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Care Transitions Innovation (C- TraIn ). Honora Englander, MD Assistant Professor of Medicine Oregon Health & Science University September 27, 2013. Objectives. Describe transitional care gaps and challenges among socioeconomically disadvantaged adults

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care transitions innovation c train

Care Transitions Innovation(C-TraIn)

Honora Englander, MD

Assistant Professor of Medicine

Oregon Health & Science University

September 27, 2013



Describe transitional care gaps and challenges among socioeconomically disadvantaged adults

Describe the Care Transitions Innovation (C-TraIn), including:

1. How the program was developed, including securing institutional support

2. What the C-TraInintervention entails

3. The program’s experience to-date, including single site implementation and expansion across the

regional Coordinated Care Organization

Discuss some lessons learned from the C-TraIn experience


Care Transitions Innovation(C-TraIn)RARE Networking Collaborative WebinarSeptember 27, 2013 Honora Englander,

  • Background – rationale and design
  • C-TraIn description
  • Experience to date
    • Successes, challenges, lessons learned
  • Next steps
  • Q&A
  • Transitions of care are increasingly recognized as target for quality improvement
  • Expected to be a source of cost savings

No single intervention was regularly associated with lower readmits; bridging were most promising

Hansen, Annals 2012

transitions among s ocioeconomically v ulnerable adults
Transitions Among Socioeconomically Vulnerable Adults
  • Few studies have focused on uninsured, low-income publicly insured patients
  • Different needs, may have different responses to interventions
  • At risk for poor health outcomes
  • Many are high-utilizers of the system
readmissions are complicated
Readmissions are complicated…

Medical, Behavioral



Socio- economic

Post-discharge care


Kansagara, Englander, et al JAMA, 2011

transitional care gaps reflect broader system fragmentation
Transitional care gaps reflect broader system fragmentation
  • Numerous contributors to readmission risk
  • Interventions to reduce readmissions not well studied in diverse populations
  • No off-the-shelf fixes; key to tailor interventions to local setting, address systems and population needs
brief history of c train
Brief History of C-TraIn
  • Health System M&M and one patient’s story
  • Needs assessment and Program Development OHSU (6/09-6/10)
    • Mixed methods survey of 116 inpatients who were uninsured or low-income publicly insured
    • Multidisciplinary provider focus groups
    • Mapped needs to specific components of C-TraIn
local needs assessment
Local Needs Assessment
  • Patients and providers described poor quality transitions for uninsured and low-income publicly insured adults
  • Opportunities to improve patient education, access to outpatient medications and care, and coordination between in- and outpatient care

Englander, Kansagara, Journal of Hosp Med 2012

Davis, Devoe, et al JGIM, 2012


“So all of a sudden I [went] from this controlled setting here with people watching out for me and taking care of me… to, I'm out there in the real world bounding around… and no real place to live as of yet. You know, it's just like, it's like a big roll of the dice.”

  • Hospitalized Patient
  • Englander, Kansagara; JHM 2012

“The package that leaves the hospital now…more often than historically, includes a PICC line, Foley catheter, oxygen--without a plan for when those are to be stopped and without communication to anyone about who's in charge next. Sometimes we end up with [the patients] coming back to see us months after they've been discharged. They've been wearing a Foley catheter all that time! It's amazing the way those balls can get dropped.”

  • PCP
  • Davis, Devoe et al, JGIM 2012
transitional care d eficiencies
Transitional Care Deficiencies
  • Communication
  • Patient education
  • Access to care
early experience at ohsu
Early Experience at OHSU
  • Started in 2010 as a hospital-funded intervention
  • Targeted adults living in the tri-county area who were uninsured, Medicaid, Medi-Medi, and low-income Medicare
  • Multi-component transitional care intervention
  • 3 partnering clinics
    • OHSU Internal Medicine Clinic, Old Town Clinic, Virginia Garcia
the health commons grant
The Health Commons Grant
  • July 2012: $17.3 million to support a system of care for high risk Medicaid adults
  • Scale up C-TraIn from 1 to 5 sites, including:
      • OHSU Medical and Surgical
      • Legacy Mt Hood, Legacy Good Sam, Legacy Emmanuel hospitals
      • Broader network of primary care clinics
    • Goal:
      • Achieve the triple-aim
      • Learn lessons to inform CCO transformation efforts
4 core c train components
4 Core C-TraIn Components:
  • Transitional Care Nurse
  • Pharmacy Consultation
  • Hospital and Clinic Linkages
  • Monthly quality improvement meetings with multidisciplinary providers across the care continuum
transitional care n urse r ole starts on admission through 30 days post dc
Transitional Care Nurse Role(Starts on admission through 30 days post-DC)
  • Needs assessment upon hospitalization
  • Personal health record
  • Cross site communication and care coordination
    • inpatient teams, PCPs, specialists, outreach workers, ADS, others
  • Home visit
  • Follow up calls, clinic visits, text messaging
pharmacy consultation inpatient intervention provides post dc consultation to tcn
Pharmacy consultation(Inpatient intervention, provides post-DC consultation to TCN)
  • Detailed medication reconciliation
    • Corroborate w/ PCP, outpatient pharmacies, family/ caregivers
  • Tailor medications to simple regimens, formulary alternatives
    • Provision of 30 days of C-Train formulary meds for uninsured and Medicare without Rx coverage (OHSU only)
  • Communication with outpatient pharmacies
  • Patient education re meds, side effects
    • Low health literacy/ numeracy
    • Pill card
dosing the intervention
Dosing the Intervention
  • Different doses for patient being discharged to skilled nursing facility, RCP, etc.
patient stories anticipatory p lanning and enhanced e ducation
Patient Stories: Anticipatory Planning and Enhanced Education
  • Middle aged man with diabetes, secondary blindness, and poor social support admitted with a diabetic foot ulcer requiring surgery. Started on insulin in the hospital.
  • In- and outpatient pharmacists collaborated to pre-load insulin pens
  • Nurse home visit reinforced self-management and follow-up plan
patient stories home visit g uides c are
Patient stories: Home Visit Guides Care
  • Elderly woman with heart failure admitted with lower extremity cellulitis. After discharge she didn’t answer phone so nurse went to home which was a safety hazard in complete disarray.
  • Nurse contacted PCP who arranged for home health and a social work referral prompted Adult Protective Services to assist in clean up and maintenance of home.
patient stories pharmacy consultation
Patient Stories: Pharmacy Consultation
  • Middle aged man with unstable housing and schizoaffective disorder assaulted and admitted as trauma with c-spine and jaw fractures, liver laceration
  • Pharmacy consult revealed he had stopped antipsychotics (? trigger for assault)
  • C-TraIn team facilitated cross-site communication w PCP and outpatient MH
  • Timely PCP f/u: food insecurity given jaw pain, arranged meals-on-wheels delivery
c train stories systems integration
C-TraIn Stories: Systems Integration
  • Cross-site collaboration
    • Inpatient and outpatient pharmacists
    • Transitional care nurse and clinic panel managers
    • Coordination with primary care partners
    • Building on connections with Skilled Nursing
  • Care plan spans the continuum of care:
    • Glucometer example

Primary: 30-day readmissions and ED visit rates


  • Transitional care quality (CTM-3)
  • Mortality
  • Timely access to outpatient care
  • Other grant-wide metrics, including admission rates across community, total cost-of-care, etc

Using experience to inform and build a system of care

ctm 3 care transitions measure
CTM-3 (Care Transitions Measure)
  • 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.
experience to date
Experience to Date
  • >600 patients served to date, >200 in year 1 of the Health Commons Grant
  • Completed a randomized trial at OHSU
  • Using findings to tailor intervention to best achieve the triple aimgoals
  • Highly-committed, multidisciplinary teams
  • Improved communication across hospital and ambulatory settings
  • Shift to anticipatory transitional care planning
  • Lessons extend beyond C-TraIn population
  • Triple-aim outcomes
  • Patient identification – who to target, how to engage
  • Anticipatory planning in a fast-moving system
  • Addictions remain key challenge for engagement
  • Primary care capacity to manage highly complex patients with numerous care teams
lessons learned
Lessons Learned
  • Diverse needs of this population challenge scope of transitional nurse role
  • Training in social determinants of health is key
  • Importance of embedding staff within Care Mgt and pharmacy teams
  • Value of work that spans care continuum, home
  • multi-disciplinary meetings (including clinic partners) optimizes work flow and outcomes
  • Project manager role critical to scaling improvement
program evaluation
Program Evaluation
  • Creating dashboard to track key activities and outcomes
  • Patient and provider surveys and interviews
  • Evaluation team comparing pre-post claims data
  • Outcomes reported quarterly (see Health Commons website for most recent dashboard)
next steps in year 2 of health commons grant
Next Steps in Year 2 of Health Commons Grant
  • Continuous quality improvement within and across sites
  • Continued alignment across grant interventions to optimize model of care and data systems
  • Program evaluation to be in full-swing
  • Beginning sustainability conversations with key stakeholders
implications for rare network
Implications for RARE network
  • Socioeconomically vulnerable adults may have different needs
  • No off the shelf fixes: context is key
  • Value of Hospital-community partnerships
  • Importance of executive leadership support
  • Value of C-TraIn lessons for all hospitalized patients
  • Optimize standard work around transitions of care
  • While focus on readmissions is important, also look at other measures of quality
Acknowledgements:Thank you to large multidisciplinary C-TraIn team across OHSU, Legacy, and numerous community sites

Honora Englander, MD

C-TraIn Director

Maggie Weller

C-TraIn Project Manager

c train team roles
C-TraIn Team Roles
  • Intervention Lead: Strategic vision and alignment
  • Hospital MD Leads: Provide input on workflow improvement; inform in-patient staff of C-TraIn
  • Transitional Care Nurses: patient education, multidisciplinary care coordination, engaging with community resources, home visits, follow up phone calls
  • Hospital Pharmacy Leads: health literacy assessment, patient education, prescribing guidance
  • Partner Clinic Champions: Provide input on workflow improvement; inform out-patient staff of C-TraIn
  • Project Manager: Track and drive completion of goals
case loads
Case Loads
  • 14 patients per month per 1.0 transitional care FTE
  • Initially targeted higher (~20 patients/ month) with goal to have more low-dose C-TraIn patients, but experience suggests paucity of lower need patients
  • Pharmacy team (0.3 FTE per 1.0 transitional care nurse) able to see higher case loads, depending on timing of consult

Readmission risk prediction models have been developed for hospital comparison and clinical intervention purposes

  • Most models in both categories perform poorly
  • Most models have relied on comorbidity and utilization data
  • Few models have examined social determinant variables

Kansagara, Englander JAMA 2011

Kansagara, JAMA, 2011


Mixed methods survey of 116 inpatients who were uninsured or low-income publicly insured

  • Mapped needs to specific components of C-TraIn

Englander, Kansagara JHM 2011


"We don’t have a community contract where

everybody acknowledges their role… ‘my role as the sender is to do these things’, ‘my role as the recipient is to do these things’…the ‘who will’ and ‘how’ of the handoff. We never get close to that sort of formality, which is really what any smart handoff or transition would require."

  • Healthcare administrator,
  • Davis, Devoe et al, JGIM 2012
  • Health Commons Web site
  • C-TraIn SharePoint site (for project teams)
upcoming rare events
Upcoming RARE Events….

Stay tuned for the next RARE Webinar in October.

RARE Action Learning Day – November 11, 2013 Crown Plaza Hotel, Plymouth, MN

Registration now open!

future webinars
Future webinars…

To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact Kathy Cummings,