Your SlideShare is downloading. ×
0
Integrating the management of
care transitions: A look at
innovative, evidence-based models
from the U.S.
5th Annual Disch...
Need to Focus on Complexity
People with chronic , medically complex, long term and disabling
conditions are a major challe...
Need to Focus on Complexity (cont’d)
 Improved quality and efficiency are being demanded in the face of
growing financial...
Typical Complex Populations
The following complex populations experience gaps in care and/or
poorly coordinated care which...
A Major Population: Frail Older People
About 15-20% of people aged 65+ will eventually need a mix of acute
care and long t...
A Major Population: Frail Older People
(cont’d)
 Frequent interactions with providers, and transitions
within and between...
Many Weaknesses in Care of Complex
Populations
Despite cross-national differences, we frequently encounter a host of
weakn...
Many Weaknesses in Care of Complex
Populations (cont’d)
 Poor collaboration at the organizational and provider levels
wit...
Bad Things Often Happen in a
Disjointed and Fragmented System
The traditional health care system is poorly joined-up, frag...
The Solution: ‘Integration’ and
‘Integrated Care’
“Integration is a coherent set of methods and models on the
funding, adm...
Overall Goals of Integrated Care
Integrated care is a holistic, person-centered , population-based and
coordinated approac...
Care Transitions in Integrated Care: A
Special Challenge
“Care transition” describes a continuous process in which the pat...
Care Transitions in Integrated Care: A
Special Challenge (cont’d)
 Patient/caregiver and provider confusion
 Poor satisf...
American Case for Care Transition
Management
In addition to the considerable human costs, poorly managed care
transitions ...
U.S.—”Silicon Valley” of Evidence-
Based Care Transition Models
The U.S. has become a rich proving ground for evidence-bas...
U.S.—”Silicon Valley” of Evidence-
Based Care Transition
 Care Transitions Intervention (CTI) (Coleman Model)
www.caretra...
Coleman Model (1)
The CTI model—developed at an integrated delivery system in Colorado
from 2002 to 2003—is focused on the...
Coleman Model (1) (cont’d)
 Post-discharge: TC conducts one (1) home visit 24-72 hrs post-
discharge; actively engages pa...
Coleman Model (2)
Supporting evidence:
 Lower 30-day readmission; lower readmission after 90 and 180
days (Coleman et al,...
Coleman Model (3)
Performance indicators :
 Processes:
1. # coaches trained
2. % acceptance/attrition
20
3. % coached pat...
Coleman Model (3) (cont’d)
5. Lower ratio of # discrepancies found to # medication reviewed
among coached patients (i.e., ...
Naylor Model (1)
The TCI model, a model of care coordination with an interdisciplinary
approach, is delivered to elderly p...
Naylor Model (1) (cont’d)
 Home visit: TCN visits patient within 24-hours of charge to evaluate
ADLs/IADLs and safety; re...
Naylor Model (2)
Supporting evidence:
 45% reduction in readmission rate (Naylor et al, 1999)
 Increased time to readmis...
Naylor Model (3)
 Processes:
1. # patients referred for TCM intervention
2. # patients accepting TCM
3. # patients workin...
Naylor Model (3) (cont’d)
5. Higher patient quality of life (QoL) scores on SF-36 (i.e, health-
related quality of life)
6...
Building an Optimum Care Transition
Management Model
When taking into account the evidence-based elements of the Coleman
a...
Building an Optimum Care Transition
Management Model (cont’d)
 Accurate and timely sharing of patient information
 Close...
Upcoming SlideShare
Loading in...5
×

Dennis L. Kodner - Integrating the Management of Care Transitions: A look at innovative, evidence-based models from the U.S.

469

Published on

Dr Dennis L. Kodner, PhD, FGSA, Adjunct Professor of Medicine, Division of Geriatric Medicine, McGill University, Canada & Principal, Integrated Care Group LLP, USA delivered the presentation at the 2014 Discharge Planning Conference.

The 2014 Discharge Planning Conference - Assisting health services to adopt an integrated and consumer directed approach to discharge planning.

For more information about the event, please visit: http://bit.ly/dischargeplan14

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
469
On Slideshare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
13
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Transcript of "Dennis L. Kodner - Integrating the Management of Care Transitions: A look at innovative, evidence-based models from the U.S."

  1. 1. Integrating the management of care transitions: A look at innovative, evidence-based models from the U.S. 5th Annual Discharge Planning Conference Melbourne, Australia 25th July 2014 Dr. Dennis L. Kodner, PhD, FGSA, Principal, Integrated Care Group, LLC (USA) and Adj. Professor of Medicine, McGill University (Canada) – Email: DLKodner@aol.com
  2. 2. Need to Focus on Complexity People with chronic , medically complex, long term and disabling conditions are a major challenge to health systems globally. There are several reasons for increasing preoccupation and concern::  Populations with so-called ‘complex’ illnesses are growing 2  Populations with so-called ‘complex’ illnesses are growing significantly as a result of rapid aging and earlier onset of lifestyle- related chronic illnesses  Health systems are largely geared to acute illness and the short- term treatment of single diseases; not multi-morbid conditions with medical, physical, social and other lifelong consequences  Complex conditions are difficult to manage, relatively expensive, and demand new ways of delivering and organizing care
  3. 3. Need to Focus on Complexity (cont’d)  Improved quality and efficiency are being demanded in the face of growing financial constraints.. 3 ((KodnerKodner, 2012; Goodwin, 2012), 2012; Goodwin, 2012)
  4. 4. Typical Complex Populations The following complex populations experience gaps in care and/or poorly coordinated care which frequently lead to an adverse impact on care experiences and care outcomes::  Frail older people 4  Frail older people  People with severe or multi-morbid chronic conditions  People with severe physical disabilities  People with intellectual, developmental or cognitive disabilities  People with serious mental health and/or drug addiction problems..
  5. 5. A Major Population: Frail Older People About 15-20% of people aged 65+ will eventually need a mix of acute care and long term care over time. These frail older people present a complex set of needs and challenges: 5  Health impaired; sometimes cognitively and/or mentally  Multiple, ongoing co-morbidities  Dependent in functioning and self-care (i.e., ADL/IADL)  High risk of hospitalization/rehospitalization and institutionalization
  6. 6. A Major Population: Frail Older People (cont’d)  Frequent interactions with providers, and transitions within and between systems, settings and levels of care  Access, coordination and continuity problems 6  Difficult to manage and relatively costly  Caregiver burden and stress..
  7. 7. Many Weaknesses in Care of Complex Populations Despite cross-national differences, we frequently encounter a host of weaknesses in health care systems that work against effectively meeting the needs of complex populations in an integrated way:: 7  Greater emphasis on ‘cure’ vs. ‘care’  Fragmented, misaligned policy-making, planning, regulation and financing  Imbalance between institutional and community services
  8. 8. Many Weaknesses in Care of Complex Populations (cont’d)  Poor collaboration at the organizational and provider levels within and between the various sectors  Lack of a single provider team and/or entity with responsibility for all care and outcomes.. 8 for all care and outcomes.. (Kodner, 2011)
  9. 9. Bad Things Often Happen in a Disjointed and Fragmented System The traditional health care system is poorly joined-up, fragmented and confusing. As a result, bad things often happen::  Patients get lost 9  Needed services fail to be delivered, are delayed or provided in the wrong settings  Quality and patient satisfaction decline  Health outcomes suffer  Care is more costly.
  10. 10. The Solution: ‘Integration’ and ‘Integrated Care’ “Integration is a coherent set of methods and models on the funding, administrative, organizational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the cure and care sectors...[to] enhance quality 10 within and between the cure and care sectors...[to] enhance quality of care and quality of life, consumer satisfaction and system efficiency for patients with complex problems cutting across multiple providers, services and settings...[where] the result of such multi-pronged efforts to promote integration...is called integrated care.” (Kodner & Spreewenberg, 2002)
  11. 11. Overall Goals of Integrated Care Integrated care is a holistic, person-centered , population-based and coordinated approach to addressing the multiple needs of individuals with complex conditions who suffer gaps in service as well as fragmented care. There are three (3) overarching goals:: 11 1- Better patient journey, experience and satisfaction 2- Improved care outcomes—personal health status, quality of life, etc. 3- Enhanced efficiency and cost-effectiveness..
  12. 12. Care Transitions in Integrated Care: A Special Challenge “Care transition” describes a continuous process in which the patient ‘s care shifts from one setting to another. Frail older people and other complex patient groups are especially vulnerable to poorly managed care transitions. There are many possible adverse consequences: 12  Serious unmet needs  High rates of preventable hospital readmissions  Avoidable medication errors, complications from procedures, infections and falls  Underuse, overuse, or misuse of health care resources, including duplication and waste
  13. 13. Care Transitions in Integrated Care: A Special Challenge (cont’d)  Patient/caregiver and provider confusion  Poor satisfaction with care  Increased health care costs.. 13
  14. 14. American Case for Care Transition Management In addition to the considerable human costs, poorly managed care transitions have a major impact on the U.S. health care system:  Inadequate care coordination—including management of care transitions—is responsible for $25-45 billion USD in wasteful 14 transitions—is responsible for $25-45 billion USD in wasteful spending annually due to avoidable complications and unnecessary hospital readmissions .  20% of U.S. fee-for-service Medicare beneficiaries (primarily elderly) discharged from hospital are readmitted within 30-days  50% of these patients had no contact with a physician between first hospitalization and readmission..
  15. 15. U.S.—”Silicon Valley” of Evidence- Based Care Transition Models The U.S. has become a rich proving ground for evidence-based care transition models. Numerous models have been developed and tested over the past 15 years or so. Models largely focus on hospital-to- home transitions that are designed to reduce readmissions and/or poor 15 outcomes, as well as costs. Following are the more well-known models:  BOOST (Better Outcomes for Older Adults through Safe Transitions –Society of Hospital Medicine www.hospitalmedicine.org/BOOST  Bridge—Rush University Medical Center, Chicago www.hmprg.org/programs-projects/illinois-transitional-care- consortium
  16. 16. U.S.—”Silicon Valley” of Evidence- Based Care Transition  Care Transitions Intervention (CTI) (Coleman Model) www.caretransitions.org  Project RED (Re-engineered Discharge)—Boston Medical Center, Boston 16 Boston www.bu.edu/fammed/projectred/index.html  Transitional Care Model (TCM) (Naylor Model) www.transitionalcare.info
  17. 17. Coleman Model (1) The CTI model—developed at an integrated delivery system in Colorado from 2002 to 2003—is focused on the 65+ population, but may also be applied to younger adults. Point of entry is through hospital. Patient must be community-dwelling and have at least one of 11 high-risk diagnoses . 17 Intervention is organized around Transition Coach (TC) /Advanced Practice Nurse and lasts for 30-days post-discharge. Program design:  4 pillars: Medication management, patient-centered record, primary care and specialist follow-up, and knowledge of “red flags”  Pre-discharge: TC conducts hospital visit and uses tools such as Personal Health Record (PHR)
  18. 18. Coleman Model (1) (cont’d)  Post-discharge: TC conducts one (1) home visit 24-72 hrs post- discharge; actively engages patient in medication reconciliation; uses role-playing to transfer skills; and, reviews any red flags that indicate a worsening condition and strategies to address them  18  Follow-up: TC makes three (3) follow-up phone calls reinforcing coaching; discusses patient encounters with health care professionals; follows-up with primary care and specialist physicians; and, provides support for patient’s self-management role..
  19. 19. Coleman Model (2) Supporting evidence:  Lower 30-day readmission; lower readmission after 90 and 180 days (Coleman et al, 2006) 19 days (Coleman et al, 2006)  Higher Patient Activation Assessment (PAA) scores (Parrish et al, 2009)  Earlier recognition and resolution of changes in older adult’s health status (Enderlin et al, 2013)  Estimated cost savings for panel of 350 coached patients over 12- months is $300,000 USD (CTI, nd)..
  20. 20. Coleman Model (3) Performance indicators :  Processes: 1. # coaches trained 2. % acceptance/attrition 20 3. % coached patients with Personal Health Record (PHR) 4. % coached patients who report using PHR 5. % coached patients who schedule follow-up PCP appointment  Outcomes: 1. Higher PAA scores 2. % coached patients with increased patient activation 3. % coached patients achieving 30-day health goal 4. Higher Care Transition Measures (CTM) scores (i.e., quality of transition)
  21. 21. Coleman Model (3) (cont’d) 5. Lower ratio of # discrepancies found to # medication reviewed among coached patients (i.e., accuracy of medications) 6. % patients who attend scheduled PCP follow-up visit (i.e., primary care follow-up) 7. % coached patients who can identify all red flag conditions for 21 7. % coached patients who can identify all red flag conditions for his/her disease..
  22. 22. Naylor Model (1) The TCI model, a model of care coordination with an interdisciplinary approach, is delivered to elderly patients at high-risk of poor post-discharge outcomes. Patients must have two or more risk factors (e.g., poor self- health ratings, multiple chronic conditions, history of recent 22 hospitalizations, etc.). Point of entry is through hospital (on admission). Model is organized around Transitional Care Nurse (TCN) and lasts for 30- 90 days post-discharge (60-days average). Program design:  Pre-discharge: TCN performs hospital-based assessment; visits patients daily; collaborates with care team to reduce adverse events and prevent functional decline; develops streamlined, evidence- based plan of care
  23. 23. Naylor Model (1) (cont’d)  Home visit: TCN visits patient within 24-hours of charge to evaluate ADLs/IADLs and safety; recommend adaptations; and , refer to other services  Follow-up: TCN accompanies patient to post-discharge MD visit and subsequent visits; facilitates MD-RN collaboration across episodes of 23 subsequent visits; facilitates MD-RN collaboration across episodes of acute illness; conducts weekly home visits for one month; makes weekly patient phone contact if in-person visit not scheduled; provides on-call support (phone/home visit) 7 days per week; actively engages patients and family caregivers with focus on their goals; and, facilitates communication among patient, family caregivers and health care professionals..
  24. 24. Naylor Model (2) Supporting evidence:  45% reduction in readmission rate (Naylor et al, 1999)  Increased time to readmission/death; reduced readmission rate 24  Increased time to readmission/death; reduced readmission rate (Naylor et al, 2004)  Earlier recognition and resolution of changes in older adult’s health status (Enderlin et al, 2013)  Lowered mean total costs by 39% ($7,636 USD vs $12,481 USD) (Naylor et al, 2004)..
  25. 25. Naylor Model (3)  Processes: 1. # patients referred for TCM intervention 2. # patients accepting TCM 3. # patients working with TCN 25 4. % eligible patient pop. working with TCN  Outcomes: 1. Higher average PAA scores 2. % patients with increased patient activation scores 3. Lower % TCM patients reporting complications (i.e., complications) 4. % TCM patients demonstrating medication self-management skills that minimize adverse events as rated by TCN
  26. 26. Naylor Model (3) (cont’d) 5. Higher patient quality of life (QoL) scores on SF-36 (i.e, health- related quality of life) 6. % TCM patients reporting satisfactory care (i.e., patient satisfaction) 7. % TCM patients with no outstanding medication reconciliation 26 7. % TCM patients with no outstanding medication reconciliation items (30-days post-discharge) and % TCM patients with no worsening symptoms (30-days post-discharge)..
  27. 27. Building an Optimum Care Transition Management Model When taking into account the evidence-based elements of the Coleman and Naylor interventions as well as related best practices widely found in other U.S. models, an optimum care transition management model should contain the following core components: 27  Comprehensive discharge planning starting at hospitalization  Medication reconciliation—medications, doses and contraindications  Patient/caregiver education and training using coaching and/or “teach back” methods—medications, self-care, and symptom recognition/management  Personal health record maintained by patient—health status, medications, questions to ask providers, etc.
  28. 28. Building an Optimum Care Transition Management Model (cont’d)  Accurate and timely sharing of patient information  Close, ongoing relationship with patient/family caregiver  Close, ongoing communication, collaboration and coordination 28  Close, ongoing communication, collaboration and coordination between providers  Prompt post-discharge follow-up visit with PCP and specialist(s)  Ongoing patient advocacy..
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×