# Presentation: 512323

## The Transitional Care Model:

**Mary D. Naylor, PhD, RN**Marian S. Ware Professor in GerontologyDirector, NewCourtland Center for Transitions and HealthUniversity of Pennsylvania, School of Nursing

**The Transitional Care Model:**
**Translating Research into Practice**
***Development and Translation of the Transitional Care Model for Older Adults***

- January 28, 2009

## Transitional Care  

***Transitional care*** – range of time limited services and environments designed to ensure health care continuity and avoid preventable poor outcomes among at risk populations as they move from one level of care to another, among multiple providers and/or across settings.

## Context for Transitional CareAcute Care Episode:  

- Adapted from the National Quality Forum committee on Measurement Framework: Evaluating Efficiency across Episodes of Care

## The Case for Transitional Care

- High rates of medical errors
- Serious unmet needs
- Poor satisfaction with care
- High rates of preventable readmissions
- Tremendous human and cost burden

## Different Goals of Evidence-Based Interventions

- Address gaps in care and promote effective “hand-offs”
- Address “root causes” of poor outcomes with focus on longer-term, positive outcomes

## Quality Cost  Transitional Care Model (TCM)

**Engaging Elder/Caregiver**

**Managing Symptoms**

**Educating/**
**Promoting ****Self-Management**

**Assuring Continuity **

**Coordinating****Care**

**Maintaining****Relationship**

**Notes:**

Transitions in health and care have been a central concept in nursing.  Today, transitional care is generally defined as  broad set of services and environments “...designed to ensure the coordination and continuity of health care as patients move between different locations and different levels of care...” 

The key components of the Model as applied to older adults and refined over the years its testing are:
Screening high risk populations
Assessing patient’s and caregivers needs/identifying their goals and preferences
Educating patients and caregiver (attention to cultural differences, literacy)
Monitoring and managing symptoms initially and progressively promoting self-management
Collaborating with physicians and other health team members
Assuring continuity of care from hospital to home
Maintaining a strong patient/provider relationship

Screening high risk population
Assessing patients’ and caregivers’  
  needs
 Educating patients and caregivers
 Screening high risk population 
 Screening high risk population 

American Geriatrics Society Position Statement, 2003

A broad set of services  “...designed to ensure the coordination and continuity of health care as patients move between different locations and different levels of care...” 

American Geriatrics Society Position Statement, 2003

A broad set of services  “...designed to ensure the coordination and continuity of health care as patients move between different locations and different levels of care...” 

American Geriatrics Society Position Statement, 2003

## Unique Features 

**Care is delivered and coordinated**
- ...by same nurse
- ...across settings
- ...7 days per week
- ...using evidence-based protocol
- ...with focus on long term outcomes* *

**Notes:**
Although some 15 years have passed since we began testing this model, unique features that continue to persist are the fact that care in this model Spans hospital to home; the same APN who coordinated the hospital discharge plan implemented it in the patient’s home 
Care provided by highly skilled APNs who substituted for traditional post-discharge nursing follow-up
Flexible protocol, supported by evidence-based guidelines, allowed flexibility to individualize care...APNs used clinical judgment to determine frequency, intensity, and nature of contacts...also determined whether to use home visits or telephone as mode of contact

On-going collaboration with patients’ physicians (generalists to HF specialists) w/ support as needed from expert multidisciplinary team via email or phone

## Findings from Randomized Clinical Trials

- Funding: National Institutes of Health, National Institute of Nursing Research, National Institute on Aging (1990-2010)

**Notes:**
Since a major goal has been to develop thru science solutions that are applicable to most elders entering out system (not just to those with a certain disease), we tested this intervention with  elders hospitalized with one of the 8 most common medical or surgical reasons for admission of Medicare beneficiaries in 1992(363 were ultimately enrolled in this RCT)
Modifications to the intervention
Development of a high-risk profile
Greater attention in protocol to risk factors associated with poor outcomes
Increased APN visits during hospitalization
Addition of 4 week home care component
Followed both groups thru 6 months assessing patient, caregiver and cost outcomes and capturing the experiences of intervention patients thru case studies recorded by APNs.

## Transitional Care Model

- Protocol Overview

## Across RCTs, TCM has consistently...

-  Increased time to first rehospitalization
-  Decreased total all-cause rehospitalizations
-  Increased patient satisfaction
-  Improved physical function and quality of life*
-  Decreased total health care costs
- *Most recently completed RCT only

## Barriers to Adoption 

- Organization of current system of care
- Lack of quality and financial incentives
- Culture of care

## Translating TCM into Practice

- Penn research team formed partnerships with Aetna Corporation and Kaiser Permanente to test “real world” applications of research-based model of care for high risk elders.
- Funded by The Commonwealth Fund and the following Foundations: Jacob and Valeria Langeloth, The John A. Hartford, Gordon & Betty Moore, and California HealthCare; guided by National Advisory Committee  (NAC)

## Project Goals (Aetna)

- Test TCM in defined market
- Document facilitators and barriers
- Provide for ongoing NAC input
- Present findings to Aetna decision makers
- Widely disseminate findings

##      Tools of Translation

- Patient screening and recruitment
- Orientation of TCNs (web-based modules)
- Documentation and Quality Monitoring (clinical information system - CIS)
- Quality improvement (case conferences and CIS)
- Evaluation

## Integrating TCM within Aetna

-  Project team
-  Key decisions
- Link to geriatric case management program
- Partner with home care agency
- Target 200 members in mid-Atlantic region
- Clearly define roles and work flow processes

## Key Indicators of Success

- Decisions by Aetna re: adoption
- Decisions by other insurers and providers to implement model
- Use of findings by CMS and insurers to reimburse evidence-based transitional care

## Value  =

**Health Resource Utilization (Costs)**

- Environment:  Extant comprehensive system of telephonic care management
- Question:  Does the Transitional Care Model offer greater value in this environment?

**Quality/Satisfaction**

## Quality (N=172)

***Significant improvements pre- and post-TCM in the following outcomes:***
- self-reported health status (1 item)
- symptom status (Symptom Bother Scale)*
- depression (Geriatric Depression Scale)
- functional status (SF-12)
- quality of life (one item)
- *improvements in 10/13 symptoms at p <0.05

## Satisfaction

*Members (N=171)*
- Overall high satisfaction - Mean of 3.0 on each of the 15 survey items (1 low - 4 high)
*Physicians (N=25)**
- Overall high satisfaction with APN involvement in members’ care – Mean of 3.5 on each of 10 survey items* (1 strongly disagree – 4 strongly agree
- **  Satisfaction data from MDs with at least 3 TCM patients

## Health Resource Utilization

- Quasi-experimental design simulating RCT
- Each elder in TCM matched with “control”
- 155 pairs using stringent criteria (e.g., # of comorbid conditions) were available for final HR analyses
- HR data obtained from Aetna’s claims’ dataset

## Rehospitalization Rates*

*Significant reductions in readmission rates and hospital days through 3 months*
- 0-3 months, 45 TCM vs. 60 controls (25% decrease; 99 fewer hospital days)
- 0-6 months, 104 TCM vs. 112 controls
- 0-12 months, 184 TCM vs. 203 controls
- *ED rates similar (85 TCM vs. 81 controls at 12 mos.)

## Skilled Nursing Facility Rates

*Trend toward reduced SNF admissions between TCM vs. controls**** ***
- 0-3 months, 5 TCM vs. 11 controls
- 0-6 months, 14 TCM vs. 22 controls
- 0-12 months, 26 TCM vs. 38 controls

## Skilled Home Care Visits

*Trend toward decreased use of home visits for TCM vs. controls*
- 0-3 months, 252 TCM vs. 436 controls
- 0-6 months, 393 TCM vs. 728 controls
- 0-12 months, 658 TCM vs. 1153 controls

## TCN Visits 

- Mean # of home visits = 7.26 (2-19); mean length = 50 minutes
- Mean # of MD office visits = 0.7 (0-3); mean length = 62 minutes
- Mean # of patient phone calls = 7.82; mean length = 8 minutes

## Costs

*Significant reductions in total health care costs through 3 months; savings continue thru 12 months*
*	*
-  $439 PMPM savings at 3 months
-  $181 PMPM savings at 12 months

## Factors Considered in Interpreting Findings

- Hospital component of TCM was not implemented in applying model with Aetna’s members
- Regional variations in service use
- Comparison group obtained from region with 20% _lower_ utilization rate than mid-Atlantic region

## TCM as High Value Proposition for Aetna

**High Quality + Satisfaction**

**Reductions **
**in Acute Readmissions (Costs)**

**=**

## Progress to Date

- TCM proposed for expansion as part of Aetna’s 2009 Strategic Plan
- Kaiser enrollment complete; data analyses ongoing
- University of Pennsylvania Health System has adopted TCM; Blue Cross plans to reimburse for its members

## Next Steps for Penn Team

- Continue efforts to promote widespread adoption of TCM
- Use findings to promote needed policy changes
- Continue to build the science

## How can we improve post-discharge outcomes for hospitalized cognitively impaired elders?

- Funding:  Marian S. Ware Alzheimer Program, and National Institute on Aging (2005-2010)

## How can we improve transitions of elders in LTC to and from hospitals?

- Funding:  Rand-Hartford Center for Interdisciplinary Geriatric Health Care Research (2005-2008); National Institute on Aging, National Institute of Nursing Research (2006-2011)

## Acknowledgements

- Research team, nurses and staff
- NewCourtland Center for Transitions and Health
- Translation Partners
- Funders

- www.transitionalcare.info

## Slide 33

**Notes:**
Before returning to the case of Mr. Jenkins, let me acknowledge that there is no shortage of groups who have been identified as the culprits in failing to respond to the changing health care needs of consumers in this country...

## Thank You!