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Service Delivery Innovation Profile

Intensive, Nurse-Led Care Management During and After Hospitalization Reduces Readmissions and Costs for High-Risk Seniors


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Snapshot

Summary

The Transitional Care Model is an intensive, nurse-led care management program provided to high-risk seniors during and after hospitalization. A transitional care nurse with geriatric experience assesses inpatient and family needs, conducts discharge planning, implements the discharge plan through home visits and telephone communication, facilitates and encourages patient self-care, and serves as a liaison with community-based clinicians and services. Three randomized controlled trials found that the program reduced readmissions, inpatient days (when readmission occur), and care costs.

Evidence Rating (What is this?)

Strong: The evidence consists of three randomized controlled trials that compare key outcome measures related to hospital readmissions and cost savings among program participants to those in a control group.
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Developing Organizations

University of Pennsylvania School of Nursing
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Date First Implemented

1987
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Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Medically or socially complex; Age > Senior adult (65-79 years)end pp

Problem Addressed

Recently hospitalized older patients are often discharged with complex health care needs and/or suffer complications that lead to readmission.1 Many of these problems could be prevented, as they are often the result of a failure to adequately understand and manage complex postdischarge care needs, such as following medication regimens.
  • High readmission rates: An analysis of Medicare claims data from 2003 to 2004 found that the 30-day readmission rate for Medicare beneficiaries was nearly 20 percent, and 34 percent were rehospitalized within 90 days.2 Readmission rates are even higher for chronically ill seniors, particularly those with multiple comorbidities, functional and cognitive impairments, emotional problems, and poor health behaviors.1
  • Often avoidable: A review of nearly 100 studies indicates that one-fourth to one-third of readmissions among older patients could be prevented.1 Readmissions often occur because older patients and their family members do not adequately understand their complex postdischarge care needs, including how to follow complicated medication regimens and when and how to obtain periodic followup care from different providers.3 Patients and family members may also have difficulty accessing providers due to transportation issues and other problems. This lack of understanding and inadequate followup can make patients vulnerable to medication errors, exacerbations of symptoms, and other problems that commonly lead to readmission.1,3

What They Did

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Description of the Innovative Activity

The transitional care nurse assesses inpatient and family needs, conducts discharge planning, implements the discharge plan through home visits and telephone communication, facilitates and encourages patient self-care, and serves as a liaison with community-based clinicians and services. Key elements of the program include the following:
  • Target population: The program serves newly admitted, cognitively intact inpatients age 65 and older who speak English, can be reached by telephone, live within 30 miles of the hospital, will return home after discharge, and have a documented history of a cardiovascular, respiratory, endocrine, or orthopedic condition. The patient must also have at least two risk factors, including (but not limited to) the following: age 80 or older, moderate/severe functional deficits, history of mental or emotional illness, at least four active health conditions, or at least six prescribed medications. The program does not serve those with end-stage renal disease, a primary neurologic diagnosis, major psychiatric illness, or a primary diagnosis of cancer. Any member of the health care team on site can determine whether someone qualifies for the program.
  • Program enrollment: The patient recruiter describes program services to eligible patients and invites them and their caregiver(s) to participate. If the patient agrees, the patient is referred to the program, which is housed within the health system’s home care agency (or other applicable unit as determined by the organization).
  • Patient and caregiver assessment: The transitional care nurse visits the inpatient within 24 hours of enrollment and then continues to visit the patient daily during the hospital stay. The nurse gathers data on the patient, including sociodemographics, general health status, use of health and social services before hospitalization, functional status, mental status, emotional status, and perception of health status. The nurse also performs a caregiver assessment to determine the caregiver's capacity to provide care.
  • Discharge planning: Throughout the hospitalization, the transitional care nurse continues to assess patient and caregiver needs on a daily basis, with an eye toward discharge planning requirements. The nurse works with primary care and specialist physicians, nurses, and other hospital staff to prevent adverse events and functional decline that could lead to readmission, and to develop a comprehensive, streamlined discharge plan. The nurse revisits and adjusts this plan during the daily visits, as necessary. In collaboration with hospital clinicians, the nurse develops a discharge education plan to facilitate patient self-care based on the patient’s specific conditions and needs. The nurse maintains ongoing communication with the patient’s clinicians to report on the patient’s progress and to ensure prompt response to any changes in the patient’s health status. Twenty-four hours before discharge, the nurse visits the patient to review the plan of care and provide self-care education, contacts the hospital care team to finalize discharge preparations, and coordinates medical and social services needed after discharge.
  • Implementation of discharge plan through home visits and telephone communication: The transitional care nurse visits the patient at home within 24 hours of discharge. Regular home visits continue, based on a protocol that specifies a minimum number of visits (at least weekly during month one, biweekly during months two and three). Supplemental home visits occur at the nurse’s discretion, with visit content being based on the nurse’s clinical judgment. The nurse also periodically telephones the patient to address questions, monitor progress, and reinforce the care plan. Additionally, the nurse is available by telephone 7 days a week to the patient, caregiver, and providers to address questions and concerns and to enable an early response to health risks. An emergency plan with instructions for after-hours contact is also posted in the patient’s home.
  • Liaison with community-based clinicians and services: The transitional care nurse accompanies the patient to the first followup visit with the primary care clinician (physician or nurse practitioner) to ensure thorough communication about the care plan established in the hospital. This visit allows the nurse to establish a face-to-face relationship with the primary care clinician, thus allowing for easier engagement in problem-solving with the clinician should the patient’s health status subsequently decline. The nurse also helps identify and arrange needed social services for the patient and caregiver.
  • Discharge from program: A patient no longer requires program services once the nurse feels, based on their clinical judgment, that the patient is no longer at risk for poor outcomes in the short and long term, and that the patient and caregiver can adequately manage the patient’s conditions on their own.

Context of the Innovation

In the mid-1980s, Mary Naylor, PhD, began working with the U.S. Senate Committee on Aging to examine the impact of shortened length of stay and other major consequences of the newly implemented Prospective Payment System on Medicare beneficiaries and their family caregivers. Subsequently, Dr. Naylor joined the University of Pennsylvania and formed a working group with colleagues from nursing, medicine, and the Wharton School of Business who shared an interest in the effects of major policy changes on the senior population. One focus was whether the negative effects of shortened length of stay could be overcome by improving the quality of discharge planning. Eventually, this multidisciplinary working group developed the Transitional Care Model, which has been tested and refined over the past 20 years. Model developers note that between 20 and 25 percent of Medicare beneficiaries meet the criteria for program eligibility.7 Tests of the initiative were conducted at the Hospital of the University of Pennsylvania, a part of the multihospital, academic University of Pennsylvania Health System located in Philadelphia, PA, along with other hospitals and practice sites in urban, suburban, and rural settings in the Philadelphia area. Based on strong positive results, the University of Pennsylvania Health System adopted the model in 2009.

Did It Work?

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Results

Three randomized controlled trials found that the program reduced readmissions, inpatient days when readmissions do occur, and care costs.
  • Fewer readmissions:
    • A study of 363 high-risk seniors hospitalized with a variety of common medical conditions were randomly assigned to receive usual care or the Transitional Care Model intervention; at 24 weeks postdischarge, 20 percent of those in the program had been rehospitalized, compared to 37 percent of those in the control group.4
    • A study of 276 seniors, hospitalized for treatment of cardiac conditions, randomized patients to receive usual care or the Transitional Care Model intervention.5 At 6 weeks postintervention, medical (but not surgical) patients receiving the intervention had 61 percent fewer hospital readmissions. Only 10 percent of program participants had been readmitted, compared to 23 percent of the usual care group.5
    • A randomized study involving 239 seniors hospitalized with heart failure found that the readmission rates for program participants were lower at the 6-week, 26-week, and 52-week followup (10 percent vs. 23 percent, 28 percent vs. 56 percent, and 48 percent vs. 61 percent, respectively).6 At the 1-year point, program participants also had fewer hospital days (588 vs. 970), with a higher percentage having avoided rehospitalization (45 percent vs. 32 percent).6
  • Fewer inpatient days after readmission: In the study of 276 seniors cited above, those program participants who required readmission had 70 percent fewer inpatient days once readmitted than did members of the control group.5
  • Lower care costs:
    • In the study of 363 seniors cited above, total costs of postdischarge services (as measured by Medicare reimbursement) at 24 weeks after discharge were twice as high in the control group as for those participating in the program.4 Total cost savings associated with use of the Transitional Care Model amounted to nearly $600,000, or approximately $3,000 per patient.4 This net reduction accounted for all program expenses, including staff salary.
    • In the study of 276 seniors cited above, total charges for health care services 6 weeks after discharge for the medical intervention group were $295,598 less and mean charges $4,293 less than charges for the control group.5
    • In the study of seniors with heart failure, average costs per patient after 1 year were $7,636 among program participants, compared to $12,481 in the usual care group.6 (Figures include the direct cost of the intervention.) The program resulted in a 37.6 percent reduction in total costs over the 12-month study period.6
  • Improved quality of life and satisfaction with care: In the study of seniors with heart failure, intervention patients experienced short-term improvements in overall quality of life, physical dimension of quality of life, and satisfaction with care.6

Evidence Rating (What is this?)

Strong: The evidence consists of three randomized controlled trials that compare key outcome measures related to hospital readmissions and cost savings among program participants to those in a control group.

How They Did It

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Planning and Development Process

Program developers highlight the following key elements of the planning and development process; potential adopters can contact Dr. Mary Naylor for information about how the University of Pennsylvania can assist with these steps.
  • Communicating value of transitional care management to senior leadership: Program developers described the model to senior organizational leaders and clearly explained how it could benefit the organization, providing evidence documenting the benefit and outlining a business case for adoption based on organization-specific characteristics and available financial data.
  • Integrating and adapting model to fit organizational mission and goals: The Transitional Care Model was adapted to fit the unique needs of the organization; adaptation included defining the best organizational "home” for the program; identifying a program champion; creating a project team and identifying its roles and responsibilities; and establishing timelines for achieving goals. Program developers also defined transitional care nurse workflow processes and the role of the patient recruiter in the context of the current care process.8
  • Hiring and training staff: The transitional care nurses and patient recruiter were hired and trained to implement the model using Web-based and person-to-person modules. Approximately 1 month of training was required to prepare nurses to manage a full caseload of patients.
  • Performing comprehensive evaluation: Evaluation of the program includes a pre- and post-implementation comparison of patients’ physical, functional, and emotional status, and self-reported health status and quality of life, with comparisons to benchmarks as appropriate. Patient and physician satisfaction surveys are also used.

Resources Used and Skills Needed

  • Staffing: As of 2009, the University of Pennsylvania Health System employs five transitional care nurses and one patient recruiter. On average, each transitional care nurse cares for 20 high-risk seniors. Transitional care nurses are masters-prepared nurses with geriatric-specific training and experience.
  • Costs: The primary program costs consist of salary and benefits for the transitional care nurses.
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Funding Sources

National Institutes of Health; The Commonwealth Fund; California Healthcare Foundation; Jacob and Valeria Langeloth Foundation; Gordon and Betty Moore Foundation; University of Pennsylvania Health System; The John A Hartford Foundation, Inc.
Private payers cover the services provided by transitional care nurses through payment of a case rate that has been calculated based on Transitional Care Model data reflecting nurse time spent with patients from hospital admission through 60 to 90 days after discharge; the service substitutes for traditional visiting nurse services. To date, Medicare does not reimburse for transitional care nurse services.end fs

Tools and Other Resources

The University of Pennsylvania Health System uses various enrollment, analysis, and clinical assessment tools in the implementation of this initiative (see below); more information about where to access each of these tools is available directly from the innovator.
  • Enrollment tools: Screening and risk criteria assessment checklist, short portable mental health status questionnaire, patient information and demographics form, sociodemographic information form, social support assessment form, and Transitional Care Model protocol adherence checklist.
  • Analysis and outcomes tools: Medical outcomes study short form, symptom bother scale, self-care of heart failure index, geriatric depression scale, overall quality of life single-item assessment, patient satisfaction survey form, provider satisfaction survey form, and health care utilization tracking sheet.
  • Clinical assessment tools: Medication reconciliation form, diagnoses/conditions checklist, Omaha problem assessment form, Katz activities of daily living assessment, instrumental activities of daily living form, and mini-mental state examination form.
  • Other tools and support: A series of Web-based training modules that prepare nurses to become transitional care nurses has been developed and are available. Position descriptions, assistance with the interview and training processes, clinical information systems that support implementation, and ongoing support via clinical case conferences from a transitional care nurse expert.

Adoption Considerations

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Getting Started with This Innovation

  • Ensure senior leadership support: Organizational leaders should agree on the need to focus on the care of high-risk Medicare beneficiaries and to support adoption of the program.
  • Identify physician champion: Adopting the model can be challenging; a physician champion who is committed to this approach can help to overcome regulatory and operational obstacles to implementation.
  • Communicate regularly: Engage frontline providers and all major stakeholders early and continuously during implementation to ensure their support and understanding of the model and their roles in implementing it.

Sustaining This Innovation

  • Measure and report outcomes: Evaluate and analyze the impact of the program, including patient and provider satisfaction. Provide updates on the program's progress to the organization as a whole, maintaining transparency for continued understanding of the program's impact on the organization and patient care.

More Information

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Contact the Innovator

Mary D. Naylor, PhD, RN, FAAN
Marian S. Ware Professor in Gerontology
Director, NewCourtland Center for Transitions and Health
University of Pennsylvania School of Nursing
418 Curie Boulevard, Claire M. Fagin Hall RM341
Philadelphia, PA 19104-4217
E-mail: naylor@nursing.upenn.edu

Innovator Disclosures

Dr. Naylor reported having no financial interests or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.

References/Related Articles

Additional information about the Transitional Care Model can be found at: http://www.transitionalcare.info/.

A profile of the Transitional Care Model is available at: http://www.innovativecaremodels.com/care_models/21.

Naylor MD. Transitional care for older adults: a cost-effective model. LDI Issue Brief. 2004;9(6):1-4. [PubMed]

Naylor M, Brooten D, Jones R, et al. Comprehensive discharge planning in the hospitalized elderly: a randomized clinical trial. Ann Int Med. 1994;120:999-1006. [PubMed]

Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281(7):613-20. [PubMed]

Naylor MD, Brooten DA, Campbell RL, et al: Transitional care of older adults hospitalized with heart failure: a randomized controlled trial. J Am Geriatr Soc. 2004;52(5):675-84. [PubMed]

Footnotes

1 Naylor MD. Transitional care for older adults: a cost-effective model. LDI Issue Brief. 2004;9(6):1-4. [PubMed]
2 Jencks SF, Williams MV, Coleman EA: Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418-28. [PubMed]
3 Naylor MD. Transitional care of older adults. Annu Rev Nurs Res. 2002;20:127-47. [PubMed]
4 Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281(7):613-20. [PubMed]
5 Naylor M, Brooten D, Jones R, et al. Comprehensive discharge planning in the hospitalized elderly: a randomized clinical trial. Ann Int Med. 1994;120:999-1006. [PubMed]
6 Naylor MD, Brooten DA, Campbell RL, et al: Transitional care of older adults hospitalized with heart failure: a randomized controlled trial. J Am Geriatr Soc. 2004;52(5):675-84. [PubMed]
7 Interview with Mary Naylor, September 22, 2009.
8 Naylor MD, Feldman PH, Keating S, et al. Translating research into practice: transitional care for older adults. J Eval Clin Pract. 2009;15(6):1164-70. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: June 09, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 05, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 15, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.