1. Mary D. Naylor, Ph.D., R.N. Marian S. Ware Professor in Gerontology University of Pennsylvania School of Nursing

2. Goals Make the case that health care quality among elderly long-term care (LTC) recipients who require acute care services may be enhanced by: Make the case that health care quality among elderly long-term care (LTC) recipients who require acute care services may be enhanced by: –avoiding preventable acute hospitalizations; and, –improving transitions to and from hospitals when such transfers are needed

3. Goals Offer policy recommendations to prevent avoidable hospitalizations and enhance necessary care transitions Offer policy recommendations to prevent avoidable hospitalizations and enhance necessary care transitions Propose a research agenda to inform future changes in standards of care Propose a research agenda to inform future changes in standards of care

4. Elders 85 and Older: One among the fastest growing age groups in the U.S. Number (in millions) SOURCE: Nursing Staff in Hospitals and Nursing Homes: Is it adequate?, 1996; page 33.

5. Acute Hospitals vs. LTC short-term services dominated by medical model short-term services dominated by medical model providers choose + deliver services providers choose + deliver services high tech high tech limited family involvement limited family involvement Payor: Medicare Payor: Medicare long-term health, social and housing services long-term health, social and housing services providers help with ADLs +IADLs providers help with ADLs +IADLs low tech low tech family equal partners family equal partners Payor: Medicaid Payor: Medicaid

6. Transitions between LTC and Acute Care Hospitals Transitions between LTC and Acute Care Hospitals

7. Nature of Problems Poor communication Poor communication Negative effects of hospitalization Negative effects of hospitalization Inadequate discharge planning Inadequate discharge planning Gaps in care during transfers Gaps in care during transfers

8. Consequences High rates of acute clinical events High rates of acute clinical events Serious unmet needs Serious unmet needs Poor satisfaction with care Poor satisfaction with care High hospital readmission rates High hospital readmission rates

9. Clinical Barriers to Addressing Problems with Transitions Providers knowledge, skills and resources Providers knowledge, skills and resources Limited use of palliative care Limited use of palliative care Dearth of quality performance measures Dearth of quality performance measures

10. Non-Clinical Barriers to Addressing Problems with Transitions Regulatory challenges Regulatory challenges Financial constraints Financial constraints Pressures from families and health care administrators Pressures from families and health care administrators

11. The Search for Solutions

12. Related Areas of Inquiry Efforts to fully integrate acute and LTC Efforts to fully integrate acute and LTC Transitional care interventions targeting chronically ill elders Transitional care interventions targeting chronically ill elders Innovative care models Innovative care models

13. Lessons from Integration Efforts Described the unique issues and challenges confronting acutely ill, frail elders Described the unique issues and challenges confronting acutely ill, frail elders Highlighted the benefits of avoiding preventable hospitalizations Highlighted the benefits of avoiding preventable hospitalizations

14. Suggested value of: Suggested value of: –Early identification of acute care needs –Increased access to selected primary, acute and palliative care services within LTC –Flexible funding and benefits Lessons from Integration Efforts

15. Care Models Designed to Avoid Preventable Hospitalizations Evercare Evercare Hospital at Home Hospital at Home The Day Hospital The Day Hospital Palliative Care Program in LTC Palliative Care Program in LTC

16. Mrs. Anderson: A Case Study

17. Lessons Learned from Transitional Care Interventions Identified individual and system barriers to effective transitions Identified individual and system barriers to effective transitions Highlighted importance of multidimensional strategies targeting problems common during hand-offs Highlighted importance of multidimensional strategies targeting problems common during hand-offs

18. Lessons Learned from Transitional Care Interventions Suggested value of: Suggested value of: –Nurse-led, interdisciplinary teams –Streamlined care delivery –Information systems that span settings –Quality measures and other incentives

19. Care Models Designed to Improve Care Transitions Care Transitions Coaching Intervention Care Transitions Coaching Intervention Advanced Practice Nurse (APN) Transitional Care Model Advanced Practice Nurse (APN) Transitional Care Model

20. Mr. Jenkins: A Case Study

21. Policy Recommendations

22. Leutzs Conceptual Framework Linkage Linkage Coordination Coordination Full Integration Full Integration

23. Key Assumptions The financing and delivery of acute and LTC will continue to be characterized by a patchwork of public and private services and funding The financing and delivery of acute and LTC will continue to be characterized by a patchwork of public and private services and funding

24. Key Assumptions There is an adequate evidence base to justify: There is an adequate evidence base to justify: –increasing access to primary care, management of common conditions and palliative care within LTC; and, –use of nurse directed interdisciplinary teams, guided by evidence-based transitional care protocols

25. Proposed Structures, Incentives to Enhance Coordination of Care Delivery Design, testing and integration of quality measures and monitoring systems Design, testing and integration of quality measures and monitoring systems Development of information systems that span settings Development of information systems that span settings

26. Proposed Structures, Incentives to Enhance Coordination of Care Delivery Preparation of current + future providers emphasizing… Preparation of current + future providers emphasizing… –geriatrics –palliative care –interdisciplinary team care –advance care planning –transitional care/care coordination Dissemination of best practices Dissemination of best practices

27. Proposed Structures, Incentives to Improve Coordination of Care Benefits Create incentives to foster adoption of evidence-based models of on-site primary or palliative care and transitional care Create incentives to foster adoption of evidence-based models of on-site primary or palliative care and transitional care Modify Medicares Hospice benefit to minimize barriers for use within LTC Modify Medicares Hospice benefit to minimize barriers for use within LTC

28. Research Agenda Describe impact of transitions Describe impact of transitions Identify most effective and efficient models to: Identify most effective and efficient models to: –avoid preventable hospitalizations –improve care coordination, continuity and transitions Define financial and other incentives to optimize quality and cost outcomes Define financial and other incentives to optimize quality and cost outcomes