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Bridge Model ASA 2012


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Presentation from the Illinois Transitional

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Bridge Model ASA 2012

  1. 1. The Bridge ModelAn Innovative Social Work Model of Transitional Care Aging in America Conference Washington, D.C. – March 29th, 2012
  2. 2. AgendaI. Welcome and IntroductionsII. Bridge Model Overview and ProcessIII. Research and EvaluationIV. Unique Components of the Bridge ModelV. Rural ImplementationVI. Policy and Health Systems Implications
  3. 3. The Illinois Transitional Care Consortium Community-based organizations  Aging Care Connections  Shawnee Alliance for Seniors  Solutions for Care Hospitals  Rush University Medical Center  MacNeal Hospital  Adventist LaGrange Memorial Hospital  Herrin Hospital  Memorial Hospital of Carbondale Research, Evaluation & Policy  University of Illinois at Chicago, School of Public Health  Health & Medicine Policy Research Group
  4. 4. Bridge Model Overview & ProcessWalter Rosenberg, Rush University Medical Center – Health & Aging
  5. 5. Basic Definitions  What is care coordination?  What is transitional care?  What is social work?
  6. 6. Core competencies Engagement and assessment Resource linkage Self-management support and education Counseling Team interaction Care coordination
  7. 7. Why Social Work? Why do readmissions take place?  Root cause analysis  Medical  Psychosocial  Existing resources or redundant resources? Geriatric Interdisciplinary Team Training (GITT)  Rush post-graduate course  “The Glue” Reintroduction to healthcare  Putting social work back on the map
  8. 8. Root Cause Analysis Hospital-level  Chart reviews  Interdisciplinary focus groups  Individual interviews Community-level  Identify community providers  Interdisciplinary focus groups  Individual interviews
  9. 9. Bird’s eye viewPre-Discharge Post-Discharge 30-day follow-up • Referral • Assessment • Confirm long- • Assessment • Connection to term support • Information providers structure gathering • Psychosocial • Collect data • Community support resources • Decreased readmissions • Decreased mortality • Increased physician follow-up • Increased understanding of medications and discharge plan of care • Decreased patient and caregiver stress
  10. 10. Quick information Telephonic 5-6 calls over a period of 5-6 days Calls made to:  Client/caregiver  Primary care  Hospital of origin  Pharmacy  Community-based organizations
  11. 11. Target Population  Must have all of the below  60+  Chronic condition  Previous hospitalization within 6 months  Must have at least one of the below  Discharged with home health  Living alone  Discharged to a skilled nursing facility  Current practice  Expanded demand and realistic pressures
  12. 12. Assessment domains Common Problem Areas  Transition/Discharge Plan  Home Health  Follow-up Medical Care  Medication Management  Self-Management  Psychosocial
  13. 13. Pre-dischargeThe participant enters Referrals can originate Preparation forthe hospital with more from an electronic discharge must include than an illness. medical record, a as broad a picture of discharge planner, the Pre- the patient/consumer as•Caregiver patient or a family possible•Family Referral member. Discharge•SESHospital Assessme •Discharge plan of care•Race Admission (Target •Risk screen built in to •Community resources nt and•Gender Population) the EMR •Systemic challenges Interventio•Ethnicity •If non-hospital staff, •Community physicians•Religion requires access to the n •Interdisciplinary team•Mental Health EMR •Essential information•Personal Values and •Balance between Beliefs consistency and flexibility
  14. 14. Post-discharge Walking through the The map is not the Longer termhouse doors, one walks territory. What involvement to ensure back into their real life changed? How can we the patient/consumer help? Post- remains connected•Caregiver•Family Discharge •Understanding of •Still connected to•SES Back Assessme discharge plan of care 30-day necessary resources?•Race •Understanding of •Quality assurance Home•Gender nt and medications Follow-up •Emotional support•Ethnicity Interventio •Follow-up on (30% re-contacts post-•Religion n community resources intervention)•Mental Health •Ensure physician•Personal Values and follow-up Beliefs •Caregiver support •Emotional support
  15. 15. A Case Example Mrs. Harrison – Widowed – 75 years old – Has diabetes and COPD Admitted through the ED after a fall – Hospitalized for 5 days – Discharged with home health care – 10 medications prescribed
  16. 16. Mrs. Harrison at HomeCommunity PCP doesn’t know Mrs. Harrison was Is this the Mrs. Harrison is afraid she will fall again and Mrs. Harrison’s primary caregiver is have to return to the overwhelmed and has to Mrs. Harrison doesn’t worst case admitted to the hospital. hospital. which medications to work. know return The Home Health Care Agency doesn’t arrive on to resume and which to time. stop taking at home. Mrs. Harrison is feeling Mrs. Harrison’s two scenario,Mrs. Harrison is having children can’t agree howdifficulty coping with her mobility changes. Mrs. Harrison has to best manage their mother’s medical needs. depressed because she can’t get around anymore like she used to. Mrs. Harrison can’t questions about her or is it medical bill and doesn’t afford her medications anyway. know what her insurance Harrison is feeling Mrs. Harrison has no Mrs. a typical transition? will cover. transportation to her follow-up medical appointments. isolated now that she’s homebound. Mrs. Harrison’s Community Services are delayed
  17. 17. Mrs. Harrison is afraid Mrs. Harrison’s primaryCommunity PCP doesn’tContact Community PCP Facilitate home Support caregiver and caregiver is she will fall again and know Mrs. Harrison was to inform of Mrs. evaluation by Home listen to concerns. Link have to return to the overwhelmed and has to Mrs. Harrison doesn’t admitted tohospital stay. Harrison’s the hospital. Health Care Agency. communication resources. Facilitate to community Call The Home Health Care know which medications to work. hospital. with pharmacy, return Agency doesn’t arrive on Agency to troubleshoot to resume and which to prescribing physician, Mrs. HarrisonWork with Home Health Care Agency anddifficulty coping with her Communicate home at home. and taking Mrs. Harrison is feeling stop scheduling issues. Mrs. Harrison’swith health nurse. time. How does Bridge help? two children to plan forMrs. Harrison is having children can’t agree how immediate care needs. to best manage their Screen for supportive depressed because she mental health programs can’t get around physician to identify Refer to care or ongoing counseling at Home mobility changes. mother’s medical needs. anymore like she used Refer Mrs. Harrison to management. therapy needs. services. Mrs. Harrison has to. patient access Mrs. Harrison can’t questions about her Connect to pharmacy immediately and connect afford her medications medical bill and doesn’t assistance program. to Senior Health anyway. know what her insurance Harrison is feeling Mrs. Mrs. HarrisonProgramMrs. and connect to Refer Link Harrison has no Insurance to Communicate with CCU will cover. (SHIP) Counselor isolated now that she’s case managerServices transportation to her medical transportation local friendly visiting Community to ensure follow-up medicalresources and assist in homebound. program. were delayed prompt resumption or appointments. scheduling services. start of services
  18. 18. Research & EvaluationSusan Altfeld, University of Illinois at Chicago – School of Public Health
  20. 20. The Bridge Model Evidence Base The Bridge Model is an adaptation of the Enhanced Discharge Planning Program (EDPP)  EDPP is an evidence-based model developed and evaluated with a randomized-controlled trial at Rush University Medical Center (ITCC partner) Bridge implements the evidence based components of EDPP and best practices developed by ITCC partner sites  Bridge is a hospital and community partnership  Illinois Department on Aging and AgeOptions partnership for Community Based Care Transitions through Administration on Aging
  21. 21. Evaluation of the Bridge Model Important variables from our previous work and other evidence based care transitions interventions  Patient characteristics  Health status  Patient stress  Caregiver stress  Understanding of responsibilities for managing health  Medical follow up  Hospital readmissions  Mortality  Satisfaction
  22. 22. Evaluation data collection - ITCC Bridge Intake assessment 2 day post discharge assessment 30 day follow up assessment Satisfaction survey Both “patient” and “caregiver” versions of the assessment surveys  Telephone  Email /telephone satisfaction surveys Readmissions and mortality data from Medicare through the Quality Improvement Organization in Illinois
  23. 23. Evaluation of the Bridge Model Who are our participants?  3090 participants at 5 sites across Illinois  May 2010-December 2011
  24. 24. Bridge client demographics Preliminary data May 2010-December 2011 Research sample (N=519) Male 29.7% 75+ 63.5% Living alone 44.7% Non-English speaking 12.3% Minority/”non-White” 29.1%
  25. 25. 2-day post-discharge assessment Older adult client’s health  At this time, how is your health?/ how is (Mr./Ms. patient last name)s health?) Excellent 2.2% Very good 18.3% Good 46.8% Fair 26.2% Poor 6.4%
  26. 26. 2-day post-discharge assessment Older adult (patient) stress “Since I left the hospital, managing my needs has been stressful for me” 34.4%
  27. 27. 2-day post-discharge assessment Caregiver stress “Since (older adult patient) left the hospital, has managing his/her needs been stressful for you?” 52.2%
  28. 28. 2-day post discharge assessment Understand medications  “I understand the purpose of each of my medications and how to take each of them” 95.5%
  29. 29. 2-day post discharge assessment Understand symptoms/”red flags”  “I understand what symptoms I need to watch out for” 95.5%
  30. 30. 2-day post discharge assessment Cue to action “I understand who to call if these symptoms occur” 98.0%
  31. 31. 2-day post discharge assessment Problems/“Surprises”  “Are things more difficult than you expected since leaving the hospital, less difficult or about what you expected?” More difficult 23.5% Less difficult 12.1% As expected 64.4%
  32. 32. 30-day outcomes patient follow up/adherencePhysician visit within 30 days of discharge 84.7%
  33. 33. 30-day outcomes adverse eventsMortality 1.7%
  34. 34. 30-day outcomes adverse eventsReadmissions Awaiting report
  35. 35. 30-day outcomes adverse eventsNursing home placement 3.0%
  36. 36. Satisfaction survey Decision making “The assistance or information you received from the Bridge Program helped you (or your loved one) make decisions about your care.” 84.7%
  37. 37. Satisfaction survey Links to community services “The assistance or information you received from the Bridge Program helped you (or your loved one) connect to services and resources.” 77.9%
  38. 38. Satisfaction survey Patient stress  “The Bridge Program helped to make the hospital discharge experience less stressful for you/ (the patient).” 90.9%
  39. 39. Satisfaction survey Caregiver stress  “The Bridge program helped to make the hospital discharge experience less stressful for family or other loved ones.” 97.8%
  40. 40. Satisfaction survey Satisfaction  “I would recommend this program to others.” 89.5%
  41. 41. Satisfaction Survey - QuotesSatisfactionUnmet needs/anything you would change/what did you like about theBridge Program?“I like everything about the Bridge Program.”“You are providing a great service.”“I would like it to be much more advertised for everyonewherever they live.”“It would be nice for everyone to receive the services likemy father.”“I cannot think what else the social worker could have doneadditionally since she was very helpful throughout ….”
  42. 42. Unique Components of the Bridge ModelIlana Shure, Aging Care Connections – Aging Resource Center
  43. 43. Unique Components of the Bridge Model Social work model Builds off of the aging network Bridge requires a true partnership between the community-based organization and the hospital  The community-based organization is in the leadership role
  44. 44. Bridge Care Coordinator Qualifications Master’s in social work Expertise in geriatric field Strong clinical and advocacy skills Experience in both community and hospital settings Knowledge of state, federal and community resources
  45. 45. Aging Network • Administration on Aging & OlderAoA Americans Act • State Unit on AgingSUA • Area Agency on AgingAAA • Care Coordination Unit (Unique to Illinois)CCU
  46. 46. AAAs are Your Community Service Experts • Adult Day Care Medicaid • Case Management Waiver • Emergency Home Program Response • In-home Services • Home Delivered Meals Older • Caregiver Support Area Agencies on Americans Services Act • Transportation Aging Services • Information and Assistance Private • Counseling and /or • Ethnic Resources Volunteer • Community-specific and Services local
  47. 47. Connecting to Community-based ServicesAssessment of needSet-up services based on assessment (eligibilityand application); including caregiver supportBenefits Check-Ups (receiving all eligiblebenefits)Provide information & assistance for olderpeople and their families
  48. 48. Aging Network – a critical tool in the Bridgetoolkit Identifying older adults in the hospital who are at-risk for potential adverse events post-discharge Connecting the hospital and the older adult to the existing Aging Network (home and community-based resources) Reduce the risk of adverse events  reduce re- hospitalizations
  49. 49. Complementing the Aging Network The Aging Network provides an important safety net. Here are other areas critical to successful transitions addressed by Bridge:  Transition/Discharge Plan complications  Home Health – systemic and client-level issues  Follow-up Medical Care  Medication Management  Self-Management  Psychosocial complications
  50. 50. Who are Your Transitional Care Partners? Hospital Hospital – Aging Network collaboration Non- Primary traditional Care Resources PhysicianPharmacy AAA Home Health Skilled Community Nursing Based Facility Agencies Caregivers
  51. 51. Working Together Recognize the differences between cultures We come from different perspectives and have different languages  What does MI mean to you?  Working together you encounter a lot of “Why a Duck?” situations… Address concerns early and troubleshoot problems together Share both successes and challenges
  52. 52. Culture Change is a Challenge  Integrate at all levels of the hospital system  Front desk reception to Regional Director  Be patient and persistent  Guest versus Team Member  Troubleshoot challenges before they become barriers  Learn both cultures and languages  Network, network, network
  53. 53. The Aging Resource Center (ARC) On-Site at theHospital Physical office space for the Bridge Care Coordinators (BCCs) to receive referrals and access hospital and community records A library of resources for Bridge clients and caregivers Space for the BCCs to collaborate with the interdisciplinary team A location for the BCC to meet with Bridge clients and their families to discuss community-based resources available The ARC is an on-site hospital location for the Bridge Program. The establishment of an ARC symbolizes the commitment of both partners to sustaining Bridge.
  54. 54. The Role of the ARC Symbol of hospital-community collaboration Greater ability to interface with the community Promotes the notion of “systems” approach to discharge planning Maximizes the opportunity for a servable moment
  55. 55. Benefits of the ARC Time and expertise to focus on participant and the transitional process Community expertise The transition happens fast and the BCC has to know how to put all of the pieces together in an expedited manner to ensure a safe transition home. Not only does the BCC need to know the unique language, values, and perspectives of the client and family but also what services and resources are available to the individual.
  56. 56. Rural Implementation of the Bridge ModelAmanda Groaning, Shawnee Alliance for Seniors
  57. 57. Shawnee Alliance for Seniors Shawnee Alliance for Seniors, an Illinois Care Coordination Unit, serves the southernmost counties of Illinois  An entirely rural area roughly 4,557 square miles  The largest community, Carbondale, has 20,000 residents  20.5 % of population in the lower 13 counties is over the age of 60
  58. 58. Shawnee Alliance for Seniors (con’t) Shawnee utilizes BCCs with experience working in the rural area and have a sensitivity to and awareness of issues specific to rural elders, including:  Limited access to care  Literacy and Language Barriers  Geographic and Social isolation  Extended family such as neighbors and friends often must step in when the elder has no family members living in the immediate area
  59. 59. Problems Facing Seniors in Rural Areas Limited Access to Care  Distance  5 out of the 13 counties do not have hospitals  Most seniors face at least a 30 minute drive to access basic services  Limited public transportation services  Lack of Resources  Smaller populations means less funding for services  Emergency and Specialty needs referred out of the area
  60. 60. Literacy and Language Barrier  Limited Education  Due to need to work  Gender bias  Disability  Language Barrier  Limited access to interpreters  Few resources and materials  Reliance on Family as translator
  61. 61. Geographic and Social Isolation Pros  Cons  Community support  Isolation from resources,  Extended family family, and friends  Better communication and  Dependence on non-family relationships between supports that are not always agencies who are sharing reliable clients  Higher risk for burn-out and caregiver stress
  62. 62. Role of the Bridge Care Coordinator What does a BCC bring to the table?  Integration of community resources in the hospital  On site materials and direct access to the Bridge Care Coordinator  Expanded access to care for clients and caregivers  Education to hospital staff  Breadth of post-discharge support
  63. 63. Initial Bridge Assessment Medical record review Patient set up with in home services to assist with care  Home delivered meals were arranged for 5 days a week  Health education for his diabetes  Medication management  Transportation
  64. 64. 2-day follow-up Medications management Health Education for diabetes Concerns over bathing, possible need for DME New financial concerns over electrical bill
  65. 65. 30-day follow-up Transportation Possible financial exploitation
  66. 66. Policy and Health Systems ImplicationsKristen Pavle, Health & Medicine Policy Research Group – Center LTC Reform
  67. 67. Transitional Care: Integrating Medical and SocialModels of Care  Medical models of care do not sufficiently cover an individual’s comprehensive needs, but health care is typically categorized and reimbursed as a medical commodity  Culture Change  Systems Change  Bridging silos of care
  68. 68. How do we A Systemic Look at a coordinate this care Transitional Care Event transition?! Care Coord -inator Hospital Community Health Insurer
  69. 69. Transitional Care, Health Reform, andCommunity Involvement Affordable Care Act  Aging & Disability Resource Center Care Transitions Grant  Providing Aging & Disability Resource Centers (community- based organizations) an opportunity to participate in a nation- wide care transitions network  Sharing best-practices  Highlighting community (ADRC) and hospital partnerships  Provisions 3025 & 3026 (next slide)
  70. 70. Affordable Care Act Provisions 3025 and3026 Section 3025 - The “Stick”  Withholding total Medicare reimbursement rates up to 3% for high readmission rates. Section 3026 Community-based Care Transitions Program – The “Carrot”  Contracting with CMS to provide fee-for-service care transition services through Medicare  $500 Million, several contracts/projects already accepted
  71. 71. 3026 Impact on Integrating Medical & Social Over the next 5 years, Mathematica and the Lewin Group will be evaluating the Community-based Care Transitions Program through a contract with CMS Will this opportunity contribute to a change in the health care system as we know it?  Bridging silos? Bridging hospital and community? Holding different entities across the care continuum accountable for quality outcomes in care?
  72. 72. Bridge Model and 3026 The Bridge Model has been used in two Community- based Care Transitions Program proposals that have been accepted  Illinois: “Bridge Transitional Care Partnership”  Illinois Transitional Care Consortium partnership with AgeOptions (suburban Cook County AAA/ADRC)  Pennsylvania: “Philadelphia Bridge Care Transition Program, North Philadelphia Safety Net Partnership”.  Philadelphia Corporation for Aging, Einstein Medical Center Philadelphia, Temple University Hospital
  73. 73. Opportunities for Bridge Model Training The Illinois Transitional Care Consortium offers a training package to agencies/hospitals interested in replicating the Bridge Model  Full-day, in-person training  Follow-up consultation via conference calls over 3-months post-training Bridge Model
  74. 74.
  75. 75. Thank You to Our Funders & Partners
  76. 76. Contact Information  Susan Altfeld (  Amanda Groaning (  Kristen Pavle (  Walter Rosenberg (  Ilana Shure (