Evidence-based Solutions for Transitional and Post Acute Care Kathy H. Bowles PhD, RN, FAAN Associate Professor NewCourtland Center for Transitions and Health University of Pennsylvania School of Nursing Beatrice Renfield Visiting Scholar, VNS of NY Meridian Health

November 30, 2011

Acknowledgements 

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Factors to Support Effective Discharge Decision Making 

Funded by the National Institute of Nursing Research (NINR) RO1-NR007674

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PI: Dr. Kathy Bowles. Co-I’s: Holmes, Liberatore, Naylor, Ratcliffe

Decision Support: Optimizing Post Acute Referrals & Impact on Pt Outcomes 

Funded as a competing continuation NINR RO1-NR007674

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PI: Dr. Kathy Bowles, Co-I’s: Hanlon, Holmes, Naylor, Ratcliffe, Shaha, Stabler

Hospital to Home: Cognitively Impaired Elders/Family Caregivers 

Funded by the National Institute on Aging R01AG023116 and the Marian S. Ware Alzheimer's Program at the University of Pennsylvania.

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PI: Dr. Mary Naylor, Co-I’s: Hirschman, Bowles, McCauley, Bradway, Pauly, Hanlon

Promoting Self Care Through Telehomecare: Impact on Outcomes 

Funded by NINR RO1-NR008923

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PI: Dr. Kathy Bowles, Co-I’s: Dansky, Naylor, Riegel, Goldberg, Glick, Weiner

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Objectives  State the challenges to effective discharge planning and transitional care  Discuss evidence based solutions to effective discharge planning, information transfer, transitional care, and post discharge monitoring

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Barriers to Effective Discharge Planning  Discovered lack of post acute referrals 

Confirmed with 2 pilot studies

 No national guidelines for Medicare discharge referral decisions  

Over 14 million affected annually Various discharge planning models

 Lack of protocol exacerbated by:   

Shortened lengths of stay Inconsistent assessments Varying levels of expertise & risk tolerance

 Potential outcomes: 

Increased costs, poor discharge outcomes, & premature deaths 3

Challenges of Transitional Care  Increasingly complex patients  Multiple providers  Inconsistent decision making  Frequent transitions across settings

 Lack of information transferred across settings  Loss of continuity

 Inconsistent patient involvement in self care

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Significance  Within 30 days of discharge:  

19% of Medicare beneficiaries are re-hospitalized (Jencks, Williams, Coleman, 2009) Estimate: up to 76% of these readmissions may be preventable (MedPAC Report, 2007)

 Of the Medicare beneficiaries readmitted within 30 days: 

64% received no post acute care between discharge and readmission (MedPAC Report, 2007)

 Eliminating just 5.2% of preventable Medicare readmissions could save an estimated $5 billion annually (Lubell, 2007)  Suggested interventions to prevent these re-admissions:  

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Identify and refer high risk patients before discharge Improve care coordination and communication across settings Devise new approaches to follow-up 5

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Improving Discharge Planning  Improve identification of patients in need of discharge planning  Development and validation of a screen for specialized discharge planning services Dr. Diane Holland, Nurse Researcher,

Mayo Clinic Rochester, MN Post Doc Fellow University of Penn (2009-2011)

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ESDP components  Four item screen completed upon admission includes an assessment of:    

Age Walking limitation Living alone Disability

 Cut off score determines those who the discharge planner should target for comprehensive assessment Holland, D.E., Harris, M.R., Leibson, C.L., Pankratz, V.S., & Krichbaum, K.E. (2006). Nursing Research, 55(1), 62-71

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D2S2 Components  Screening tool completed on day 1-3 and every 8 days:

 Cut off score determines those who the discharge planner should consider for post acute referral For more information contact Eric Heil or Kathy Bowles [email protected] [email protected] .

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RightCare Solutions: current work    

Patients admitted to medical units Age 55 and older Randomized by unit or team Baseline, 7 day and 60 day follow-up    

Readmissions and ED use Problems and unmet needs Quality of life Quality of the transition

 Studies are ongoing at: 

Hospital of the University of Pennsylvania  New York University Hospital  Johns Hopkins University Hospital

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Preliminary Findings  Patients who reach the cut-off score on the Discharge Decision Support System: 

Are identified for post acute care interventions  Have significantly more problems and unmet needs after discharge  Are more likely to be readmitted by 30 and 60 days  Are more likely to be readmitted sooner  Have worse QOL regarding mobility, pain, depression, and self care

 When the D2S2 says do NOT refer but referral is still offered, patients refused 40% of the time 12

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Unique Features of the TCM  Care is provided:  

by transitional care nurses (TCNs - usually master’s prepared nurses) who specialize in care of high-risk groups and their caregivers across hospital and home settings by the same TCN

 Guidelines, allow flexibility to individualize care:  

TCNs used clinical judgment to determine frequency, intensity, and nature of contact TCNs determine whether to use home visits or telephone as mode of contact

 On-going collaboration with patients’ physicians and other providers, with support from an expert multidisciplinary team via email or phone (as needed)

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The Intervention  Initial TCN visit within 24 hrs of admission to hospital  Identification of patients’ and caregivers’ goals  Individualized care plan guided by standardized assessment  Home visit within 24 hours of hospital discharge  

At least one home visit per week during the first month At least, bimonthly visits until program discharge

 Collaboration at the first primary care visit  Telephone contact each week an in-person visit is not scheduled  Intervention length = 2 months (range 1-3 months) 15

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Improving the transfer of information  The Omaha System is an ANA standardized language

 Problem Classification Scheme of 42 patient problems and symptoms  Intervention Scheme with four major interventions and targets  Problem Outcome Rating Scale  Used in the Transitional Care Model to document nursing care from hospital to home  Improves the communication of a standardized problem list and provides suggested interventions for each problem

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Solutions for Effective Transitions  Telehealth Technology  Use of remote monitors in patients’ homes to teach self care and monitor chronic illness management Bowles, K.H., & Baugh, A.C. (2007). Applying Research Evidence to Optimize Telehomecare. Journal of Cardiovascular Nursing, 22(1), 5-15. Bowles, K.H., Holland, D.E, & Horowitz, D.A. (2009). Comparing in-person home care, home care with telephone contact, or home care with telemonitoring: Outcomes of different disease management delivery methods. Journal of Telemedicine and Telecare.15: 344-350.

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Take Home Messages  The lack of time and resources available to hospital discharge planners calls for improved methods  to efficiently and accurately identify patients in need of discharge planning and post acute care

 The quality of hospital discharge planning decisions determines  whether older adults receive the health and social services they need  or are sent home with unmet needs and without services, leading to increased risk of readmission or developing costly, poor outcomes  Decision support can improve these important decisions

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Take Home Messages  The Transitional Care Model is a highly effective advanced practice nurse led model to support the transition from hospital to home.  Telehealth monitoring is an increasingly used strategy to teach self care and monitor for exacerbations of chronic illness, but further research is needed.

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References Bowles, K.H., & Baugh, A.C. (2007). Applying Research Evidence to Optimize Telehomecare. Journal of Cardiovascular Nursing, 22(1), 5-15. Bowles, K.H., Foust, J.B., & Naylor, M.D. (2003). A multidisciplinary perspective of hospital discharge referral decision making. Applied Nursing Research, 16(3), 134-143. Bowles, K.H., Holmes, J.H., Ratcliffe, S., Liberatore, M., Nydick, R., & Naylor, M.D. (2009). Factors Identified by Experts to Support Discharge Referral Decision Making. Nursing Research, 58(2), 115-122. Bowles, K.H., Naylor, M.D., & Foust, J.B. (2002). Patient characteristics at hospital discharge and a comparison of home care referral decisions. Journal of the American Geriatrics Society, 50, 336-342. Bowles, K.H., Ratcliffe, S.J., Holmes, J.H., Liberatore, M., Nydick, R., & Naylor, M.D. (2008). Discharge Referral Decisions Made by Experts Compared to Hospital Clinicians and the Patients’ 12-Week Post-Discharge Outcomes. Medical Care, 46(2), 158-166. Bowles, K.H., Holland, D.E, & Horowitz, D.A. (2009). Comparing in-person home care, home care with telephone contact, or home care with telemonitoring: Outcomes of different disease management delivery methods. Journal of Telemedicine and Telecare.15: 344-350. Holland, D.E., Harris, M.R., Leibson, C.L., Pankratz, V.S., & Krichbaum, K.E. (2006). Nursing Research, 55(1), 62-71. Naylor, M., Brooten, D., Jones, R., Lavizzo-Mourey, R., et al. (1994). Comprehensive discharge planning for the hospitalized elderly: A randomized clinical trial. Annals of Internal Medicine, 120, 999-1006. Naylor, M.D., Brooten, D., Campbell, R., et al. (1999). Comprehensive Discharge Planning and Home Follow-up of Hospitalized Elders. JAMA, 281, 613-620.

Naylor, M.D., Brooten, D.A., Campbell, R.L., et al. (2004). Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J.Am.Geriatr.Soc., 52(5), 675-84. 22

Discussion & Questions

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