provider-provider communication  Provide info to PCP at key transition points  Verbal communication when urgency/uncertainty exists  Timely and quality discharge summaries  Medication management and reconciliation  Address goals of care  Provide support after discharge  Use of home healthcare when appropriate  Enhance self-management  Follow-up phone call/visit 9 Guidedcare.org Caretransitions.org Transitionalcare.info

10.  Specially trained RNs based in primary physicians’ offices  GCNs collaborate with 3-4 physicians in caring for 50-60 high-risk older patients with chronic conditions and complex health care needs

11. Assesses needs and preferences Creates an evidence-based “care guide” and a patient-friendly “action plan” Monitors the patient proactively Supports chronic disease self-management Smoothes transitions between care sites Communicates with providers in EDs, hospitals, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies in the community Educates and supports caregivers Facilitates access to community services Boyd C et al. Gerontologist, 2007

12.  Comprehensive primary care can produce better outcomes for multi-morbid older patients.  Increased quality of care  Increased physician and nurse satisfaction  Decreased caregiver strain  Decreased utilization, especially SNF days and ED visits  The results of such models of care may be even better in integrated delivery systems. www.guidedcare.org

13.  Assessment of symptoms  Understanding of hospitalization, diagnoses, test results, and treatment plan  Medication and self-management  Ensuring follow up and implementation of plan of care  Creation and understanding of emergency plan  Inpatient- or outpatient-based programs 13

14. Need for a broader understanding and approach Transitional Care 1.0 ScreeningPatient-level Target processesDischarge planning Communication SettingsHospital Data sourcesMedical records Administrative data Patient report InterventionCoaches Navigators Evaluation measuresUtilization Satisfaction 14

15.  Describe common themes of current approaches to improving care transitions in the United States  Discuss lessons learned from implementing care transitions initiatives  Present broader approaches for future interventions to improve care transitions 15

16. 16

17. Multi-morbidity Cognitive impairment Functional impairment and risk of falls Limited health literacy Complex medical regimens and treatment burden Polypharmacy Polymanagement Caregiver burden Frequent transitions across multiple care settings Hearing or visual impairment Bowel or bladder incontinence Pressure ulcers Malnutrition or dehydration 17

18. Competing demands leading to difficulty in prioritization of care plans Inability of patient to comprehend or implement care plans Inability to tolerate transitions and changes to care plans Increased care needs upon discharge Confusion among health care providers regarding plan of care Need to incorporate palliative care principles 18

19.  Describe common themes of current approaches to improving care transitions in the United States  Discuss lessons learned from implementing care transitions initiatives  Present broader approaches for future interventions to improve care transitions 19

20. 20

21.  Many factors affect care transitions  Readmission risk varies and prediction remains poor  Discharge destination matters 21

22. Transitional Care 1.0Transitional Care 2.0 ScreeningPatient-levelHome environment System level Regional level Target processesDischarge planning Communication Palliative care Caregiver activation Systems redesign SettingsHospitalCommunity Ambulatory care Assisted living Skilled/long-term care Home Data sourcesMedical records Administrative data Patient report Organizational data Caregivers Healthcare providers InterventionCoaches Navigators Regional HIT Transportation Home-based care 22

23.  Track measures that are independent of patient factors but relevant to patient outcomes  Factor in features of local health system  Incorporate feedback, comparison to peers  Tailor communication to the situation  Promote access to “the other side”  Consider unintended consequences 23

24. 24

25.  Care transitions initiatives often target hospitalized patients and focus on readmission reduction.  Interventions originating outside of the hospital are not as common.  The next frontier is incorporating system-level approaches to a broader range of settings. 25

26. Alicia I. Arbaje, M.D., M.P.H. aarbaje@jhmi.edu Health tips for older adults: www.youtube.com/aarbaje

27. 27

28. 28 PtPt Home Care SNF LTC SNF LTC

29. 29 PatientPatient Home Care SNF LTC SNF LTC

30. 30

31. 31 Hospital Care Early Readmission Care Transition Hospital Organizational Characteristics Provider Role Perception Socio-Demographic, Health, and Post-Discharge Environmental Factors Care Processes Post-Acute Care Setting Characteristics Quality Measures

32. 0 mi 200 400 600 800 1000 >75 th Percentile (Above 37%) 25-75 th Percentile (35% to 37%) < 25 th Percentile (35%) Older Adults Readmitted or Dead within 180 Days of Hospital Discharge 32

33. 33 More needsLess needs

34. 34 ScenarioPossible Recovery Plan Patient level Patient not able to obtain all medications Vouchers to purchase medications Bedside or home delivery Reassessment of goals of care Transportation arrangements for medication pickup Patient or caregiver concerned about symptoms or plan of care Emergency assistance hotline to reach case manager or healthcare providers Remote assessment or educational interventions Patient’s cognitive or functional impairment impeding implementation of care plan Engagement of community social workers to do an in-home assessment of care needs and caregiver support

35. 35 ScenarioPossible Recovery Plan Health system level Durable medical equipment does not arrive as scheduled (e.g., oxygen, walkers, hospital bed) Emergency assistance hotline to reach home care agency Send out temporary supplies Post-acute facility or home care agency concerned about patient’s clinical status or unclear about plan of care Emergency assistance hotline to reach case manager or healthcare providers Access to inpatient EMR, nursing assessments, and medication administration records Regional level Patients’ care transitions unable to be tracked beyond the health system Health information exchange across healthcare systems Outpatient providers not aware of patient’s care transitions Automated systems for notification of patient care transitions Bi-directional communication systems to allow outpatient providers to communicate with inpatient, subacute, or home care providers in real time about the plan of care

36. All Patients Age 65+ 25% High-Risk 75% Low-Risk Review previous year’s claims data with HCC software

37. 13,534 Patients of 14 teams/49 physicians 3,383 (25% highest-risk) 904 = Consenting Patients (Baseline Evaluation) Random Allocation 419 in seven Control teams 485 in seven Guided Care teams Boult C et al. J Gerontology, 2008

38. Guided CareUsual Care Age77.278.1 Race (% white)51.148.9 Sex (% female)54.255.4 Education (12+)46.443.4 Living alone32.030.6 Chronic conditions4.3 HCC score2.12.0 ADL difficulty30.929.3

39. AGGREGATE Activation Decision Support Problem Solving Coordination Goal Setting Effects on Quality of Care 2.1 1.3 1.5 1.8 Quality rated in the highest category on PACIC PACIC Boyd et al. J Gen Intern Med, 2009

40. Marsteller et al. Ann Fam Med, 2010 Change in Satisfaction

41. Wolff et al. J Gerontology Med Sci, 2009

42. Very satisfied Very dissatisfied Satisfaction Items 1= Familiarity with patients 2= Stability of patient relationships 3= Comm. w/ patients; availability of clinical info; continuity of care for patients 4= Efficiency of office visits; access to evidence based guidelines 5= Monitoring patients; communicating w/ caregivers; efficiency of primary care team 6= Coordinating care; referring to community resources; educating caregivers 7= Motivating patients for self management Satisfied Somewhat satisfied Somewhat dissatisfied Dissatisfied

43. Guided Care Nurse Salary$71,500 Fringe benefits (@ 30%)21,450 Travel (to pts’ homes, hospitals)588 Communication services Internet, cell phone1,800 Equipment (amortized over 3 years) Computer500 Cell phone67 TOTAL$95,905

44.  After 32 months, Guided Care patients experienced  29% fewer home health care episodes  13% fewer hospital readmissions  26% fewer skilled nursing facility days  8% fewer skilled nursing facility admissions*  Reduced the use of services in an Integrated Delivery System.  52% fewer skilled nursing facility days  47% fewer skilled nursing facility admissions*  49% fewer hospital readmissions  7% fewer emergency department visits* 44 Boult C, Arch Int Med, 2011

45. Boult et al. Arch Intern Med, 2011 *

46. -15% -49% -21% -47% -52% -17% 8% -7% 9%

47.  Guided Care: a New Nurse-Physician Partnership in Chronic Care (Springer Publishing Company)  Online course for registered nurses  Online course for physicians and practice leaders  Orientation booklet for patients www.GuidedCare.org/adoption.asp