Care Transitions in the Aging Population

Secondary Information Here

Presenters: Joni Sellers MSN, MHA, RN, CDE and Dina Harlan RN

Objectives• Understand the demands of the aging population on healthcare resources• Verbalize the importance of effective transitions of care in the aging population• Identify gaps in care and barriers to healthy outcomes in the aging population• Identify tools for addressing risk and overcoming barriers

Aging in America• Adults aged 65+ is a fast growing population

– 55 million in 2010– 80 million by 2040

• Importance of managing care transitions– chronic illness and falls

• increases acute and long-term institutional stays• decreases independence in the home setting

Impact of Aging• Nearly one-fifth of Medicare beneficiaries discharged from a hospital return within 30 days

– 2 million per year• Reducing avoidable readmissions

– improves patient safety– enhances quality of care– lowers health care spending

Aging and Care Settings• Outpatient stays• Inpatient stays• Skilled nursing or rehab stays • Home

High-Risk Population• Multiple comorbidities• Age• Multiple admissions

– deconditioning• Impaired functionality• Poor social support• History of depression

Care Transition Gaps• Medication management

– Major gap in care• Durable medical equipment

– Lack of communication between providers• Home health

– Opportunity to identify and address gaps

Readmission to hospital• About 1 in 6 Medicare patients was rehospitalized within 30 days in 2009

– heart attack, heart failure, surgery, hip fractures or pneumonia rates same or higher than 2004• Least likely – surgery patients

– 12.7%• Most likely – heart failure

– 21.2%

Contributing Factors• Socioeconomic status• Demographic factors• Co-morbid conditions• Access to social supports• Dual eligibility

– These 9 million beneficiaries are the most chronically ill – Have health care costs five times greater than Medicare only

Four Types of Readmissions• Planned readmission related to the initial admission

– such as a series of chemotherapy treatments or reconstructive surgery following removal of a body part

• Planned readmission unrelated to the initial admission– removal of a lung tumor discovered during initial stay

• Unplanned readmission unrelated to the initial admission– fracture sustained in a car accident following stay for pneumonia

• Unplanned readmission related to the initial admission– surgical site infection or adverse reaction to a medication

Are Readmissions Always Bad?• Link between readmissions and mortality for beneficiaries admitted for heart failure

– Hospitals with higher readmission rates actually had lower 30-day mortality rates– Highest readmission rate for HF is first 7 days– Discharge to home vs. facility increases readmission rate– Elderly who live alone are most functional

Faulty Care Transitions• Hospitalists introduce discontinuity in care• Inadequately performed care transition results in

– decreased patient understanding– medication errors– increased stress on the caregiver– increased readmission rates– increase in care costs

The Red Herring• There are six co-morbidities associated with readmission

– congestive heart failure– renal disease (ESRD)– cancer (with and without metastasis)– weight loss– iron deficiency anemia

• ESRD rates = 31.6% compared to 16.9% in non-ESRD

Preventing Unplanned Readmissions• Identify high-risk patients

– Co-morbidities– Dual eligible– Black Medicare patients

• Care coordination between providers• Goal

– Provide quality of care– Minimize risk of preventable hospital readmissions

Seems So Obvious!• Collaboration between health care providers

– improves outcomes– patient satisfaction– quality of life

Care Transition Influencers• Case managers

– Appropriate referrals and placement• Home health/public health nurses

– Early identification of gaps in care• Post-discharge education

– Follow-up appointments– Medication review– DME– Anticipated symptoms

Project BOOST• Better Outcomes for Older adults through Safe Transitions• By improving hospital discharge processes, Project BOOST aims to:

– Reduce 30 day readmission rates for general medicine patients (with particular focus on older adults)– Improve patient satisfaction scores and H-CAHPS scores related to discharge– Improve flow of information between hospital and outpatient physicians and providers– Identify high-risk patients and target specific interventions to mitigate their risks for adverse events– Improve patient and family preparation for discharge

(http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/Boost_vanity_landing.cfm)

Project BOOST 5 Key Elements• A Comprehensive Intervention developed by a panel of nationally recognized

experts based on the best available evidence.

• A Comprehensive Implementation Guide provides step-by-step instructions and project management tools, such as the Teach Back Training Curriculum, to help interdisciplinary teams redesign work flow and plan, implement, and evaluate the intervention.

• Longitudinal Technical Assistance provides face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a train the trainer DVD and curriculum for nurses and case managers on using the Teach Back process, and webinars targeting the educational needs of other team members including administrators, data analysts, physicians, nurses and others.

• The BOOST Collaboration allows sites to communicate with and learn from each other via the BOOST Listserv, BOOST Community site, and quarterly all-site teleconferences and webinars.

• The BOOST Data Center, an online resource center, allows sites to store and benchmark data against control units and other sites and generates reports

Project BOOST and ACA• Hospital Readmissions Reduction Program (Sec. 3025, Sec. 10309):

FY2013: Inpatient PPS hospitals with higher-than-expected readmissions rates will experience decreasedMedicare payments for all Medicare discharges. Evaluation will be based on the 30-day re-admission measuresfor heart attack, heart failure and pneumonia that are currently part of the Medicare pay-for-reporting program andreported on Hospital Compare.

• FY2015: The list of conditions can be expanded to include COPD and several cardiac and vascular surgicalprocedures, as well as, any other condition or procedure the Secretary chooses.

• Community Care Transitions Program (Sec. 3026):Beginning in 2011, this five year Medicare pilot program will be available to PPS hospitals identified by the HHS Secretary as having high readmission rates. Hospitals serving medically underserved populations, small community hospitals, and rural hospitals will be given priority for participation, as will hospitals participating in an eligible Administration on Aging program. Hospitals may elect to join the pilot program with community-based organizations or those that provide care transition services.

Improving Discharge Transition• Institutional support

– time, equipment, informatics, and personnel • Multidisciplinary team or steering committee

– focused on improving the quality of care transitions in the institution• Engagement of patients and families

– recognition of the central role they play in post–hospital care plan• Data collection and reliable metrics

– CMS core measures ( relate to achievement of recommended treatment in four clinical areas: heart attack, heart failure, pneumonia, and surgical care)

– PQRI measures (Physician Quality Reporting Initiative: physician-level, voluntary pay for reporting program)

– transformed into reports that inform the team and frontline workers of progress and problem areas to address

• Specific aims, or goals– time defined, measurable, and achievable

Improving Discharge Transition• Standardized discharge pathways

– highlight key medications, medication changes, important follow-up and self-management instructions, and pending tests• Policies and Procedures

– institution specific, widely disseminated , embedded in the order set • Comprehensive education programs

– for health care providers and patients– reinforcing both general and institution-specific information about the discharge process and use of specific tools

Geriatric Evaluation for Transition• Problem medications• Psychological• Principal diagnosis• Polypharmacy

• Poor health literacy• Patient support• Prior hospitalization• Palliative care

Includes risk assessment using 8Ps

(http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/PDFs/TARGET.pdf)

Transitional Care Model• Dr Mary Naylor PHD, RN

– Pts. assigned a TCN upon admission– Comprehensive assessment of patient and family caregiver needs – Discharge plan with the family and hospital provider team – Implements the plan in the patient’s home– Assists the patient with management of their care needs – Facilitates communication and the transition to community providers and services(http://innovativecaremodels.com/care_models/21/key_elements)

Home Follow-Up• The Transitional Care Nurse is available to the patient seven-days per week through home visits and telephone access for one to three months of home follow-up (two months on average) • Targets cognitively intact older adults

– 2 or more risk factors– including poor self-health ratings– multiple chronic conditions– history of recent hospitalizations

Key Components• Each nurse manages an active caseload of 15 to 20 patients, with an average of 18 patients

– In-hospital visit for assessment and goal setting– In-home visits by phone or in person– Nurse visit with physician at initial follow-up and one more visit if needed

• Facilitate, advocate, educate

What are you doing in your communities?

Questions?

ADDITIONAL INFORMATION • Weblinks• "After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries," The Dartmouth Institute for Health Policy & Clinical Practice, Sept. 28 (www.dartmouthatlas.org/downloads/reports/Post_discharge_events_092811.pdf)• "Rehospitalizations among patients in the Medicare fee-for-service program," The New England Journal of Medicine, April 2, 2009 (www.ncbi.nlm.nih.gov/pubmed/19339721)• Hospital Compare, Dept. of Health and Human Services (www.hospitalcompare.hhs.gov)• Project Re-Engineered Discharge, Boston University Medical Center (www.bu.edu/fammed/projectred)• BOOSTing (Better Outcomes for Older adults through Safe Transitions) Care Transitions resource room, Society of Hospital Medicine (www.hospitalmedicine.org/boosttoolkit)• "Care About Your Care: Tips for Patients When They Leave the Hospital," The Dartmouth Institute for Health Policy & Clinical Practice (www.dartmouthatlas.org/downloads/reports/Atlas_CAYC_092811.pdf)• "Examining the Drivers of Readmissions and Reducing Unnecessary Readmissions for Better Care," TrendWatch, American Hospital Assn., September (www.aha.org/research/reports/tw/11sep-tw-readmissions.pdf)

References• Coleman, E, Parry, C, et, al. The care transitions intervention: a patient-centered approach to ensuring effective transfers between sites of geriatric care. Home Health Care Serv Q 2003; 22(3):1-17. PMID: 14629081• Simon, SR, Lee, TH, et, al. Communication problems for patients hospitalized with chest pain. J Gen Intern Med. 1998 Dec;13(12):836-8. PMID: 9844081• van Walraven, c, Mamdani, M, et, al. Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med. 2004 Jun;19(6):624-31. PMID: 15209600• Preen D, Bailey B, Wright A, et al. Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial . Int J Qual Health Care. 2005; Feb 17(1):43-51. PMID: 15668310• Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007; 297:831-41. PMID: 17327525• Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. J Hosp Med 2008;2:314-323. PMID: 17935242