Transitional Care
Workgroup Meeting
July 12, 2013
1
Welcome and Introductions
Chad Boult, MD, MPH, MBA
Program Director, Improving Healthcare Systems
2
Housekeeping:
Providing Input
Today’s webinar participants can provide input via
e-mail (transitionalcare@pcori.org); via ...
What Research Questions Are Within
PCORI’s Mandate?
PCORI funds studies that compare the benefits and
harms of two or more...
How PCORI Manages the Potential for
Conflict of Interest
The researchers, patients, and stakeholders who have been invited...
Introductions:
Moderators
6
Trent Haywood, MD, JD
Chief Medical Officer, Blue Cross and Blue Shield
Doris Lotz, MD, MPH
Me...
Introductions:
Workgroup Members
Leah Binder, MA, MGA
– Purchasers
Tara A. Cortes RN, Ph.D.
– Home Healthcare
Jeffrey Dela...
Background on
Transitional Care Workgroup
Lynn Disney, PhD, JD, MPH
Senior Program Officer, Improving Healthcare Systems
8
9
How We Select Targeted Research Topics
Evolution of the Topic
1,000+ research topics collected
841 accepted
308 assigned to Improving Healthcare Systems (IHS) pr...
PCORI Advisory Panel on IHS
Prioritized Five Research Topics
11
TOP TWO
• Models of Transitional Care
• Models of Patient-...
Setting the Stage—
Current State of Evidence
Mary D. Naylor, PhD, FAAN, RN
Marian S. Ware Professor in Gerontology and Dir...
Transitional Care: Meaning of Concept
Transitional care – range of time limited
services and environments that are
designe...
The Case for Transitional Care
Patients’ poor ratings of experiences
with healthcare system
Serious unmet needs reported b...
Transitional Care: Published Evidence
21 clinical trials of diverse innovations focused on chronically
ill older adults
9 ...
Core Components of Effective
Interventions
16
Citation
Comprehensive
assessment, care
planning
Interactions with post
acut...
Core Components of Effective
Interventions
17
Citation
Self management
support
Comprehensive
medication
management
Use of
...
Effects on Health, Quality of Life and
Patients’ Care Experience
18
Citation Health
Quality
of life
Patients’ Care
Experie...
Effects on Healthcare Resource Use
19
Citation
Total readmissions,
all cause
(no. of months)
Time to first
readmission
(no...
Examples of Unanswered Questions
That Could Build Upon This Evidence
What are common triggers of major health
transitions?...
Unanswered Questions
How can behavioral health be more effectively incorporated
into transitional care?
How can transition...
Unanswered Questions
How can transitional care approaches more
effectively engage patients and family caregivers
and promo...
Measuring Patient-Centered Outcomes
Sara J. Singer, PhD, MBA
Assistant Professor, Harvard University, School of Public Hea...
How a Question Becomes a Measure
Identify
what
matters
Develop a
framework
Draft
measures
Test the
measures
Use the
measur...
What Matters?
Scan the literature  Talk to stakeholders 
Identify gaps
 Gap 1: Just because structures and services are...
Develop a Framework That Describes
What Matters
Aim to be comprehensive and mutually exclusive
26
Things that matter
Coord...
Develop Specific Questions to Measure
What Matters
Borrow or craft items that address your framework
 Check that question...
Test, Refine and Use the Survey
28
In the last 6 months, how often did this provider discuss
whether the care you were rec...
Test, Refine and Use the Survey
Before using a survey
 Do patients understand intended meaning of the questions?
 Is the...
Test, Refine and Use the Survey
 Do measures relate to things that should be related?
  Refine
Retest  repeat
30
Clini...
Provide rapid feedback of results 
Teach/learn  Act/refine  Repeat
Test, Refine and Use the Survey
31
0%
20%
40%
60%
80...
Importance and Evidence for Outcomes
Importance
 Importance to individual
 Importance to health of population
Evidence
...
Scientific Soundness of Measure
Scientific Soundness
 Reliability: Measure results are repeatable
 Validity: Measure res...
Feasibility and Usability - Reality Check
Feasibility
 How do we actually capture the information we are
measuring?
 How...
BREAK
35
• Visit us at www.pcori.org
• Follow @PCORI on Twitter
• Watch our YouTube channel PCORINews
Vignette
It is March 5, 2018, and Jane Smith is about to be
discharged from Center Hospital, where she was diagnosed
with ...
Collaborative Workgroup Discussion
Focus: Provide targeted input without scientific
jargon
Honor Timelines: Provide brief ...
Workgroup Objectives:
Narrowing the Broad Topic
Transitional care is a very broad concept
The process today is to take thi...
Questions from Patient and
Stakeholder Perspectives
39
LUNCH
40
• Visit us at www.pcori.org
• Follow @PCORI on Twitter
• Watch our YouTube channel PCORINews
Comments Submitted by Others
E-mail (transitionalcare@pcori.org)
Twitter (#PCORI)
The webinar “chat” feature
Lauren Holuj,...
Discussion of Proposed
Research Questions
42
BREAK
43
• Visit us at www.pcori.org
• Follow @PCORI on Twitter
• Watch our YouTube channel PCORINews
Refinement of Research
Questions to be Addressed
44
Recap and Next Steps
45
We Still Want to Hear from You
We welcome your input on today’s discussions
We are accepting comments and questions for
co...
Thank You for Your
Participation
47
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Transitional Care Workgroup

  1. 1. Transitional Care Workgroup Meeting July 12, 2013 1
  2. 2. Welcome and Introductions Chad Boult, MD, MPH, MBA Program Director, Improving Healthcare Systems 2
  3. 3. Housekeeping: Providing Input Today’s webinar participants can provide input via e-mail (transitionalcare@pcori.org); via Twitter (#PCORI); or the webinar “chat” feature. Please submit questions today, as they occur to you. We will collect and synthesize these for discussion at 12:45 p.m. (ET). We welcome additional input through July 19, 2013, at 5:00 p.m. (ET) via e-mail transitionalcare@pcori.org. 3
  4. 4. What Research Questions Are Within PCORI’s Mandate? PCORI funds studies that compare the benefits and harms of two or more approaches to care. Cost effectiveness: PCORI will consider the measurement of factors that may differentially affect patients’ adherence to the alternatives, such as out-of- pocket costs, but it cannot fund studies related to cost- effectiveness or the costs of treatments or interventions. Disease processes and causes: PCORI cannot fund studies that focus on risk factors, origins, or mechanisms of disease. 4
  5. 5. How PCORI Manages the Potential for Conflict of Interest The researchers, patients, and stakeholders who have been invited to this workgroup will be involved in the process of determining the specific subject areas that we should address in a PCORI Funding Announcement (PFA). The broader community of researchers, patients, and other stakeholders who are participating by web, Twitter, and chat can be involved as well. Participants in this workgroup are eligible to apply for funding if PCORI decides to produce a funding announcement studying models of transitional care. The Moderators of this workgroup will not be eligible to apply for funding under this PFA. Input received during the workgroup deliberations will be broadcast via webinar, and the webinar will be archived and made available to other researchers, patients, and stakeholders via the PCORI website. 5
  6. 6. Introductions: Moderators 6 Trent Haywood, MD, JD Chief Medical Officer, Blue Cross and Blue Shield Doris Lotz, MD, MPH Medicaid Medical Director, State of New Hampshire
  7. 7. Introductions: Workgroup Members Leah Binder, MA, MGA – Purchasers Tara A. Cortes RN, Ph.D. – Home Healthcare Jeffrey Delafuente, MS, FCCP, FASCP – Pharmacists Gretchen Dickson, MD, MBA – Family Practitioners Eric E. Howell, MD – Hospitalists Elizabeth (Libby) Hoy – Patients James E. Lett II, MD, CMD – Patient Advocacy Mary D. Naylor, PhD, FAAN, RN – Researchers Shelley Price, MS, FHIMSS – Healthcare Information Technology Erin Rand-Giovannetti, PhD, MPH – Researchers John Schall, MPP – Caregivers David Schulke – Hospitals/Health Systems Sara J. Singer, PhD, MBA – Researchers Nancy Skinner, RN-BC, CCM – Case Managers7
  8. 8. Background on Transitional Care Workgroup Lynn Disney, PhD, JD, MPH Senior Program Officer, Improving Healthcare Systems 8
  9. 9. 9 How We Select Targeted Research Topics
  10. 10. Evolution of the Topic 1,000+ research topics collected 841 accepted 308 assigned to Improving Healthcare Systems (IHS) program  Program director screened, consolidated, and rated topics 89 resulted from program director screening and were scored 15 scored highest and selected for advisory panel consideration  Topic briefs commissioned for all 15 topics  Reviewed and ranked by IHS Advisory Panel—April 19-20, 2013 10Link to PCORI Website—Full Description
  11. 11. PCORI Advisory Panel on IHS Prioritized Five Research Topics 11 TOP TWO • Models of Transitional Care • Models of Patient-Empowering Care Management NEXT THREE • Features of Health Insurance Coverage • Co-location of Mental Health and Primary Health Care • Models of Perinatal Care Management
  12. 12. Setting the Stage— Current State of Evidence Mary D. Naylor, PhD, FAAN, RN Marian S. Ware Professor in Gerontology and Director of the NewCourtland Center for Transitions and Health, University of Pennsylvania, School of Nursing 12
  13. 13. Transitional Care: Meaning of Concept Transitional care – range of time limited services and environments that are 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 health care team members and across settings such as hospitals to homes. 13
  14. 14. The Case for Transitional Care Patients’ poor ratings of experiences with healthcare system Serious unmet needs reported by patients and family caregivers High rates of preventable medical errors and associated poor outcomes Tremendous human burden 14
  15. 15. Transitional Care: Published Evidence 21 clinical trials of diverse innovations focused on chronically ill older adults 9 of 21 studies reported positive impact on health outcomes and reductions in preventable rehospitalizations Effective interventions:  Extended from hospital to home  Offered multiple solutions  Relied on teams (including patients) with nurses as “coordinator” Naylor MD, Aiken LH, Kurtzman ET, Olds DM, & Hirschman KB. (2011). THE CARE SPAN -- The Importance of Transitional Care in Achieving Health Reform. Health Affairs, 30(4):746-754. 15
  16. 16. Core Components of Effective Interventions 16 Citation Comprehensive assessment, care planning Interactions with post acute, community clinicians Coordination/ referrals for community services Care Transitions Program Coleman et al., 2006 Parry et al., 2009 — — + + — — Chronically Critically Ill Daly et al., 2005 + + + Project RED Jack et al., 2009 + + — Transitional Care Model Naylor et al., 1994 Naylor et al., 1999 Naylor et al., 2004 + + + + + + + + + Congestive Heart Failure Rich et al., 1995 + — + Telehealth (with HF) Wakefield et al., 2008 — — —
  17. 17. Core Components of Effective Interventions 17 Citation Self management support Comprehensive medication management Use of Information Technology Care Transitions Program Coleman et al., 2006 Parry et al., 2009 + + + + — — Chronically Critically Ill Daly et al., 2005 — + — Project RED Jack et al., 2009 + + Transitional Care Model Naylor et al., 1994 Naylor et al., 1999 Naylor et al., 2004 + + + + + + + + + Congestive Heart Failure Rich et al., 1995 — + — Telehealth (with Heart Failure) Wakefield et al., 2008 + — —
  18. 18. Effects on Health, Quality of Life and Patients’ Care Experience 18 Citation Health Quality of life Patients’ Care Experiences Care Transitions Program Coleman et al., 2006 Parry et al., 2009 — NS — — — — Chronically Critically Ill Daly et al., 2005 NS — — Project RED Jack et al., 2009 + — — Transitional Care Model Naylor et al., 1994 Naylor et al., 1999 Naylor et al., 2004 NS NS NS — — + + NS + Congestive Heart Failure Rich et al., 1995 NS + — Telehealth (with HF) Wakefield et al., 2008 NS + —
  19. 19. Effects on Healthcare Resource Use 19 Citation Total readmissions, all cause (no. of months) Time to first readmission (no. of months) Length of readmission stay (no. of months) Other resource use Care Transitions Program Coleman et al., 2006 Parry et al., 2009 + (3 mo) + (3 mo) — — — — — — Chronically Critically Ill Daly et al., 2005 NS NS + (2 mo) — Project RED Jack et al., 2009 +(1 mo) — — + Transitional Care Model Naylor et al., 1994 Naylor et al., 1999 Naylor et al., 2004 + (1.5 mo) + (6 mo) + (12 mo) NS + (6 mo) + (12 mo) + (1.5 mo) + (6 mo) NS NS NS + Congestive Heart Failure Rich et al., 1995 + (3 mo) — + (3 mo) — Telehealth (with HF) Wakefield et al., 2008 + (12 mo) + (12 mo) NS NS
  20. 20. Examples of Unanswered Questions That Could Build Upon This Evidence What are common triggers of major health transitions? (e.g., decline in function, death of spouse) What transitional care outcomes matter most to patients (e.g., trust, achieving their health goals, functional status, quality of life)? To their family caregivers? How do we consistently measure them? What risk stratification strategies are effective at identifying who will benefit most from transitional care approaches of different intensities? 20
  21. 21. Unanswered Questions How can behavioral health be more effectively incorporated into transitional care? How can transitions between hospitals and homes be better aligned with primary care and community organizations? What components of effective transitional care interventions are most valuable? Which models are most effective? Which tools/technologies are most helpful? What is the impact potential on various patient or community subgroups? (e.g., people with low health literacy or advanced illness, communities with fewer resources) 21
  22. 22. Unanswered Questions How can transitional care approaches more effectively engage patients and family caregivers and promote shared decision making? What are the unique transitional care needs of family caregivers? How can their needs be best addressed? Can transitional care evidence be extended to improve palliative care outcomes? What are the facilitators and barriers to successful implementation of effective transitional care? 22
  23. 23. Measuring Patient-Centered Outcomes Sara J. Singer, PhD, MBA Assistant Professor, Harvard University, School of Public Health Erin Rand-Giovannetti, PhD, MPH Research Scientist, National Committee for Quality Assurance 23
  24. 24. How a Question Becomes a Measure Identify what matters Develop a framework Draft measures Test the measures Use the measures 24 Refine Refine
  25. 25. What Matters? Scan the literature  Talk to stakeholders  Identify gaps  Gap 1: Just because structures and services are integrated doesn’t mean that patients receive integrated care.  Gap 2: Patients and loved ones deliver care too. Their needs, preferences, and responsibilities are part of needs to be integrated. 25
  26. 26. Develop a Framework That Describes What Matters Aim to be comprehensive and mutually exclusive 26 Things that matter Coordination within your provider’s office Coordination across your providers / with your hospital Coordination by your provider of care at home Familiarity over time Help with care before, after, and outside of office visits Patient-centered care Support for patient’s role in caregiving --Singer et al., Patient Perception of Integrated Care (PPIC) Survey
  27. 27. Develop Specific Questions to Measure What Matters Borrow or craft items that address your framework  Check that questions are attributable and actionable  Balance number and type 27 Things that matter Coordination within your provider’s office Coordination across your providers / with your hospital Coordination by your provider of care at home Familiarity over time Help with care before, after, and outside of office visits Patient-centered care Support for patient’s shared-responsibility Questions that measure them After your most recent hospital stay, did anyone from your provider’s office contact you to ask about the condition you were in the hospital for? --Singer et al., Patient Perception of Integrated Care (PPIC) Survey
  28. 28. Test, Refine and Use the Survey 28 In the last 6 months, how often did this provider discuss whether the care you were receiving matched your values and preferences? In the last 6 months, how often did this provider discuss whether you were getting the health care you wanted?
  29. 29. Test, Refine and Use the Survey Before using a survey  Do patients understand intended meaning of the questions?  Is the survey too long?   Refine Pilot-test the survey with a small group of patients  Do groups of questions represent coherent concepts?  Are the concepts distinct from each other?  Do measures differentiate providers?  Is there room for improvement? 29
  30. 30. Test, Refine and Use the Survey  Do measures relate to things that should be related?   Refine Retest  repeat 30 Clinical and financial outcomes Patient perceptions of integrated care Integrated organizations and activities
  31. 31. Provide rapid feedback of results  Teach/learn  Act/refine  Repeat Test, Refine and Use the Survey 31 0% 20% 40% 60% 80% 100% %Always How often did you get a timely answer to your medical question after hours?
  32. 32. Importance and Evidence for Outcomes Importance  Importance to individual  Importance to health of population Evidence  Evidence that outcome leads to well-being for individuals  Logic for how the outcome can be influenced by the intervention Ex: Person-centered goal achievement – Percent of individuals who make progress towards a self-defined goal? 32
  33. 33. Scientific Soundness of Measure Scientific Soundness  Reliability: Measure results are repeatable  Validity: Measure results are correct  Meaningful difference 33
  34. 34. Feasibility and Usability - Reality Check Feasibility  How do we actually capture the information we are measuring?  How do we capture the information for populations with communication or cognitive limitations? Usability  Will the information gathered from the measure be useable and worth the cost of measurement? Ex: Person-centered goal achievement – Percent of individuals who make progress towards a self-defined goal? 34
  35. 35. BREAK 35 • Visit us at www.pcori.org • Follow @PCORI on Twitter • Watch our YouTube channel PCORINews
  36. 36. Vignette It is March 5, 2018, and Jane Smith is about to be discharged from Center Hospital, where she was diagnosed with several chronic conditions, which have left her unable to fully take care of herself. She will be leaving with several new medications and the hospitalist’s recommendation to “change your diet and activity level.” A new transitional care program has just been implemented at Center Hospital and is available to patients and caregivers, at their request. Question for Workgroup Participants: From your current perspective (patient, caregiver, clinician, payer, etc.), what are three or four questions that you would want answered before deciding whether to participate in this transitional care program? 36
  37. 37. Collaborative Workgroup Discussion Focus: Provide targeted input without scientific jargon Honor Timelines: Provide brief and concise presentations and comments Participate: Encourage exchange of ideas among diverse perspectives that are present today:  Researchers  Patients  Other stakeholders 37
  38. 38. Workgroup Objectives: Narrowing the Broad Topic Transitional care is a very broad concept The process today is to take this broad concept and:  Understand it  Determine which questions/issues are the most important to all stakeholders  Create a concise list of these high-priority questions 38
  39. 39. Questions from Patient and Stakeholder Perspectives 39
  40. 40. LUNCH 40 • Visit us at www.pcori.org • Follow @PCORI on Twitter • Watch our YouTube channel PCORINews
  41. 41. Comments Submitted by Others E-mail (transitionalcare@pcori.org) Twitter (#PCORI) The webinar “chat” feature Lauren Holuj, MHA Program Associate, Improving Healthcare Systems 41
  42. 42. Discussion of Proposed Research Questions 42
  43. 43. BREAK 43 • Visit us at www.pcori.org • Follow @PCORI on Twitter • Watch our YouTube channel PCORINews
  44. 44. Refinement of Research Questions to be Addressed 44
  45. 45. Recap and Next Steps 45
  46. 46. We Still Want to Hear from You We welcome your input on today’s discussions We are accepting comments and questions for consideration on this topic through July 19, 5:00 p.m. (ET) via e-mail (transitionalcare@pcori.org) We will take all feedback into consideration 46
  47. 47. Thank You for Your Participation 47
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