Care Transitions Models and Key Technologies for Patients in the Home

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Care Transitions Models and Key Technologies for
Patients in the Home

• Lynn Redington, DrPH, MBA
• Senior Program Director
• Center for Technology and Aging
• lredington_at_techandaging.org
• Remingtons 9th Annual
• Forecasting Think Tank Summit
• St. Pete, Florida March 13, 2011

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Center for Technology and Aging

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

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Post-Acute Care Transitions Re-admissions

• Avoidable Readmissions
• Opportunity for better care, better health, lower
  costs
• 1 in 5 patients readmitted within 30 days of
  discharge
• 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
spending.
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Many QI opportunities to reduce hospitalization .
. .
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Care Transitions Models Improve Processes,
Information Flows, and Capacity

• Evidence-based models include
• Care Transitions Intervention
• Transitional Care Model
• Guided Care
• GRACE
• Others

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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

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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

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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

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GRACE Geriatric Resources for Assessment and
Care of Elders

• The Counsell Model
• Qualifications Nurse practitioner and social
  worker
• 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
  approach

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How Technologies May Support Care Processes
Video-Based Education
Telemedicine
Smart Sensors
Wireless Broadband Networks
Home Medication Management
Remote Patient Monitoring
Patient Health Records
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Technology Usage ExamplesCTA Grantees that Aim
to Reduce Hospitalizations

• Medication Optimization Technologies
• American Society of Consultant Pharmacists
  Foundation
• Caring Choices
• Connecticut Pharmacists Foundation
• VA Central California Health Care System
• Visiting Nurse Services of New York
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• 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
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• Evidence-Based Care Transitions QI Evaluation
  Technologies
• State Units on Aging and ADRCs in
• Indiana
• Texas
• ADRC Aging and Disability Resource Center

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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
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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
  analyses
• Home telehealth compared to traditional care
  models
• 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

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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
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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
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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
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Connecticut Pharmacists FoundationCTA Grant
Project
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
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Diffusion of InnovationsLessons Learned

• Stakeholder readiness to adopt
• Business model/payment model
• Technology/Intervention model
• Evidence base/relative advantage
• Compatibility
• Complexity
• Policy issues

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Center for Technology and Aging

• www.techandaging.org