Care Continuum or Unconnected Silos

Transcription

1 Care Continuum or Unconnected Silos Julie Bynum, MD, MPH Dartmouth Medical School December 10, 2009 Goals for Today Review what we have heard & introduce what we have not heard Understand the components of interventions to improve care transitions Discuss how can we work together for our patients

2 What we have heard Overall System readmission rates and the threats posed to patients and finance Hospital discharge process Specialty Disease CHF hosp & clinic Primary Care Office Guided care Home medical home Transitional Care Definition Transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care (American Geriatrics Society Position Statement 2003) Testimony by Dr. Eric Coleman before United States Senate

3 Transitions occur across many different types of settings Transitions to and from Acute Care Settings Care Transitions Intervention (Coleman) caretransitions.org Transitional Care Model (Naylor) transitionalcare.info

4 Care Transition Intervention (Coleman) Four pillars of the intervention to enable the patient to assert more actively during transitions: 1. Medication Self Management 2. Patient-Centered Health Record 3. Empower Pts Primary & Specialty Care Follow Up 4. Knowledge of Red Flags Care Transition Intervention (Coleman) Intervention Components implemented as nurse transition coach (4 wks) 1. In hospital, home & telephone visits with patient 2. Provide and instruction on use of PHR 3. Each visit structured around four pillars Target Population 1. Acute care hospitalization and one of 10 common conditions

5 CTI Outcomes Reduction rehospitalization rates: 30 days: TC = 8% vs. 12% (p=.048) 90 days: TC = 17% vs. 23% (p=.04) 180 days: TC = 9% vs. 14% (p=.046) Non-elective hospital cost savings: 180 days: TC = $2058 vs. $2546 (p=.049) Coleman, Archives Int Med 2006;166:1822 Transitional Care Model (Naylor) Key Components 1. Focus on patient and caregiver understanding 2. Helping patients understand health issues and prevent decline 3. Medication reconciliation and management 4. Transition care, not ongoing case management

6 Transitional Care Model Intervention Components implemented by ARNP level transitional care nurse (8wks) 1. In hospital, home & telephone visits with patient 2. TCM nurse visits with physician 3. Provide continuity & communication 4. Transition from TCM with care plan Target population 1. Acute care hospitalization and one of 10 common conditions plus at least one risk factor for poor post-discharge course Transitional Care Model Outcomes Reduction in Readmission Rates Heart failure trial* 6 weeks: TCM = 10% vs. 23% 26 weeks: TCM = 28% vs. 56% 52 weeks: TCM = 48% vs. 61% Reductions in total health care costs* 26 weeks: TCM $3,630 vs. $6,661 (high risk elderly) 52 weeks: TCM $7,636 vs. $12,481 (heart failure) * Naylor, JAMA 1999;281:613 Naylor, JAGS 2004;52:675

7 Transitional Care Models Naylor Coleman Newer community models Using differently trained people to provide intervention Social workers Lay volunteers (Dye, publications forthcoming) Summarizing Models Setting Target pop n Intervention Jack hospital All discharges In hosp, post telephone pharmacist Berkshire hospital CHF discharges Boult prim care High risk elderly in clinic In hosp, evolved comprehensive disease mgt In clinic, comprehensive RN mgt Kono spec care CHF pts In clinic, comprehensive ARNP, CCM (RN, SW) Saler group practice High risk elderly in hosp Naylor hospital High risk elderly in hosp In home, comprehensive ARNP, MD Phone, home & coordination by ARNP Coleman hospital Chronic dz pts In hosp pt support, phone & visit coach post-discharge

8 Elements of Transitional Care Medication Reconciliation Red Flags Personal Health Record Interdisciplinary team approach Engaging primary care provider Information dissemination California Health Foundation f Care Transitional Processes Identifying high risk patients Stratification of interventions by pt need Variable lengths of interventions by pt need Process for engaging wider groups of natural partners California Health Foundation f

9 General Population RED - Jack CTI - Coleman GC - Boult TCM - Naylor Human Resource intensity CHF programs High risk Population Highest Risk Intensive case mgt Increased Risk Readmit Telephone f/u, coach Resource intensity All Hospitalized Patients Med reconciliation, discharge info & teaching Number of people

10 Transitional Care Cynicism Fragmented system layer on more pieces to keep it together for the patient Which patients are at risk for poor acute care transitions outcomes? Previous hospitalization Poor self reported health Depression Substance abuse Elderly (esp age >80) Multiple active chronic conditions Long length of stay Functional impairment

11 Projected Change in Percent U.S. Population Young Old compared Old Old 20% national sample of Medicare beneficiaries (%) 80+ (%) Any hospital stay Any home health agency use Any skilled nursing facility stay Death in

12 Care Transitions Local Care System Community Community HOSPITAL Assisted Living HHA HOSPITAL Clinic Assisted Living SNF Nursing home Nursing home Variations in quality and spending The Dartmouth Atlas

13 Percent of oldest old seeing 10 or more unique physicians in FORT LAUDERDALE, FL 38.8 MIAMI, FL OXFORD, MS 10.5 GRAND FORKS, ND 10.4 Percent of oldest old seeing generalist MD as their predominant ambulatory provider SIOUX FALLS, SD 92.5 MINNEAPOLIS, MN MIAMI, FL 63.2 NEW BRUNSWICK, NJ 60.9

14 In our system, do we have a problem? How would we know? How would we know? Data sources Dartmouth Atlas, internal sources, federal benchmarking, client report People we see vs. people we serve Population health What information would we need? Who do we serve? What providers also manage the people who we treat? What is our current performance?

15 Theory: Relational Coordination Coordination that occurs through frequent, high quality communication supported by relationships of shared goals, shared knowledge and mutual respect enables organizations to better achieve their desired outcomes. Jody Hoffer Gittel: Airline Story Airline performance is an index of quality: customer complaints, mishandled bags and late arrivals, as well as efficiency: gate time per departure and staff time per passenger.

16 Surgery Story Surgical performance is an index of quality: patient satisfaction, postoperative freedom from pain and post-operative functioning, as well as efficiency: number of inpatient days in the hospital. Each performance measure was adjusted for differences in patient and hospital characteristics, and combined into a single performance index. Relational Coordination - Three Dimensions - 1. Shared Knowledge 2. Shared Goals 3. Mutual Respect

17 Make our own Care Transition Story? Shared Knowledge Remember the elephant and which part we each see! Imagine you are responsible for a population in an integrated health system with financial risk. System Integration

18 Make our own Care Transition Story? Shared Goals What would they be? Reduce readmission Prevent hospitalization Something else? (Less functional decline, Lower costs, Aging in place) Depends on who we bring to the table. Can we find shared goals so local parties can be motivated to participate? Patient Care A Coordination Challenge Jody Hoffer Gittel:

19 Silos connected only by the patient Care Continuum or Unconnected Silos? Recognize the only continuum in health care is the person s (patient s) experience.

20 Make our own Care Transition Story? Mutual Respect Culture of Health Care across providers Specialization Compete for get resources not outcomes Culture of Blame How we sometimes think Clinic SNF Hosp HHA

21 The reality the frequent flyers are the same people across the system Clinic HHA Hosp SNF Putting the value back on what is important to our patients Policy Standpoint Public reporting/pay for performance Accountable Care Organization Medical Home Independence at Home

22 Putting the value back on what is important to our patients Policy Standpoint Accountable Care Organization Medical Home Independence at Home Public reporting/pay for performance Community Standpoint Aging in place Volunteer and civic engagement A Perfect Storm "perfect storm" occurred as early as the 1840s when William Makepeace Thackeray used it in his novel, Vanity Fair. "I have heard a brother of the story-telling trade work himself up into such a rage and passion with some of the villains whose wicked deeds he was describing and inventing, that the audience could not resist it; and they and the poet together would burst out into a roar of oaths and execrations against the fictitious monster of the tale, in the midst of a perfect storm of sympathy."

23 Closing Comment Our patients, people in our community, are put at risk by silos we have created in health care. There are many creative and effective ways to protect from those risks. But they require collaboration across our professional groups and settings. Making our patient s well-being the common shared goal.