Transcript IMPROVING CARE TRANSITIONS FOR OLDER ADULTS: THE ENHANCED DISCHARGE PLANNING PROGRAM S U S A N A L T F E L.

IMPROVING CARE TRANSITIONS FOR OLDER ADULTS:
THE ENHANCED DISCHARGE PLANNING PROGRAM
S U S A N A L T F E L D , P H D 1, A N T H O N Y P E R R Y , M D 2,
V A N E S S A F A B B R E , M S W 3, G A Y L E S H I E R , M S W 2, A N N E
BUFFINGTON, MPH1 AND ROBYN GOLDEN, AM, LCSW2
1
UNIVERSITY OF ILLINOIS AT CHICAGO, 2 RUSH UNIVERSITY
MEDICAL CENTER, 3 UNIVERSITY OF CHICAGO
DEVELOPING A DEEPER UNDERSTANDING
OF CARE TRANSITIONS
• Patient and caregiver needs
• Intervention processes
WHAT IS TRANSITIONAL CARE?
Coordination of care from one setting to
another:
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Hospital to home
Hospital to skilled nursing facility
Skilled nursing to home
Within hospital – unit to unit
IMPROVING CARE TRANSITIONS –
WHY?
• 19.6% of Medicare patients are re hospitalized within 30 days of hospital
discharge (Jencks, S. et al., (2009). Rehospitalizations among patients in the
Medicare fee-for-service program, NEJM, 2009)
• 19% of patients experience an adverse event within 3 weeks of hospital
discharge
• U.S. health care spending associated with potentially preventable
readmissions estimated at $12 billion to $17.4 billion per year (MedPAC.
(2007). Promoting Greater Efficiency in Medicare)
• 40-50% of hospital readmissions are linked to social problems and lack of
community resources (Proctor et al, (2000) Adequacy of home care and
hospital readmission for elderly congestive heart failure patients)
IMPROVING CARE TRANSITIONS
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Promote patient safety
Enhance patient satisfaction
Promote communication between care settings
Prevent re-hospitalization by addressing major causes of
adverse outcomes
• Psychosocial factors affecting the access to and utilization of
quality post-discharge care
EVIDENCE-BASED INTERVENTIONS TO
IMPROVE CARE TRANSITIONS
• BOOST (Williams)
• Project RED (Jack)
• Care Transitions Intervention (Coleman)
• Transitional Care Model (Naylor)
• Illinois Transitional Care Consortium Bridge (Altfeld, ITCC)
• Enhanced Discharge Planning Program (Altfeld, Golden,
Rooney, Perry et al)
EVIDENCE-BASED INTERVENTIONS TO
IMPROVE CARE TRANSITIONS
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BOOST
Project RED
Care Transitions Intervention
Transitional Care Model
Illinois Transitional Care Consortium Bridge
Enhanced Discharge Planning Program
How are they different?
EVIDENCE-BASED INTERVENTIONS
• BOOST – hospital based, discharge planning/teaching
intervention
• Project RED - hospital based, discharge planning/teaching
intervention
• Care Transitions Intervention – hospital to home, advanced
practice nursing model, care coordination through home visits
• Transitional Care Model – hospital to home, transitions
coach, enhanced communication across levels and between
providers
• Illinois Transitional Care Consortium Bridge – social work
coordination, emphasis on post d/c follow up
• Enhanced Discharge Planning Program
ENHANCED DISCHARGE PLANNING
PROGRAM
Telephone intervention
Master’s level social workers
Bio psychosocial focus
Patient referrals based on electronic medical
record
• Core intervention - 48 hour post discharge
telephone assessment
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ENHANCED DISCHARGE PLANNING
PROGRAM
• Randomized controlled trial of 720 patients
• All patients older than 65 with medical and psychosocial
risk factors
• Randomized to follow-up intervention or usual care
• Qualitative study
• Interviews with intervention social workers
ENHANCED DISCHARGE PLANNING
PROGRAM INTERVENTION
• The mean duration of the intervention was
5.8 days (s.d.=11.3)
• Range 1 to 72 days.
• The mean number of contacts was 5.4
(s.d.= 6.3).
• Range 1 to 44 days
LOGISTIC REGRESSION ANALYSES –
ADHERENCE OUTCOMES
OUTCOME
Physician
communication
Odds ratio
95%CI Lower
95% CI Upper
2.04
1.28
3.24
Physician
appointment
2.70
1.64
4.45
Physician
appointment kept
2.09
1.51
2.89
Physician
appointment made
and kept
2.22
1.59
3.10
.38
0.16
0.88
30 day mortality
Note: All models are adjusted for Admission type, prior admission in past year, coping,
insurance except mortality which was adjusted for coping since other covariates not
significant when included in the model
OUTCOMES – READMISSIONS AND ED USE
• Patient report re readmission/Emergency
Department use not validated by hospital records
• Primary issue: recall of specific admission dates/intervals
We are awaiting analysis of CMS data to explore readmissions
and ED use
WHO WERE THESE
PATIENTS?
WHAT DID THEY NEED?
WHAT DID EDPP DO?
PATIENT DEMOGRAPHICS
• Mean age=74.5 years
• 49.2% Caucasian/45.6% African American
• 59.4% Unmarried
• 62.6% Urban
• 91.1% Medicare
• 22.6% Medicaid
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INTERVENTION GROUP
• 300 of 360 (83.3%) of patients had
problems identified by an EDPP
clinician upon assessment
• For 219 (73%) of these individuals,
needs did not emerge until after
discharge
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NEED FOR POST-ASSESSMENT
INTERVENTION
• More than one call was needed for 254 of the 360
(70.6%) patients in this study.
• These patients had issues that needed intervention
and could not be resolved in the initial contact.
NEEDS IDENTIFIED
TRANSITIONAL CARE/HEALTH
Delay in service – home health
Issues with coordination between care providers
Medication management issue
Challenges with management of post-d/c care
Challenges with management of new treatment/dx
Difficulties obtaining community services
Communication with service and medical providers
Difficulty understanding discharge plan of care
Transportation
36
70
59
102
63
85
53
60
36
10.0
19.5
16.4
28.4
17.6
23.7
14.7
16.7
10.0
NEEDS IDENTIFIED
PSYCHOSOCIAL
Caregiver burden
Coping with change
Psychiatric illness
Inadequate social support
Insurance issues
Bereavement and end of life concerns
Suspected abuse and/or neglect; selfneglect
126
124
39
35
25
15
35.0
34.5
10.8
9.8
7.0
4.2
1
0.3
QUALITATIVE INTERVIEWS
• Clinical intervention themes
• Broad view of the client system
• Patient, caregiver, health
professionals/paraprofessionals
• Need to transcend institutional roles to
resolve problems
QUALITATIVE INTERVIEWS
• Patient/caregiver themes
• “surprises”
• More stressful than anticipated
• Fatigue
• Suggests that better discharge planning is
not the answer
POST-INTERVENTION CONTACT
• Almost 1/3 of intervention patients (29.3%)
contacted the EDPP clinician for additional services
or information after the case was closed
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QUESTIONS AND
COMMENTS
For more information, contact:
Susan Altfeld
[email protected]
312-355-1134
Thank you to the Rush EDPP clinical team--Madeleine Rooney, Debra Markovitz and Michele
Packard--- for their dedication to patients and
caregivers and their contributions to this research