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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 l.jpg

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


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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”)


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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.


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    Many QI opportunities to reduce hospitalization . . .


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    Care Transitions Models Improve Processes, Information Flows, and Capacity

    • Evidence-based models include:

      • Care Transitions Intervention

      • Transitional Care Model

      • Guided Care

      • GRACE

      • Others


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    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


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    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


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    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


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    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


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    How Technologies May Support Care Processes

    Video-Based

    Education

    Telemedicine

    Smart Sensors

    Wireless Broadband Networks

    Home

    Medication

    Management

    Remote Patient Monitoring

    Patient Health Records


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    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


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    Veterans Health Administration (Central CA)CTA Grant Project

    POTS = Plain Old Telephone Service


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    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


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    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


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    Indiana State Unit on AgingCTA Grant Project


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    Washington State Unit on AgingCTA Grant Project


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    Connecticut Pharmacists FoundationCTA Grant Project


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    Diffusion of InnovationsLessons Learned

    • Stakeholder readiness to adopt

    • Business model/payment model

    • Technology/Intervention model

      • Evidence base/relative advantage

      • Compatibility

      • Complexity

  • Policy issues


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    Center for Technology and Aging

    www.techandaging.org


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