The Care Transitions Intervention Kimberly Irby, MPH Colorado Foundation for Medical Care www.cfmc.org/integratingcare Acknowledgments: Objectives To provide an overview of the Care Transitions Intervention (Developer: Eric Coleman, MD, MPH; ) Preparing patients and caregivers to participate in care delivered across settings The Four Pillars Coaching vs. Doing Stories from the field To discuss the importance of patient activation Silent Care Coordinators Older patients and family caregivers function as their own care coordinators First line of defense for transition related errors CTI model explicitly recognizes their role as integral members of the interdisciplinary team
The Care Transitions Intervention Self-management model Encourages patients and caregivers to take a more active role during transitions Key Elements: Transition Coach Personal Health Record Medication Discrepancy Tool (MDT) The Four Pillars Intervention Details: Transition Coach Hospital Visit Nursing Home Visit* Home Visit (ideally within 48 hours of discharge) 3 Phone Calls *when applicable Personal Health Record Patient-owned and operated Record of medical history and associated warning signs Medication list Advance directives Space for patient questions and concerns Should be portable, readable, easy to locate and update
Medication Reconciliation You re Only Old Once! A Book for Obsolete Children, Dr. Seuss From the MDT: 50% System 1/3 discharge instructions incomplete, illegible or inaccurate 1/3 conflicting information 1/6 duplicate meds 50% Patient 2/3 non-intentional non-adherence Coleman EA, Smith JD, Raha D, Min S. Posthospital Medication Discrepancies Prevalence and Contributing Factors. Arch Intern Med. 2005;165:1842-1847 The Four Pillars 1. Medication self-management 2. Use of a dynamic patient-centered record, the Personal Health Record 3. Timely primary care/specialty care follow up 4. Knowledge of red flags that indicate a worsening in their condition and how to respond Coaching vs. Doing A coach helps the patient set goals A coach helps the patient anticipate barriers and plan for their resolution A coach strategizes with the patient ways to take action to meet goals A coach does not do it for the patient A coach is not a caregiver A coach is not an educator
Coaching and Readmissions 48% 30 days 44% 90 days 43% same-diagnosis 180 days Evidence of Effectiveness: Results of A Randomized Controlled Trial J Am Geriatr Soc 52:1817-1825, 2004 Variable Intervention Control P-Value Age (years) 76.0 76.4 0.52 Female (%) 48.2 52.3 0.26 Married (%) 58.2 53.8 0.23 Lives alone (%) 30.9 30.8 0.99 Sad or Blue (%) 30.3 26.4 0.24 CHF (%) 16.5 12.9 0.17 COPD (%) 17.0 18.5 0.61 Arrhythmia (%) 12.8 19.0 0.02 CAD (%) 14.1 13.5 0.81 Chronic Disease Score 6.8 7.1 0.31
Variable Intervention Control P-Value Prior Hosp (%) 1+ past 6 mo Prior ED (%) 1+ past 6 mo D/C Destin. Home (%) Homecare (%) SNF (%) Other (%) 29.3 26.1 0.36 40.3 38.9 0.69 50.8 24.7 21.0 3.5 52.9 25.9 19.3 1.9 0.71 Friday D/C (%) 14.6 16.5 0.48 Variable Intervention Control Re-hospitalized w/in 30 days Re-hospitalized w/in 90 days Re-hospitalized w/in 180 days Adjusted P-value 8 % 12 % 0.05 17 % 23 % 0.03 26 % 31 % 0.09 Variable Readmit for Same Dx w/in 30 days Readmit for Same Dx w/in 90 days Readmit for Same Dx w/in 180 days Intervention Control Adjusted P-value 3 % 5 % 0.04 5 % 10 % <0.01 9 % 14 % <0.01
Variable Non-elective mean hospital costs 30 days Non-elective mean hospital costs 90 days Non-elective mean hospital costs 180 days Intervention Control P-value $784 $918 0.03 $1519 $2016 0.01 $2058 $2546 0.03 Anticipated Cost Savings For 350 chronically ill older adults with an initial hospitalization, anticipated net costs savings over 12 months: $295,574 Care Transitions Measure (CTM ) The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. When I left the hospital, I clearly understood the purpose for taking each of my medications.
Implementation Considerations Community-based implementation Hospital-specific implementation Providers as coach Volunteers as coach Partnerships with AAA and ADRC Local adaptations Measurement Considerations Process Measures Proximal Outcome Measures Utilization Measures Care Transitions Intervention (CTI) Count of patients coached Count of medication discrepancies PAM scores Patient Activation Assessment scores Readmission rates Admission rates Emergency department utilization rates Stories from the field
The personal impact Mr. H: A patient story I feel that I must tell someone about how greatly I benefited from and appreciate the services of the nurse who follows up on patients discharged from your hospital. She comforted me and helped make several forceful phone calls, and soon all was well. What a great help! What a relief! Thanks. Further Evidence Coleman et al. (2006): Lower 30-day readmission; lower readmission at 90 days and 180 days. Coleman et al. (2004): Lower readmission for same diagnosis at 90 days and 180 days. Additional articles of interest http://caretransitions.org/publications.asp 23 Patient Activation Patient Activation Measure (PAM ) http://www.insigniahealth.com/solutions/ patient-activation-measure
What s he saying? I sure hope my wife is getting this.. Patient Activation Measure(PAM ) - Integration with the CTI No I m good to go. Whatever you say is what we ll do Doctor Blah blah blah, blah blah. Any questions? How can you tell? Patient Activation Measure (PAM ) A 13 item measure used to guide clinical interventions that support patient activation to maximize outcomes Developed by Judith Hibbard, Jean Stockard, and Martin Tusler at the University of Oregon and Eldon R. Mahoney at PeaceHealth. The PAM is a copyright protected instrument and is the property of the Insignia Health Use of the PAM must be arranged by contacting Insignia Health PAM Stages of Activation Stage 1 Believes Active Role Important: Taking an active role in my own health care is the most important factor in determining my health and ability to function. Stage 2 Confidence and Knowledge to Take Action: I am confident that I can follow through on medical treatments Ineed to do at home. Stage 3 Taking Action: I am able to handle symptoms of my health condition on my own athome. I have made the changes in my lifestyle like diet and exercise that are recommended for my health condition. Stage 4 Staying the Course Under Stress: I am confident I can figure out solutions when new situations orproblems arise with my health condition. I am confident that I can maintain lifestyle changes like diet and exercise even during times of stress.
Can We Measure Activation? Sample Questions: #1: When all is said and done, I am the person who is responsible for taking care of my health. The PAM is scored on a 100 point continuum. Most patients score between 35 and 80 #12: I am confident I can figure out solutions when new problems arise with my health PAM questions assess three core domains knowledge, skills and confidence, that drive health behavior and outcomes 28 Does Activation correlate with important outcomes? 29 Is Activation Changeable? What Interventions change it?
31 Activation is developmental Medicare Segmentation 15-20% 20-30% 30-35% 20-30% Activation level insights guide support toward what is realistic and achievable for a given level PAM-Tailored Coaching Process If readmitted, continue to build confidence and do not let this derail the patient 33
PAM tailored coaching Outcomes Coleman CTI model 1 >300 patients coached Measurement Patient Activation Measure (PAM ; Insignia Health) 2 http://www.insigniahealth.com/solutions/patient-activation-measure NW Denver longitudinal data (sample size: 49) Critical Success Factors Patients will complete the PAM, and do so accurately. Proper administration is critical.convey caring and not evaluation The low activated (L1/L2) are 2 3x more likely to be readmitted Help the low activated focus on just a couple important tasks in their first two weeks following discharge Help patients build competency and confidence. Competency comes from confidence over time it s a journey. Best practice/evidence-based selfcare is achieved by those at L3 & L4 Allocate more resource to the low activated (L1 & L2), while shifting from the most activated (L4) L3 and 4 do not require intense support, but they do require appropriate support or they will ignore you Questions Kimberly Irby, MPH kirby@cfmc.org www.cfmc.org/integratingcare This material was prepared by CFMC (PM-4010-092 CO 2011), the Medicare Quality Improvement Organization for Colorado, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.