Transcription

1 OVERVIEW The Transitional Care Model (TCM) provides comprehensive in-hospital planning and home follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions. For the millions of Americans who suffer from multiple chronic conditions and complex therapeutic regimens, TCM emphasizes coordination and continuity of care, prevention and avoidance of complications, and close clinical treatment and management all accomplished with the active engagement of patients and their family and informal caregivers and in collaboration with the patient s physicians. Because TCM focuses on individualized, multidisciplinary evidence-based clinical protocols that prevent decline and reduce readmission for an extended period, TCM complements primary care provided by regular physicians, telephonic case management programs or disease management programs that focus only on one health conditions. Promoting the use of TCM by a health care system is achieved through the following: 1) effectively communicating the value of the model to key stakeholders; 2) integrating and adapting the model to fit the mission and goals of each organization; 3) recruiting, orienting and preparing transitional care nurses and patient recruiter to implement the model; 4) providing ongoing clinical and technical support to these staff; 5) quality monitoring and quality improvement; and 6) conducting a comprehensive evaluation.

2

3 TRANSITIONAL CARE NURSE (TCN) CARE PROTOCOL Schedule of TCN Visits Findings from our three completed RCT s have informed the development of the TCN schedule: patients will be visited within 24 hours of study enrollment; at least daily throughout hospitalization (using clinical judgment for visits on Sundays and for those with long length of hospital stays, as needed); within 24 hours of discharge to home (from hospital or from skilled nursing facility [SNF]); at least weekly during the first month post-discharge from hospital to SNF (if applicable); and, at least semi-monthly through the duration of the intervention. Hospital visits are expected to range from 15 to 60 minutes, home care visits 30 to 60 minutes, and telephone contacts 5 to 20 minutes, with initial hospital and home visits lasting longest. While the proposed schedule defines minimal expectations, TCNs will use their clinical judgment to determine the frequency (number) and intensity (length) of patient and caregiver visits and telephone contacts. Hospital Component The primary purposes of hospital contacts are to: establish a trusting relationships with the patient and caregiver, develop individualized plans of care in collaboration with the patient and caregiver and the patient s physician, and initiate implementation of the individualized, collaborative plans. Post-discharge Component The home component will begin immediately following hospital discharge to home. Based on prior work, it is estimated that about 10% of patients may be discharged to a nursing home or rehabilitation center for short-term post-acute services (one to three weeks). TCNs will continue to implement the protocol with the patient while in the SNF setting and on transfer to home. The length intervention will not extend due to a SNF stay. Home Follow-up Visit: In addition to assessing the effects of transition from hospital to home on the overall health status of the patient and the emotional status of the caregiver, TCNs will assure that patients/caregivers understand and have access to all prescribed post-discharge therapies and are environmentally safe. Patients should be seen within 24 hours of discharge from hospital to home, or from SNF to home, with any variation documented in the patient chart. TCNs will play a major role in coordinating care provided by others and promoting access to health and community resources. During the intervention, TCNs will promote patients adaptation by focusing on: managing risk factors to prevent further decline;

4 managing problem behaviors; assessing and managing physical symptoms; preventing functional decline; managing depression; promoting adherence to therapies; assuring proper medical management; validating knowledge and skills; and reducing caregiver burden. SNF Visit (when applicable): In addition to assessing the effects of transition from hospital to SNF and improve the management of the overall health of the patient, TCNs will work actively to ensure that patients/caregivers understand and have access to all prescribed post-discharge therapies and are environmentally safe. Patients should be seen within 24 hours of discharge from hospital to SNF. TCNs will work actively to establish a productive working relationship with the SNF staff providing care for the patient (e.g., nursing staff, social worker, physician, nutritionist, etc.) to provide input and assist in coordinating the transition from the hospital to the SNF and to home. TCNs will be in contact with the SNF staff and the patient and/or caregiver via telephone or visit at least weekly during the SNF stay. Frequency of actual visits is expected to increase during the time of transition from the hospital to the SNF and at the time of transition from the SNF back to the patient s home. During the intervention time at the SNF, TCNs will promote patients adaptation by focusing on: managing risk factors to prevent further decline; managing problem behaviors; assessing and managing physical symptoms; preventing functional decline; managing depression; promoting adherence to therapies; advocating to implement proper medical management; validating knowledge and skills; and reducing caregiver burden. Weekend Coverage: Weekend coverage consists minimally of 4 hours of telephonic coverage on Saturday and Sunday. Each TCN is responsible for signing off to the covering TCN on Friday. The TCN covering the weekend will follow up on any patient needs and use their clinical judgment to determine if any visits need to occur. Any patients discharged on Friday or Saturday will be seen within 24 hours of discharge. If a patient is discharged to a SNF/rehab the first visit can be delayed to Monday of the next week. Hospitalized patients are to be seen minimally one day of the weekend, with the TCN exercising their clinical judgment if a second weekend visit is necessary.

5 Prior to the weekend, each TCN s should visit all high risk patients on Friday as late in the day as possible. Any major issues or concerns for high risk patients should be documented and communicated to the weekend covering TCN. Telephone Availability: Daily telephone availability of the TCNs will extend from the index hospital admission through the duration of the intervention. TCNs will be available from 8AM to 8PM Mondays through Fridays and 8AM to noon (or alternative 4 hour segments on each day) on weekends to respond to patients /caregivers needs and concerns. Patients and caregivers will be provided with a written plan with instructions for emergency care. Phone contacts will be made by the TCN during any week that a patient is not visited at home. The purposes of these calls will range from monitoring patient s health status to reinforcing caregiver s skill acquisition. Discharging the Patient and Caregiver TCNs will use their clinical judgment to determine the length of intervention for each patient. Based on prior research with a similar population, termination of the intervention will be guided by the following criteria: goals identified by patients and caregivers and related to managing the acute episode of illness and transitioning to home are met; the patient is medically stable; the caregiver is able to identify early symptoms that require intervention; and the caregiver knows how to intervene to prevent poor outcomes. By the completion of the intervention, the TCN will have arranged for any necessary follow-up care in consultation with the patient/caregiver and patient s physician. A discharge letter will be written to the physician formally discharging the patient, stating attained goals, general impression, discharge medications, recommendations and issues requiring follow-up (if needed) with additional providers copied to assure continuity of care. A separate patient/caregiver discharge letter will be written reinforcing goals attained, strategies developed, emergency plan and reminders to patient re: agreed plan of care.

6 SCREENING CRITERIA & RISK ASSESSMENT Are the following statements true for the patient: Admitted to hospital within the last hours? 65 years of age or older? English speaking? Reachable by telephone? Alert and cognitively intact? (see Instruments, SPMSQ >6) Documented history of a primary cardiovascular, respiratory, endocrine, or orthopedic health problem? Does not have end-stage renal disease? Does not have primary neurological diagnosis? Does not have major psychiatric illness? Does not have a primary diagnosis of cancer? Lives within 30 miles of the admitted facility? Returning home after discharge (SNF/rehab stay < 3 weeks)? If yes to all of the above, does the patient have two (or more) of the following risk factors: Age 80 or older Moderate to severe functional deficits History of mental/emotional illness Four or more active co-existing health conditions Six or more prescribed medications Two or more hospitalizations within past 6 months Hospitalization in the past 30 days Inadequate support system Poor self-rating of health Documented history of non-adherence to therapeutic regimen PATIENT DATA Patient data is collected from patients, caregivers (as identified by the patient), or medical records, including: sociodemographics caregiver involvement and availability physical data general health status severity of illness illness specific data number of prescribed daily medications health resources (utilization activity prior to hospitalization)

7 ASSESSMENT TOOLS Short Portable Mental Status Questionnaire (SPMSQ): The SPMSQ measures intellectual function by assessing response to 10 items. The questionnaire is scored correct or incorrect. Scores range from 0-10 with a higher number indicating higher intellectual function. Adjustment for educational attainment can be made to allow one more error for a subject with only a grade school education, and allow one less error for a subject with education beyond high school. Geriatric Depression Scale (GDS): Fifteen item self-report instrument in a "yes" or "no" format that takes 5-10 minutes to administer. Developed specifically for the elderly and standardized on elderly samples. Contains few somatically-based items and has had extensive psychometric testing. Validity was established by correlation with both diagnostic clinical ratings and other self-report measures of depression. Scores of 0-5 are normal for non depressed responders; scores of 6-10 indicate mild depression; and 11-15, moderate to severe depression. Instrumental Activities of Daily Living (Lawton s IADL): Lawton's IADL is used to measure ability to perform money and medication management, shopping, and household chores. On completion, a lower score equates with worsening function. Katz Activities of Daily Living (Katz ADL): Katz ADL index measures ability to conduct selfcare. This six-item instrument assesses independence or dependence in the activities of bathing, dressing, toileting, transferring, continence and feeding. Scores range from 0-6, with lower scores indicating more disability. Overall Quality of Life (QoL): Overall QoL is measured by a respondent s self-report of current quality of life in answer to the question: "How would you rate your quality of life? Response choices are "excellent", "very good", "good", "fair", or "bad". High correlation has been demonstrated between perceived and actual quality of life and outcomes. Subjective Health Rating: Self assessment of health measures the respondent s perception of his/her overall health using a single item question: "How would you rate your overall health at the present time?" Responses are recorded as "excellent", "good", "fair", or "poor". Highly significant correlations have been reported between self-reports and physician ratings of health status. Symptom Bother Scale: Measures the presence and severity of 13 physical symptoms typically associated with aging and chronic illness (e.g., pain, aches, itching). Patients will rate the absence or presence of a specific symptom. If a symptom is present, they will further rank the degree to which they were bothered by each symptom on a 1 to 3 scale, with higher scores indicating worse symptoms. Symptom bother was positively associated with difficulty with ADLs and depression, and negatively associated with subjective health, providing support for the validity of the scale. The Mini Mental State Exam (MMSE): MMSE is a widely used tool that measures orientation to time and place, recall ability, short-term memory and arithmetic ability in elderly patients. It consists of 30 questions. The MMSE total score ranges from 0 to 30 and reflects the number of correct responses. In general, scores > 23 indicate intact cognition, mild CI, moderate CI and < 12 severe CI. However, cutoff scores will be modulated according to educational level. This instrument is easily administered, well tolerated and can be completed within 5-10 minutes. It is a useful adjunct to the SPMSQ if the score lower than expected, or contradicts other assessment data.