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Care Transitions Models and Key Technologies for Patients in the Home. Lynn Redington, DrPH, MBA Senior Program Director Center for Technology and Aging [email protected] Remington’s 9 th Annual Forecasting Think Tank Summit St. Pete, Florida March 13, 2011.

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Care Transitions Models and Key Technologies for Patients in the Home

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Care Transitions Models and Key Technologies for Patients in the Home

Lynn Redington, DrPH, MBA

Senior Program Director

Center for Technology and Aging

[email protected]

Remington’s 9th Annual

Forecasting Think Tank Summit

St. Pete, Florida March 13, 2011


Center for Technology and Aging

  • Established in 2009 with funding from The SCAN Foundation, located at the Public Health Institute

  • Mission: Expand the use of technologies that help older adults lead healthier lives and maintain independence

  • Independent, non-profit resource center on issues related to diffusion of technology for older adults

  • Technology Diffusion Grants Programs

    • e.g., Tech4Impact grant (Technologies forImproving Post-Acute Care Transitions “Tech4Impact”)


Post-Acute Care Transitions & Re-admissions

  • Avoidable Readmissions:

    • Opportunity for better care, better health, lower costs

    • 1 in 5 patients readmitted within 30 days of discharge

    • 76% of readmissions are preventable

    • A $25 billion savings potential

  • Call to action:

    • Improve care transitions (e.g., hospital to home)

    • Improve care coordination, outreach, patient engagement and support

  • References:

    New England Journal of Medicine, Jencks S, et al “Rehospitalizations among patients in the Medicare fee-for-service program” N England Journal of Medicine 2009; 360: 1418-28.

    PricewaterhouseCoopers, 2008. The price of excess: Identifying waste in healthcare spending.


    Many QI opportunities to reduce hospitalization . . .


    Care Transitions Models Improve Processes, Information Flows, and Capacity

    • Evidence-based models include:

      • Care Transitions Intervention

      • Transitional Care Model

      • Guided Care

      • GRACE

      • Others


    The Care Transitions Intervention (CTI)

    • “The Coleman Model”

    • Qualifications: CTI Coach can be layperson

    • Length of intervention: 30 days

    • Average cost: $196 per patient

    • Steps:

      • Four pillars--Medication management; Patient-centered record; Follow-up; Red flags

      • Five encounters--Hospital/SNF Visit; Home Visit; 3 Follow-Up Calls


    Transitional Care Model (TCM)

    • “The Naylor Model”

    • Qualifications: Transitional Care Nurses are advanced practice nurses (BA-prepared nurses under study)

    • Length of intervention: 1 to 3 months

    • Average cost: $982 per patient

    • Steps:

      • Visit patient in hospital, home visit w/24 hours, accompany patient to 1st doctor visit, facilitate clinician collaboration and communications with patient/family, on call 7 days a week


    Guided Care

    • Developed at Johns Hopkins University since 2001

    • Qualifications: Guided Care Nurse must be an RN

    • Length of intervention: For life

    • Average cost: $1743 per patient per year

    • Steps:

      • Conduct comprehensive home assessment, create care guide and action plan for patient, provide monthly monitoring and self-management coaching, coordinate care, facilitate access to community services, engage/educate informal caregivers


    GRACE: Geriatric Resources for Assessment and Care of Elders

    • “The Counsell Model”

    • Qualifications: Nurse practitioner and social worker

    • Length of intervention: Long term/indefinite

    • Average cost: $1432 per patient per year

    • Steps:

      • In-home assessment, home visit after any hospitalization, one phone or in-person follow-up per month, collaborate with PCP, hospital discharge planner and others in a team-based approach


    How Technologies May Support Care Processes

    Video-Based

    Education

    Telemedicine

    Smart Sensors

    Wireless Broadband Networks

    Home

    Medication

    Management

    Remote Patient Monitoring

    Patient Health Records


    Technology Usage Examples:CTA Grantees that Aim to Reduce Hospitalizations

    • Medication Optimization Technologies

    • American Society of Consultant Pharmacists Foundation

    • Caring Choices

    • Connecticut Pharmacists Foundation

    • VA Central California Health Care System

    • Visiting Nurse Services of New York

    • Remote Patient Monitoring Technologies

    • AltaMed Health Services, Stamford Hospital

    • California Association of Health Services at Home

    • Centura Health at Home

    • New England Healthcare Institute

    • Sharp HealthCare Foundation

    • HealthCare Partners

    • Catholic Healthcare West

    • Personal Health Records Technologies

    • State Units on Aging and ADRCs in:

    • California

    • Rhode Island

    • Washington

    • Evidence-Based Care Transitions QI Evaluation Technologies

    • State Units on Aging and ADRCs in:

    • Indiana

    • Texas

    • ADRC = Aging and Disability Resource Center


    Veterans Health Administration (Central CA)CTA Grant Project

    POTS = Plain Old Telephone Service


    The Early Adopter Experience: Veterans Health Administration (1 of 2)

    • VHA has evaluated, piloted, reevaluated, and deployed telehealth technologies in a continuing process of learning and improvement far beyond adoption in the private sector

    • Largest national program--enables detailed analyses

    • Home telehealth compared to traditional care models:

      • Studies conducted on patients enrolled in the VA’s Care Coordination/Home Telehealth program in 2006 and 2007 show:

        • 25% reduction in bed days of care

        • 20% reduction in numbers of admissions

        • 86% mean satisfaction score rating


    The Early Adopter Experience: Veterans Health Administration (2 of 2)

    Age Distribution of all CCHT Patients

    • Net cost = $1,600 / patient / year vs.

      • VHA’s home-based primary care services = $13,121 / patient / year

      • Market nursing home care rates average = $77,745 / patient / year

    • VHA takes “systems approach” to integrate the elements of the CC/HT program. This includes:

      • Product selection

      • Training

      • Protocols for patient selection, management

      • Data analytics

    • Since VHA implemented CCHT in 2003, a total of 43,430 patients have been enrolled


    Indiana State Unit on AgingCTA Grant Project


    Washington State Unit on AgingCTA Grant Project


    Connecticut Pharmacists FoundationCTA Grant Project


    Diffusion of InnovationsLessons Learned

    • Stakeholder readiness to adopt

    • Business model/payment model

    • Technology/Intervention model

      • Evidence base/relative advantage

      • Compatibility

      • Complexity

  • Policy issues


  • Center for Technology and Aging

    www.techandaging.org


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