CMS National Conference on Care Transitions

1. CMS National Conference on Care Transitions December 3, 2010

2. Implementation of the Transitions of Care Model in a Community Setting Andrew Miller, MD, MPH Director, Physician Services Healthcare Quality Strategies, Inc. (HQSI)

3. New Jersey Care Transitions Project Community • Southwestern New Jersey • Main partner organization: Virtua

4. Virtua Home Care • Implemented Transitional Care Model (TCM) • Key requirements for program • Financial feasibility • Sustainability

5. Role of Penn School of Nursing Team • Presentations to Virtua leadership • Training • Online training modules (reviewed by Penn nurse trainer) • Site visit by Virtua Home Care nurses to Philadelphia • Ongoing support • Periodic case conferences • Availability for telephone consultation

6. Adaptations • To make the model feasible and sustainable in a primarily Fee-for-Service, pre-Affordable Care Act environment • Enrolled only patients eligible for Medicare home health services • Baccalaureate nurses instead of Advanced Practice Nurses (APNs)

7. Adaptations (cont’d) • No visit in the hospital by the Transitional Care Nurses (TCNs) • TCN does not accompany patient to the first follow-up visit to the physician • Allowed enrollment of patients after discharge from the hospital • Initial refusals • Patients identified by a home health nurse

8. Additional Training Provided to TCNs • Management of patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes • Availability of community resources for patients with chronic conditions

9. Pilot Project • Started as a small pilot within Virtua Home Care • Four TCNs (2.4 FTE) • Ultimate goal is spread throughout the agency

10. Virtua Home Care’s Sense of Ownership • New name: • Transitions of Care Program • Potential concern: • Loss of fidelity with the evidence-based TCM

11. Outcomes Number of Hospitalizations Number of Transitions of Care Program enrollments = 81 Analysis is limited to 61 patients with identifiable inpatient hospital claims prior to enrollment.

12. Outcomes (cont’d) 30-Day Acute Care Hospitalization Rate *Q3 2010 data is incomplete. Result is preliminary.

13. Outcomes (cont’d)

14. Advice about Implementing the Transitional Care Model • It is as good as Dr. Naylor says it is • Invest the time and resources necessary to identify and train the TCNs • The TCM works very well in a community-based setting • Build at least a simple evaluation system from the start

15. Role of the QIO (HQSI) • Making the home health agency aware of the TCM program • Facilitating: bringing the agency together with the Penn School of Nursing team • Assisting with implementation: serving on steering committee • Funding support: for training provided by Penn team • Analytic support: for examining outcomes

16. For more information, contact: • Andrew Miller, MD, MPHDirector, Physician ServiceHealthcare Quality Strategies, Inc.557 Cranbury Road, Suite 21East Brunswick, NJ 08816-5419732-238-5570, extension 2072amiller2@njqio.sdps.org