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Care Transitions Models and Key Technologies for Patients in the Home


... The Coleman Model Qualifications: CTI Coach can ... Guided Care GRACE: Geriatric Resources for Assessment and Care of Elders How Technologies May ... – PowerPoint PPT presentation

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Title: Care Transitions Models and Key Technologies for Patients in the Home

Care Transitions Models and Key Technologies for
Patients in the Home
  • Lynn Redington, DrPH, MBA
  • Senior Program Director
  • Center for Technology and Aging
  • Remingtons 9th Annual
  • Forecasting Think Tank Summit
  • St. Pete, Florida March 13, 2011

Center for Technology and Aging
  • Established in 2009 with funding from The SCAN
    Foundation, located at the Public Health
  • Mission Expand the use of technologies that help
    older adults lead healthier lives and maintain
  • Independent, non-profit resource center on issues
    related to diffusion of technology for older
  • Technology Diffusion Grants Programs
  • e.g., Tech4Impact grant (Technologies for
    Improving Post-Acute Care Transitions

Post-Acute Care Transitions Re-admissions
  • Avoidable Readmissions
  • Opportunity for better care, better health, lower
  • 1 in 5 patients readmitted within 30 days of
  • 76 of readmissions are preventable
  • A 25 billion savings potential
  • Call to action
  • Improve care transitions (e.g., hospital to home)
  • Improve care coordination, outreach, patient
    engagement and support

References New England Journal of Medicine,
Jencks S, et al Rehospitalizations among
patients in the Medicare fee-for-service program
N England Journal of Medicine 2009 360
1418-28. PricewaterhouseCoopers, 2008. The price
of excess Identifying waste in healthcare
Many QI opportunities to reduce hospitalization .
. .
Care Transitions Models Improve Processes,
Information Flows, and Capacity
  • Evidence-based models include
  • Care Transitions Intervention
  • Transitional Care Model
  • Guided Care
  • Others

The Care Transitions Intervention (CTI)
  • The Coleman Model
  • Qualifications CTI Coach can be layperson
  • Length of intervention 30 days
  • Average cost 196 per patient
  • Steps
  • Four pillars--Medication management
    Patient-centered record Follow-up Red flags
  • Five encounters--Hospital/SNF Visit Home Visit
    3 Follow-Up Calls

Transitional Care Model (TCM)
  • The Naylor Model
  • Qualifications Transitional Care Nurses are
    advanced practice nurses (BA-prepared nurses
    under study)
  • Length of intervention 1 to 3 months
  • Average cost 982 per patient
  • Steps
  • Visit patient in hospital, home visit w/24 hours,
    accompany patient to 1st doctor visit, facilitate
    clinician collaboration and communications with
    patient/family, on call 7 days a week

Guided Care
  • Developed at Johns Hopkins University since 2001
  • Qualifications Guided Care Nurse must be an RN
  • Length of intervention For life
  • Average cost 1743 per patient per year
  • Steps
  • Conduct comprehensive home assessment, create
    care guide and action plan for patient, provide
    monthly monitoring and self-management coaching,
    coordinate care, facilitate access to community
    services, engage/educate informal caregivers

GRACE Geriatric Resources for Assessment and
Care of Elders
  • The Counsell Model
  • Qualifications Nurse practitioner and social
  • Length of intervention Long term/indefinite
  • Average cost 1432 per patient per year
  • Steps
  • In-home assessment, home visit after any
    hospitalization, one phone or in-person follow-up
    per month, collaborate with PCP, hospital
    discharge planner and others in a team-based

How Technologies May Support Care Processes
Video-Based Education
Smart Sensors
Wireless Broadband Networks
Home Medication Management
Remote Patient Monitoring
Patient Health Records
Technology Usage ExamplesCTA Grantees that Aim
to Reduce Hospitalizations
  • Medication Optimization Technologies
  • American Society of Consultant Pharmacists
  • Caring Choices
  • Connecticut Pharmacists Foundation
  • VA Central California Health Care System
  • Visiting Nurse Services of New York
  • Remote Patient Monitoring Technologies
  • AltaMed Health Services, Stamford Hospital
  • California Association of Health Services at Home
  • Centura Health at Home
  • New England Healthcare Institute
  • Sharp HealthCare Foundation
  • HealthCare Partners
  • Catholic Healthcare West
  • Personal Health Records Technologies
  • State Units on Aging and ADRCs in
  • California
  • Rhode Island
  • Washington
  • Evidence-Based Care Transitions QI Evaluation
  • State Units on Aging and ADRCs in
  • Indiana
  • Texas
  • ADRC Aging and Disability Resource Center

Veterans Health Administration (Central CA)CTA
Grant Project
Focus Area Medication Adherence, Remote Patient Monitoring (RPM)
Population Vets with CHF, hospitalized within past 1-2 years
Technology In-home RPM appliance using POTS, Med Adherence Algorithm, weight scale, BP cuff
Expected Benefits Reduce hospital/ED visits improve patient activation, QOL satisfaction
Workforce Issues Care coordinator (RN), MD oversight, Automated clinician alerts, enabled patients/informal caregivers
Organizational Readiness VHA worlds largest telehealth user, rural health telehealth (see next 2 slides for background)
POTS Plain Old Telephone Service
The Early Adopter Experience Veterans Health
Administration (1 of 2)
  • VHA has evaluated, piloted, reevaluated, and
    deployed telehealth technologies in a continuing
    process of learning and improvement far beyond
    adoption in the private sector
  • Largest national program--enables detailed
  • Home telehealth compared to traditional care
  • Studies conducted on patients enrolled in the
    VAs Care Coordination/Home Telehealth program in
    2006 and 2007 show
  • 25 reduction in bed days of care
  • 20 reduction in numbers of admissions
  • 86 mean satisfaction score rating

The Early Adopter Experience Veterans Health
Administration (2 of 2)
Age Distribution of all CCHT Patients
  • Net cost 1,600 / patient / year vs.
  • VHAs home-based primary care services 13,121
    / patient / year
  • Market nursing home care rates average 77,745
    / patient / year
  • VHA takes systems approach to integrate the
    elements of the CC/HT program. This includes
  • Product selection
  • Training
  • Protocols for patient selection, management
  • Data analytics

Since VHA implemented CCHT in 2003, a total of
43,430 patients have been enrolled
Indiana State Unit on AgingCTA Grant Project
Focus Area Implementing GRACE care transitions model and technologies into VAMC Indianapolis
Population Older Vets at high risk for hospitalization and institutional care
Technology Technologies that support GRACE protocols (EHR, automated prompts, Web-access to protocols and other tools)
Expected Benefits improved performance on Assessing Care of Vulnerable Elders (ACOVE) quality indicators, higher satisfaction, and decreased hospital readmissions and long-term institutionalization
Workforce Issues Team-based approach coordinated by GRACE-trained nurse practitioner and social worker, increased engagement of patients and caregivers, local ADRC integrated into process
Organizational Readiness VA validates new innovations before taking nationwide GRACE intervention originated in Indiana Counsell is leading project
Washington State Unit on AgingCTA Grant Project
Focus Area Improving communications, coordination, self-management during care transitions
Population Patients recently discharged from hospital that are participating in the Care Transitions Intervention program
Technology EHRs and PHRs (Electronic Health Records, Personal Health Records)
Expected Benefits Reduce hospitalizations/re-hospitalizations, improve patient self-management, improve communications
Workforce Issues CTI coach, connected clinicians, increased engagement of patients and caregivers
Organizational Readiness An early adopter, Whatcom County, WA started project in 2001
Connecticut Pharmacists FoundationCTA Grant
Focus Area Remote Medication Therapy Management
Population Older Cambodian-Americans w/ history of torture/trauma, high incidence of chronic illness and low literacy rate
Technology Video conferencing, spoken format technology, EMR
Expected Benefits Reduce hospital/ED visits improve meds use improve access to culturally concordant providers
Workforce Issues Remote pharmacist visit, patient is accompanied by community health worker. Few providers trained in special needs of this population.
Organizational Readiness Connecticut partner, Khmer Health Advocates, is the only Cambodian health organization in the US
Diffusion of InnovationsLessons Learned
  • Stakeholder readiness to adopt
  • Business model/payment model
  • Technology/Intervention model
  • Evidence base/relative advantage
  • Compatibility
  • Complexity
  • Policy issues

Center for Technology and Aging