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On September 19, 2011, Mary Naylor made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (3.4 MB).

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Slide 1

The Transitional Care Model: Translating Research into Practice and Policy

Mary D. Naylor, PhD, RN, FAAN
Marion S. Ware Professor in Gerontology
Director, NewCourtland Center for Transitions and Health
University of Pennsylvania School of Nursing

Slide 2

Transitional Care

• Transitional care—range of time limited services and environments that complement primary care and are designed to ensure health care continuity and avoid preventable poor outcomes among at risk populations as they move from one level of care to another, among multiple providers and across settings.

Slide 3

The Case for Transitional Care

• High rates of medical errors.
• Serious unmet needs.
• Poor satisfaction with care.
• High rates of preventable readmissions.
• Tremendous human and cost burden.

Slide 4

Major Affordable Care Act Provisions

• Center for Medicare and Medicaid Innovation.
• Community-Based Care Transitions Program.
• Patient Centered Medical Homes.
• Shared Savings Program (ACOs).
• Federal Coordinated Health Care Office.
• Payment Innovation (Bundled Payments).

Slide 5

Context: Acute Care Episode

Image: Figure shows the following process:

• Population At Risk.
• Acute Phase.
• Post Acute / Rehab Phase.
• Secondary Prevention.

• Trajectory 1 (T1) Relatively healthy adult with onset of new chronic illness.
• Trajectory 2 (T2) Adult with multiple chronic conditions.
• Trajectory 3 (T3) Adults at end of life.

Adapted from the National Quality Forum (NQF) steering committee on Measurement Framework: Evaluating Efficiency Across Patient-Focused Episodes of Care. The committee's report presents the NQF-endorsed measurement framework for assessing efficiency, and ultimately value, associated with the care over the course of an episode of illness and sets forth a vision to guide ongoing and future efforts.

Slide 6

Published Evidence

• 21 RCTs of diverse "hospital to home" innovations targeting primarily chronically ill older adults.
• 9/21, + impact on at least one measure of rehospitalization plus other health outcomes.
• Effective interventions.
  • Multidimensional and span settings.
  • Use inter-professional teams with primarily nurses, as "hubs".

Naylor MD, Aiken LH, Kurtzman ET, Olds DM, & Hirschman KB. (2011) THE CARE SPAN—The Importance of Transitional Care in Achieving Health Reform. Health Affairs 30(4):746-754.

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Different Goals of Evidence-Based Interventions

• Address gaps in care and promote effective "hand-offs".
• Address "root causes" of poor outcomes with focus on longer-term value.

Slide 8

Transitional Care Model (TCM)

1. Screening.
2. Engaging Elder & Caregiver.
3. Managing Symptoms.
4. Educating/ Promoting Self-Management.
5. Collaborating.
6. Assuring Continuity.
7. Coordinating Care.
8. Maintaining Relationship. 

Slide 9

Unique Features

Care is delivered and coordinated:

• ...by same advanced practice nurse.
• ...in hospitals, skilled nursing facilities (SNFs), and homes.
• ...seven days per week.
• ...using evidence-based protocol.
• ...with focus on long term outcomes.

Slide 10

Core Components

• Holistic, person/family centered approach.
• Nurse-coordinated, team model.
• Protocol guided, streamlined care.
• Single "point person" across episode of care (relational/management continuity).
• Information systems that span settings (communication continuity).
• Focus on increasing value over long term.

Slide 11

Across Reported RCTs, TCM has...

• Increased time to first readmission or death.
• Improved physical function and quality of life*.
• Increased patient satisfaction.
• Decreased total all-cause readmissions.
• Decreased total health care costs.

*Most recently completed RCT only.

Slide 12

Image: A bar chart labeled TCM's Impact on Readmission Rates After Index Hospitalization compares TCM Group with Control Group at 6 weeks¹, at 26 weeks², and at 52 weeks³.

¹ Naylor MD, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, & Pauly MV. Comprehensive discharge planning for the hospitalized elderly. Ann Intern Med 1994;120:999-1006.

² Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, & Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA 1999;281:613-620.

³ Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, & Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc 2004;52:675-684.

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TCM's Impact on Total Health Care Costs*

Image: A bar chart labeled TCM's Impact on Total Health Care Cost* compares TCM Group with Control Group at 26 weeks** and at 52 weeks***.

* Total costs were calculated using average Medicare reimbursements for hospital readmissions, ED visits, physician visits, and care provided by visiting nurses and other healthcare personnel. Costs for TCM care is included in the intervention group total.

** Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, & Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA 1999;281:613-620.

*** Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, & Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc 2004;52:675-684.

Slide 14

Barriers to Widespread Adoption

• Organization of care.
• Regulatory challenges.
• Quality and financial incentives.
• Culture of caring.

Slide 15

Translating TCM into Practice

Penn research team formed partnerships with Aetna Corporation and Kaiser Permanente to test "real world" applications of research-based model of care among high risk elders.

Funded by The Commonwealth Fund and the following foundations: Jacob and Valeria Langeloth, The John A. Hartford, Gordon & Betty Moore, and California HealthCare; guided by National Advisory Committee (NAC).

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National Advisory Committee

Images: A group of logos is shown.

Slide 17

Project Goals (Aetna)

• Test TCM in defined market.
• Document facilitators and barriers.
• Present findings to Aetna decision makers.
• Widely disseminate findings.

Slide 18

Tools of Translation

• Patient screening and recruitment.
• Orientation of nurses (web-based modules).
• Documentation and quality monitoring (clinical information system).
• Quality improvement (case conferences grounded in root cause analysis).
• Evaluation.

Slide 19

Key Indicators of Success

• Decisions by Aetna re: adoption.
• Decisions by other insurers and providers to implement model.
• Use of findings by CMS and insurers to reimburse evidence-based transitional care.

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Value = [Improved] Quality/Satisfaction / [Relative to] Health Resource Utilization (Costs)

Environment: Extant comprehensive system of geriatric telephonic care management.

Question: Does the Transitional Care Model offer greater value in this environment?

Slide 21

Findings

• Improvements in all quality measures.
• Increased patient and physician satisfaction.
• Reductions in rehospitalizations through 3 months.
• Cost savings of $2170 per member through one year.

All significant at p < 0.05.

Naylor, MD, et al. (2011). High-value transitional care: translation of research into practice. Journal of Evaluation in Clinical Practice. doi:10.1111/j.1365-2753.2011.01659.x.

Slide 22

Would cognitively impaired hospitalized older adults and their caregivers benefit from TCM?

Funding: Marian S. Ware Alzheimer Program, and National Institute on Aging, R01AG023116, (2005-2010).

Slide 23

Time to First Readmission

Image: A chart labeled "Time to First Readmission" shows readmission times decreasing.

Slide 24

Mean Number of All-Cause Rehospitalizations Through Six Months

Image: A line chart labeled "Mean Number of All-Cause Rehospitalizations Through Six Months" shows rehospitalizations decreasing.

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Mean Number of Total All-Cause Rehospitalization Days Through Six Months

Image: A line chart labeled "Mean Number of Total All-Cause Rehospitalization Days Through Six Months" shows rehospitalization days decreasing.

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What do we know about effects of transitions among elderly long-term care recipients over time?

Funding: National Institute on Aging, National Institute of Nursing Research, R01AG025524, (2006-2011)

Slide 27

Does the TCM add value to the Patient Centered Medical Home?

Funding: Gordon and Betty Moore Foundation, Rita and Alex Hillman Foundation and the Jonas Center for Excellence.

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The TCM...

• Focuses on transitions of high-risk cognitively intact and impaired older adults across multiple settings.
• Has been successfully translated into practice.
• Has been recognized by the Coalition for Evidence-Based Policy as an innovation meeting "top-tier" evidence standards.

Slide 29

Implementation Progress

• Aetna—expansion of TCM proposed as part of Aetna's Strategic Plan.
• University of Pennsylvania Health System—adopted TCM (Aetna and Blue Cross reimbursing).
• Other health care systems adapting.
• Experience informing implementation of ACA provisions.

Slide 30

Key Lessons

• Solving complex problems will require multidimensional solutions.
• Evidence is necessary but not sufficient.
• Change is needed in structures, care processes, and health professionals' roles and relationships to each other and people they serve.
• Overcoming inertia requires substantial force.

Slide 31

Transformational Drivers At National Level

• National goals, endorsed measures and public reporting platforms that focus on transitions.
• Large scale pilots of evidence-based TC.
• Stretch performance targets with more generous rewards for higher performance.
• Distribution of rewards across providers/health care professionals involved.
• Enhanced preparation of current/emerging work force.

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Transformational Drivers At Local Level

• Strong champions.
• Provider awareness of what works and does not work.
• Clearly defined, aligned and actionable goals.
• Organizational commitment (C-Suite and front line).
• Upfront + ongoing investment in care teams.
• Shared accountability for higher value.

Slide 33

Image: A newspaper article titled "Getting Patients Back on Their Feet Faster" is shown.