The Coordinated-Transitional Care (C-TraC) Program
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1 The Coordinated-Transitional Care (C-TraC) Program Amy JH Kind, MD, PhD Associate Director-Clinical Madison VA Geriatrics Research Education and Clinical Center (GRECC) & Associate Professor, Division of Geriatrics University of Wisconsin School of Medicine and Public Health
2 30 Day Rehospitalizations: A Major US Health System Problem Affect 1 in 5 hospitalized patients over 65y Account for over $30 billion annually Major target in health reform * Jencks et al, NEJM, : ; Callahan et al, JAGS, 2012.
3 Neighborhood Socioeconomic Disadvantage Increases Rehospitalization Risk *Kind et al, Annals of Internal Medicine, Dec 2014
4 Transitional Care Broadly, 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 in the same location* Post-hospital transitional care is becoming standard practice in non-va hospitals Evidence-based, effective programs can reduce rehospitalizations by 1/3 * Coleman. JAGS. 2003
5 Components of Effective Transitional Care Multi-component, multi-disciplinary, team-based care Clear integration with both inpatient and outpatient sites of care Reinforced messages over time Patient-centered Post-hospital support needs vary; transitional care must be tailored to these needs
6 Concept for Comprehensive Post-Hospital Transitional Care Hospitalized Population Home- Visit Based Transitional Care Program Coordinated- Transitional Care Program (C-TraC) Hospital-Based C-TraC Nurses Outpatient Integration Highest-Risk Veterans *Veteran must be geographically close & agreeable to a home-visit *Could be identified by C-TraC nurses in addition to pre-defined patient characteristics All Higher-Risk Veterans *Examples: cognitively impaired or lives-alone or prior hospitalization or medically complex *Could be identified via existing C-TraC protocols in addition to referrals from veteran s care team Strong Discharge Practices Medication Reconciliation Discharge Teaching/Materials Medical Follow-Up Plans Quality Discharge Documentation All Hospitalized Patients * Programs are additive. They are not mutually-exclusive. Unpublished figure, Amy JH Kind, MD, PhD
7 Concept for Comprehensive Post-Hospital Transitional Care Hospitalized Population Home- Visit Based Transitional Care Program Coordinated- Transitional Care Program (C-TraC) Hospital-Based C-TraC Nurses Outpatient Integration Highest-Risk Patients *Patient must be geographically close & agreeable to a home-visit *Could be identified by C-TraC nurses in addition to pre-defined patient characteristics All Higher-Risk Veterans *Examples: cognitively impaired or lives-alone or prior hospitalization or medically complex *Could be identified via existing C-TraC protocols in addition to referrals from veteran s care team Strong Discharge Practices Medication Reconciliation Discharge Teaching/Materials Medical Follow-Up Plans Quality Discharge Documentation All Hospitalized Patients * Programs are additive. They are not mutually-exclusive. Unpublished figure, Amy JH Kind, MD, PhD
8 Concept for Comprehensive Post-Hospital Transitional Care Hospitalized Population Home- Visit Based Transitional Care Program Coordinated- Transitional Care Program (C-TraC) Hospital-Based C-TraC Nurses Outpatient Integration Highest-Risk Patients *Patient must be geographically close & agreeable to a home-visit *Could be identified by C-TraC nurses in addition to pre-defined patient characteristics All Higher-Risk Veterans *Examples: cognitively impaired or lives-alone or prior hospitalization or medically complex *Could be identified via existing C-TraC protocols in addition to referrals from veteran s care team Strong Discharge Practices Medication Reconciliation Discharge Teaching/Materials Medical Follow-Up Plans Quality Discharge Documentation All Hospitalized Patients * Programs are additive. They are not mutually-exclusive. Unpublished figure, Amy JH Kind, MD, PhD
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10 Unmet Need Many of the patients who need transitional care cannot access such services Socioeconomically disadvantaged populations Areas with poor health care access Need transitional care programs that adapt, succeed and sustain in underserved and disadvantaged areas
11 Concept for Comprehensive Post-Hospital Transitional Care Hospitalized Population Home- Visit Based Transitional Care Program Coordinated- Transitional Care Program (C-TraC) Hospital-Based C-TraC Nurses Outpatient Integration Highest-Risk Patients *Patient must be geographically close & agreeable to a home-visit *Could be identified by C-TraC nurses in addition to pre-defined patient characteristics All Higher-Risk Patients *Examples: cognitively impaired or lives-alone or prior hospitalization or medically complex Strong Discharge Practices Medication Reconciliation Discharge Teaching/Materials Medical Follow-Up Plans Quality Discharge Documentation All Hospitalized Patients * Programs are additive. They are not mutually-exclusive. Unpublished figure, Amy JH Kind, MD, PhD
12 VA Coordinated-Transitional Care Program (C-TraC) Phone-based program Specially-trained RN nurse case manager Protocolized encounters Teachings based on theory of Spaced Retrieval* Method of learning information by practicing recalling that information over increasingly longer periods of time Applicable in early stages of dementia Caregivers involved, activated at each step * Bourgeois, et al, J Comm Disord, 2003; Camp et al, Appl Cog Psych, 1996.
13 C-TraC Goals 1. Educate and empower the veteran/caregiver in medication management 2. Ensure the veteran/caregiver has medical follow-up 3. Educate the veteran/caregiver regarding red flags 4. Ensure the veteran/caregiver knows whom to contact if questions arise * Kind, Health Affairs, 2012.
14 Veteran Eligibility Hospitalized on non-psychiatric acute-care ward Discharged to community AND one or more of the following: 1. Have documentation of dementia, delirium or cognitive impairment years or older AND lives alone OR had a previous hospitalization in past 12 months * Kind, Health Affairs, 2012.
15 Coordinated-Transitional Care (C-TraC) Program * Kind at al, JAGS, 2016
16 C-TraC: In-Hospital Visit
17 C-TraC: Telephone Follow-up Initial call is hours after discharge with caregiver/veteran to reinforce Medication management Medical follow-up 3 Red flags C-TraC Nurse case manager contact information Average 36 min per call Patient led medication reconciliation 1 in 3 have medication discrepancies Active coordination with outpatient providers
18 C-TraC Cut Rehospitalizations 30-day rehospitalizations cut by 1/3 when compared to baseline group C-TraC Group (N = 500) Establishment period (Months 1-6), n = 103 Intervention period (Months 7-18), n= Day Rehospitalization Adjusted** 95% CI P-Value Odds Ratio 1.00 Ref 0.56 (0.33, 0.94) **Multivariate logistic regression model adjusted for veteran age, gender, race, Medicaid status, education level, VA service connected status; w hether veteran lives alone; presence of dementia/other cognitive impairment/delirium; charlson comorbidity score; needing more help w ith bathing, dressing, transferring and toileting in 2 w eeks prior to hospitalization; decline in ability to stand or w alk in 2 w eeks prior to hospitalization; and w hether veteran manages ow n medications * Kind, Health Affairs, 2012.
19 The Coordinated-Transitional Care (C-TraC) Program Net cost avoidance of over $1,200 per Veteran served Veterans and caregivers reported high satisfaction with intervention, decreased caregiver stress; Providers loved the program C-TraC successfully sustained (and expanded) at multiple VA and non-va launch sites
20 C-TraC Continues to Disseminate Mentored C-TraC launches at a range of VA and private hospitals throughout US Boston VA Hospital newest C-TraC site Mentored implementations, free on-line toolkit (>500 downloads) and grassroots program growth 5-year NIH-funded RCT to evaluate C-TraC s impact in a non-va dementia-specific population (results in 2020)
21 Initial Dissemination Results * Kind et al, JAGS, 2016
22 Goal: Engineer Sustainable Programs for the Most Socioeconomically Disadvantaged Areas *Kind et al, Annals, Dec 2014
23 Medicare-funded 2-year C-TraC Pilot Dissemination to Rural Colorado Implementation science to engineer a platform for sustainment at the microsystem level Replicate, adapt, succeed & sustain Protocolized adaptation in dissemination Completion: 2017 * Kind et al, JAGS 2016
24 Implementation Mentoring* for C-TraC months for full process Pre-Conditions Identification of need Review existing interventions Pre- Implementation Core elements Customize delivery Logistics/training Implementation Process evaluation Feedback/protocol refinement Maintenance and Evolution Sustain Disseminate 1. Document existing local discharge processes 2. Provide a comprehensive overview of C-TraC 1. Convene local multidisciplinary keystakeholder group 2. Coach local keystakeholders to define local high-impact outcomes, goals 3. Detailed discussion of core C-TraC elements, processes 4. Formally adapt C-TraC operations to accommodate local VA system 5. Ensure integration with (not duplication of) existing processes 6. Train newly hired C-TraC local staff in clinical program delivery, and provide on-going coaching of program leadership in program assessment, reporting and administrative barrier reduction 1. Coach local C-TraC staff to ensure they achieve widespread local stakeholder engagement prior to launch 2. Coach local C TraC leadership through iterative phased protocol refinement post-launch 3. Mentor local teams to perform continuous process monitoring, documentation 4. Mentor local C-TraC teams to perform key outcome monitoring and reporting to ensure strongest chances of post-grant sustainability 1. Mentor local C-TraC teams in final results feedback to health system leadership and stakeholders 2. Achieve local C-TraC program sustainment * Adapted from CDC s Replicating Effective Programs Implementation Theory Model * Kind et al, JAGS, 2016 Specific Steps
25 Coordinated-Transitional Care (C-TraC) Program * Kind at al, JAGS, 2016
26 Acknowledgements Dissemination Team/Collaborators Alan Bridges Becky Kordahl Sanjay Asthana Laury Jensen Ken Shay Karen Massey VISN 12 Leadership Madison VA Hospital Leadership VACO Leadership UWHC Leadership Beth Houlahan Maria Brenny-Fitzpatrick UWHC C-TraC Team Madison VA C-TraC Team Andrea Gilmore-Bykovskyi Korey Kennelty Jane Brock Steve Jencks Funding NIA 2P50AG (Asthana PI; Kind Project 3 PI) NIMHD R01MD (Kind PI) NIA Beeson Career Development Award (1K23AG034551) Madison VA GRECC VA T-21 GEC: Innovative Patient Centered Alternatives to Institutional Care VA Office of Rural Health Wisconsin Partnership Program New Investigator Award Centers for Medicare and Medicaid Services Thank you! C-TraC patients and families
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