The Bridge Program (ITCC)

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The Illinois Transitional Care Consortium (ITCC) presentation at the 2011 American Society on Aging Conference: the Bridge Model of transitional care.

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  • ITCC is a result of collective experience in the field of aging, and visionary leadership
  • Kristen – I’ve mentioning this a lot on presentations – when you get to the 40-50% make it clear that it does not imply that social workers can only prevent 40-50% of readmissions because social workers can intervene on numerous medical issues by connecting the right silos of care together. Things like medication regimen or discharge instruction confusion, etc.
  • ilana
  • Pre-discharge: referrals in one of a few ways (emr, walk-ins, d/c planners), assessment in one of a few ways (emr, interdisciplinary team, d/c-planner, family/patient)
  • Post-discharge: 48 hr. assessment and intervention (in-depth piece, follow up on important non-resource issues like pcp f/u, regimen understanding, caregiver burden, unmet needs, home health, etc. )
  • Key word: advocacy
  • Bring up own experience when possible (tell them a little story)“good patient” is a big reason why the situation changes post discharge. We’re all taught to respect doctors and we nod and say yes, but do we really understand? So even with good coaching, however (coleman, naylor), things will go wrong at d/c
  • Note that not all participants live in area…this is just a snapshot from one CCU
  • Building on what we have learned
  • Not a discharge planning issue but UNANTICIPATED SURPRISES!
  • Integrating intervention and data collection to minimize burden for pts and staff
  • Data on a much smaller sample --- designing data measures, irb approvals, hospital approvals, coordination
  • (point out on slide the name of the variable ---and then how the question was asked)
  • Marketing!
  • Walter and ilanaTell them that more details on BCCs and data is still coming
  • The Bridge Program (ITCC)

    1. 1. Bridging Hospital to Home<br />The Bridge ModelAn Innovative Social Work Approach to Transitional Care<br />American Society On Aging<br />Thursday April 28th, 2011<br />San Francisco, CA<br />
    2. 2. Kristen Pavle, Health & Medicine Policy Research Group<br />Good Morning!<br />
    3. 3. Agenda<br />ITCC, Transitional Care<br />The Bridge Model<br />Building Relationships: Hospital <br /> & Community Based Organizations<br />Aging Resource Centers<br />Business agreements/contracts<br />Cultural Competency<br />Research, Evaluation, and Data<br />Q & A<br />
    4. 4. Who we are… the Illinois Transitional Care Consortium<br />ITCC was formed to more effectively address needs of older adults transitioning from the hospital to the community by linking hospital based services with the aging network through intensive care coordination.<br />
    5. 5. ITCC members<br />Community-based organizations<br />Aging Care Connections<br />Shawnee Alliance for Seniors<br />Solutions for Care<br />Hospitals<br />Rush University Medical Center<br />MacNeal Hospital<br />Adventist LaGrange Memorial Hospital<br />Herrin Hospital<br />Memorial Hospital of Carbonda;e<br />Research, Evaluation & Policy<br />University of Illinois at Chicago, School of Public Health<br />Health & Medicine Policy Research Group<br />
    6. 6. So, why transitional care?<br /><ul><li>19.6% of Medicare beneficiaries are readmitted in 30 days
    7. 7. 19% of patients experience an adverse event within 3 weeks of hospital discharge
    8. 8. 76% of 30 day readmissions are “highly preventable”</li></li></ul><li>Older Adults and Care Transitions<br />Older adults are particularly vulnerable to poor transition outcomes<br />Multiple medical conditions, medications, and care providers<br />Physical and cognitive limitations<br />Health literacy<br />Burdened caregivers<br />Photo courtesy of “auntjojo” on Flickr.com<br />
    9. 9. The United States Health Care System<br />Medicare<br />Medicare Advantage Plans<br />Private Insurance<br />Co-Pays<br />Deductibles<br />In-Network Providers<br />Rehabilitation<br />Skilled Nursing Facilities<br />In-Patient Hospital Stays<br />Community-based Organizations<br />Primary Care Physicians<br />Specialist doctors<br />Nurses<br />Social Workers<br />Preventive Care<br />Long-term care<br />Family Caregivers<br />Medicaid<br />Home care physicians<br />Medical homes<br />Accountable care organizations<br />Direct-care workers: home health, home care<br />
    10. 10. Perfect Storm<br />Increasingly aged population<br />Greater functionality with chronic conditions<br />Living longer, yet sicker<br />Bottom Line: people need better care and we need to<br /> offer high quality care <br /> while containing costs<br />Photo courtesy of “striking_photography” on Flickr.com<br />
    11. 11. Transitional Care<br />Coordinating care from one care setting to another<br />Hospital to home<br />Hospital to nursing home<br />Nursing home to home<br />Home to nursing home<br />Within hospital or nursing home<br />Insurance transitions<br />PCP transition<br />Caregiver moving in or out<br />
    12. 12. Advisory Board<br />Jean Bohnhoff - Executive Director, Effingham County Committee on Aging<br />Thomas Cornwell - Medical Director, HomeCare Physicians<br />Bob Clapp - Senior Vice President, Hospital Affairs, Rush University Medical Center<br />Jim Durkan - President/CEO, Community Memorial Foundation<br />Karen Freda - Executive Director, Illinois Council of Case Coordination Units<br />Michael Gelder - Senior Health Policy Advisory to Illinois Governor Pat Quinn<br />Michael Koronkowski – Pharmacist and Geriatrics Professor, University of Illinois at Chicago<br />Patricia Merryweather - Vice President, Illinois Hospital Association<br />Jonathan Lavin - Executive Director, Age Options, Suburban Cook County Area Agency on Aging<br />Marta Pereyra - Coalition of Limited English-Speaking Elderly<br />Cheryl Schraeder - Director of Policy & Practice Initiatives, Institute for Healthcare Innovation, University of Illinois at Chicago College of Nursing<br />Patricia Volland - Senior Vice President, Strategy & Business Development, The New York Academy of Medicine<br />Rebecca Zuber - President, Rebecca Zuber, Inc.<br />
    13. 13. Walter Rosenberg, Rush University Medical Center<br />The Bridge Model<br />
    14. 14. A Case Example<br />Mrs. Harrison<br /><ul><li>Widowed
    15. 15. 75 years old
    16. 16. Has diabetes and COPD</li></ul>Admitted through the ED after a fall<br /><ul><li>Hospitalized for 5 days
    17. 17. Discharged with home health care
    18. 18. 10 medications prescribed</li></li></ul><li>Is this the <br />worst case scenario, <br />or is it <br />a typical transition?<br />Mrs. Harrison at Home<br />Community PCP doesn’t know Mrs. Harrison was admitted to the hospital.<br />Mrs. Harrison’s primary caregiver is overwhelmed and has to return to work.<br />Mrs. Harrison is afraid she will fall again and have to return to the hospital.<br />Mrs. Harrison doesn’t know which medications to resume and which to stop taking at home.<br />The Home Health Care Agency doesn’t arrive on time.<br />Mrs. Harrison’s two children can’t agree how to best manage their mother’s medical needs.<br />Mrs. Harrison is feeling depressed because she can’t get around anymore like she used to.<br />Mrs. Harrison is having difficulty coping with her mobility changes.<br />Mrs. Harrison has questions about her medical bill and doesn’t know what her insurance will cover.<br />Mrs. Harrison can’t afford her medications anyway.<br />Mrs. Harrison has no transportation to her follow-up medical appointments.<br />Mrs. Harrison is feeling isolated now that she’s homebound.<br />Mrs. Harrison’s Community Services are delayed<br />
    19. 19. http://blog.reflexstock.com/2009/12/a-selection-of-stunning-images/<br />The Bridge Model<br />
    20. 20. The Bridge Model<br />Overview of Components<br />Social-worker Based: Bridge Care Coordinator<br />Interdisciplinary Teams<br />Hospital  Home<br />Patient Focused, Community-Specific <br />The Aging Resource Center<br />Urban, Suburban, and Rural applicability<br />
    21. 21. The Bridge Model<br />The participant enters the hospital with more than an illness. <br /><ul><li>Caregiver
    22. 22. Family
    23. 23. SES
    24. 24. Race
    25. 25. Gender
    26. 26. Ethnicity
    27. 27. Religion
    28. 28. Mental Health
    29. 29. Personal Values and </li></ul> Beliefs <br />Referrals can originate from an electronic medical record, a discharge planner, the patient or a family member.<br /><ul><li>Risk screen built in to the EMR
    30. 30. If non-hospital staff, requires access to the EMR</li></ul>Review of the electronic medical record, meeting with an interdisciplinary pre-discharge and fast tracking community services.<br />
    31. 31. The Bridge Model Process<br />The Bridge Care Coordinator builds relationships with the community service providers.<br /><ul><li> Services get fast-tracked to </li></ul> aid in a seamless transition <br /> upon discharge <br />The Bridge Care Coordinator conducts a comprehensive assessment and intervention to identify needs unrealized prior to discharge.<br /><ul><li>Medication compliance
    32. 32. Transportation to doctor’s </li></ul> appointments<br /><ul><li>Community resources </li></ul> needed<br /><ul><li>Scheduled doctor’s </li></ul> appointment<br /><ul><li>Safety at home </li></ul>At 30 days, the participant/caregiver gets contacted and the transitional process gets assessed.<br /><ul><li>Warm handoff made to </li></ul> appropriate agencies<br /><ul><li>Doctor’s visit completed
    33. 33. Medication regimen </li></ul> understood <br /><ul><li>Safety at home
    34. 34. Any additional unmet </li></ul> needs<br />
    35. 35. Building off of Aging Network<br />Conducting Choices for Care Assessments and CCC Assessments<br />Setting up CCP Interim Services and Interim Home Delivered Meals<br />Providing and referring families for Caregiver Support Services and Respite <br />Conducting Benefits Check-Ups<br />Providing Information & Assistance to Patients and their families on site (i.e. Medicaid, Food Stamps, Circuit Breaker, Tax Freezes, Medicare Part D, Home Modification, FSS)<br />
    36. 36. Bridge Care Coordinators<br />http://commons.wikimedia.org/wiki/File:Provence_Winds_Compass_Rose.jpg<br />
    37. 37. Bridge Care Coordinators<br />Why Social Workers?<br />Systems Theory<br />Biopsychosocial <br /> framework <br />Psychosocial <br /> determinants of <br /> health<br />http://early-childhood-resources.com/2010/05/reflection<br />
    38. 38. The Post-Discharge Environment<br />http://amandabauer.blogspot.com/2010/03/romantic-circles-by-kandinsky.html<br />
    39. 39. Psychosocial Issues<br />Social isolation<br />Depression<br />Difficulty coping with change<br />Financial stressors<br />Language barriers<br />Health literacy barriers<br />Older generations taught to be “good patients”<br />40-50% of readmissions linked to psychosocial issues and lack of community resources<br />
    40. 40. Calculating the Cost<br />What is the REAL cost?<br />Staff allocation<br />Overhead<br />Training<br />Case load efficiency<br />http://www.boston.com/ae/theater_arts/exhibitionist/2007/06/salaries_of_sym.html<br />
    41. 41. Sustainability<br />Can’t do good without doing well<br />Who’s money are you saving? <br />Who is your audience?<br />Business case options<br />Readmissions<br />Higher yield patients<br />Patient Satisfaction<br />The “3026 RFP”<br />Grants<br />http://www.thinkgeek.com/gadgets/tools/a396/<br />
    42. 42. Building Relationships<br />Ilana Shure, Aging Care Connections<br />Esther Izaguirre, Solutions for Care<br />
    43. 43. Aging Resource Center<br />
    44. 44. The Role of the ARC<br />Symbol of hospital-community collaboration<br />Greater ability to interface with the community<br />Promotes the notion of “systems” approach to discharge planning.<br />Maximizes the opportunity for a servable moment. <br />
    45. 45.
    46. 46.
    47. 47. Community-Hospital Partnerships<br />Aging Care Connections (CCU - Suburban Chicago) <br />Adventist LaGrange Memorial Hospital <br />Shawnee Alliance for Seniors (CCU – Rural, downstate Illinois)<br />Memorial Hospital of Carbondale<br />Herrin Hospital<br />Solutions for Care (CCU – Suburban Chicago)<br />Mac Neal Hospital<br />Central West (CMU – Chicago)<br />Rush University Medical Center<br />
    48. 48. Aging Network: National  State<br />
    49. 49. Illinois Aging Services Network<br />
    50. 50. Establishing a Connection to the Aging Network<br />Many older adults seen at the hospital by Bridge Care Coordinators have yet to get connected to resources available through their community<br />54% of ARC clients had no previous interaction with their local Care Coordination Unit (N=399)<br />Bridge Care Coordinators connect older adults to the aging network<br />49% of ARC clients utilized services offered through their local Care Coordination Unit for the first time after their encounter with a Bridge Care Coordinator (N=399)<br />
    51. 51. Establishing an ARC<br />Time frames for developing the ARC<br />Outreach to hospital<br />Through existing programs or contracts already established<br />Begin contacting individuals at the hospital who are supportive of the model. <br />
    52. 52. Establishing a Partnership<br />Evaluate Potential Partners<br />Make the “ASK”<br />Identify what you are asking the partner to contribute<br />Establish the basic structure of the partnership prior to launching the project<br />Keep parameters loose enough to allow for growth development<br />An MoU at a minimum should be in place prior to the start date of the project<br />
    53. 53. Establishing a Partnership Cont. <br />Legal agreements should be created broadly defining the service provision, the recipient of the service and duties of each partner in the relationship including:<br />Purpose of the program<br />Responsibilities of both parties<br />Individual responsibilities of the partners<br />Financial liabilities<br />Confidentiality and data sharing<br />Termination<br />Annually review agreement!<br />http://www.fortklock.com/signatures.htm<br />
    54. 54. Lessons Learned <br />Integrate at all levels of the hospital system<br /><ul><li>Front desk reception to Regional Director</li></ul>Be patient and persistent<br /><ul><li>Guest versus Team Member</li></ul>Troubleshoot challenges before they become barriers<br />Learn both cultures and languages<br /><ul><li>Network, network, network</li></li></ul><li>Cultural Competency <br />SFC services a Diverse Population<br />40% Hispanic <br />37% Limited English Speaking or only speak Spanish<br />Bilingual and Bicultural Bridge Care Coordinators<br />
    55. 55. Cultural Competency Continued <br />Assess clients and caregivers in their language and coordinate and link them to services<br />BCC are able to participate in the important aspects of culture, value and belief systems <br />All printed material are in Spanish including Consent forms<br />
    56. 56. Cultural Competency Continued<br />Support Groups for Spanish Speaking Caregivers<br />Chronic Disease Self Management Classes taught in Spanish <br /> -Take Charge of your Health <br />Outreach Program to target cultural linguistically isolated individuals in the communities <br />
    57. 57. Susan Altfeld, University of Illinois at Chicago – School of Public Health<br />Research & Evaluation<br />
    58. 58. The Bridge Model Evidence Base<br />The Bridge Model is an adaptation of the Enhanced Discharge Planning Program (EDPP)<br />EDPP is an evidence-based model developed and evaluated with a randomized-controlled trial at Rush University Medical Center (ITCC partner)<br />Bridge implements the evidence based components of EDPP and best practices developed by ITCC partner sites<br />Bridge is a hospital and community partnership<br />
    59. 59. Rush University Medical Center Study <br />Randomized controlled trial of 720 patients<br />All patients older than 65 with multiple medical conditions<br />Half received follow-up intervention, half were in the “usual care” group<br />Qualitative study <br />Interviews with intervention social workers<br />
    60. 60. What did we learn from the Rush study?<br />83% of the patients in the intervention group had problems identified by the social worker during the assessment at 2 days post-discharge<br />For ¾ of these individuals, problems did not emerge until after discharge – <br /> “surprises”<br />
    61. 61. Needs Identified at 2 day post discharge contact* - Rush study<br />*select variables<br />
    62. 62. Randomized Controlled Trial Outcomes at 30 day follow up – patient follow up/adherence<br />
    63. 63. Adverse Outcomes –30 days post discharge<br />
    64. 64. Post-Intervention Contact- Rush RCT<br />Almost 1/3 of patients (29.3%) contacted the Bridge social worker for additional services or information <br />after the case was closed<br />49<br />
    65. 65. Evaluation of the Bridge Model <br />Important variables from our previous work and other evidence based care transitions interventions<br />Patient characteristics<br />Health status<br />Patient stress<br />Caregiver stress<br />Understanding of responsibilities for managing health<br />Medical follow up<br />Hospital readmissions<br />Mortality<br />Satisfaction<br />
    66. 66. Evaluation data collection- ITCC Bridge<br />Intake assessment<br />2 day post discharge assessment<br />30 day follow up assessment <br />Satisfaction survey<br />Both “patient” and “caregiver” versions of the assessment surveys<br />Telephone<br />Email /telephone satisfaction surveys<br />
    67. 67. Evaluation of the Bridge Model <br />Who are our participants?<br />1766 participants at 5 sites across Illinois from May 2010-March 2011<br />
    68. 68. Bridge client demographics preliminary data 5/10-3/11<br />Male 39.7%<br />75+ 52.2%<br />Frail 64.8%<br />Living alone 41.5%<br />Social need 87.2%<br />Non-English speaking 8.4%<br />Minority/”non-White” 35.7%<br />At risk for nursing home placement 37.6%<br />
    69. 69. 2-day post-discharge assessment<br />Older adult client’s health <br />At this time, how is your health?/ how is (Mr./Ms. patient last name)'s health? (N=117)<br />Excellent 4.3%<br />Very good 15.4%<br />Good 47.0%<br />Fair 19.7%<br />Poor 11.1%<br />
    70. 70. 2 day post discharge assessment<br />Older adult (patient) stress <br />Since I left the hospital, managing my needs has been stressful for me/ Since he/she left the hospital, managing his/her needs has been stressful for him/her (N=109)<br />Yes 50.5%<br />No 49.5%<br />
    71. 71. 2 day post discharge assessment<br />Caregiver stress<br />Since I left the hospital managing my needs has been stressful for my family or other caregivers/ Since he/she left the hospital managing his/her needs has been stressful for you. (N= 102)<br />Yes 57.8%<br />No 42.2%<br />
    72. 72. 2 day post discharge assessment<br />Understand medications<br />I understand the purpose of each of my medications and how to take each of them (N= 118)<br />Yes 98.3%<br />No 2.7%<br />
    73. 73. 2 day post discharge assessment<br />Understand symptoms/”red flags”<br />I understand what symptoms I need to watch out for and who to call if they occur(N= 118)<br />Yes 94.9%<br />No 5.1%<br />
    74. 74. 2 day post discharge assessment<br />Problems/“Surprises”<br />Are things more difficult than you expected since leaving the hospital, less difficult or about what you expected? (N=110)<br />More difficult 30.0%<br />Less difficult 10.9%<br />As expected 59.1%<br />
    75. 75. 30 day outcomes patient follow up/adherence<br />Physician communication- 95.1%<br />Physician visit -95.3%<br />
    76. 76. 30 day outcomes adverse events<br />Rehospitalized within 30 days of d/c- 8.9%<br />Mortality - 2.0%<br />
    77. 77. Satisfaction survey<br />Decision making<br />The assistance or information you received from the Bridge Program helped you (or your loved one) make decisions about your care<br />Strongly agree 40.1%<br />Agree 59.1%<br />Disagree 0%<br />Strongly Disagree 0%<br />
    78. 78. Satisfaction survey<br />Links to community services<br />The assistance or information you received from the Bridge Program helped you (or your loved one) connect to services and resources.<br />Strongly agree 42.1%<br />Agree 57.9%<br />Disagree 0%<br />Strongly Disagree 0%<br />
    79. 79. Satisfaction survey<br />Patient stress<br />Bridge Program helped to make the hospital discharge experience less stressful for you (the patient).<br />Strongly agree 39.1%<br />Agree 52.2%<br />Disagree 4.3%<br />Strongly Disagree 4.3%<br />
    80. 80. Satisfaction survey<br />Caregiver stress<br />The Bridge program helped to make the hospital discharge experience less stressful for family or other loved ones<br />Strongly agree 31.8%<br />Agree 59.1%<br />Disagree 4.5%<br />Strongly Disagree 4.5%<br />
    81. 81. Satisfaction survey<br />Bridge Care Coordinator - knowledge<br />The Bridge social workers were knowledgeable.<br />Strongly agree 47.8%<br />Agree 47.8%<br />Disagree 4.3%<br />Strongly Disagree 0%<br />
    82. 82. Satisfaction survey<br />Satisfaction <br />I would recommend this program to others<br />Strongly agree 41.0%<br />Agree 59.0%<br />Disagree 0%<br />Strongly Disagree 0%<br />
    83. 83. Satisfaction Survey - Quotes<br />Satisfaction<br />Unmet needs/anything you would change/what did you like about the Bridge Program? <br />“I like everything about the Bridge Program.”<br />“You are providing a great service.”<br />“I would like it to be much more advertised for everyone wherever they live.”<br />“It would be nice for everyone to receive the services like my father.”<br />“I cannot think what else the social worker could have done additionally since she was very helpful throughout ….”<br />
    84. 84. http://tinyurl.com/4kfm4ep<br />Questions?<br />
    85. 85. Contact Information<br />Susan Altfeld (saltfeld@uic.edu)<br />Esther Izaguirre (eizaguirre@solutionsforcare.org)<br />Kristen Pavle (kpavle@hmprg.org)<br />Walter Rosenberg (walter_rosenberg@rush.edu)<br />Ilana Shure (ishure@agingcareconnections.org)<br />

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