Theory Into Practice: Transitional Care Model’S Success Demonstrates That Evidence Alone Isn’T Enough

IssueBrief

January 2015

Theory into practice: Transitional Care Model’s success demonstrates that evidence alone isn’t enough

nowing the questions and the answers just isn’t enough. It all comes down to real-world applications. That’s the lesson Mary Naylor, PhD, K RN, learned developing the Transitional Care Model (TCM). From unmet medical and social needs to high rates of preventable hospitalizations and poor care experiences, the economic and human aftermath of poor transitions can be “devastating,” especially for seniors, says Naylor, who is the Marian S. Ware professor in gerontology and director of the NewCourtland Center for Transitions and Health at the The challenge is to create University of Pennsylvania School of Nursing. a bridge across the chasm

And it’s a problem with a solution—several solutions, in fact. The evidence separating theory and is clear and abundant on how to improve care transitions. The challenge, practice. Evidence must Naylor says, is to create a bridge across the chasm separating theory and practice. Evidence must be turned into action. be turned into action.

As chief architect of the Transitional Care Model (www.transitionalcare. info), Naylor has devoted much of her career to building that bridge. TCM provides a blueprint for health care organizations to improve health outcomes by applying practical, high-quality, cost-effective, evidence- based solutions to care transitions. Developed at the University of Pennsyl- vania, TCM initially focused on comprehensive in-hospital planning and home follow-up for chronically ill, high-risk older adults who have been hospitalized—as well as their family Transitions have always been a and the emphasis on educating caregivers. In recent years, this concern, especially to professional patients and family caregivers to approach has been expanded case managers. The issue has taken address root causes of poor out- to preventing hospitalizations of on more urgency because of the comes and avoid preventable community-dwelling older adults. Affordable Care Act. The ACA rehospitalizations.”6 provides opportunities for achieving Defining the problem higher-value health care—reduc- The Transitional Care Model tions in spending without reductions addresses the negative effects The scope of the problem is well in quality—by preventing avoidable associated with common break- known. Poorly coordinated care hospital readmissions. downs in care when older adults transitions from the hospital to with complex needs transition from other care settings costs billions, Professional case managers hospital to home or another care and human consequences include recognize that transition points setting. Through pre- and post-dis- poor outcomes and injuries due to are the weakest links in the chain charge coordination of care for medication errors, complications, of care, and they also understand these patients, it prepares them infections and falls.1 that better transitions and opti- and their family caregivers to more mized care coordination can effectively manage their health. At least two out of every three decrease those avoidable hospi- older Americans have multiple talizations, improve health out- Among the key elements of chronic conditions, and more than comes, lower costs and enhance the model: 10 million Medicare beneficiaries— the patient experience, says roughly 20 percent of those Ameri- Patrice Sminkey, chief executive Nurse-coordinated, team- cans—now live with five or more officer for the Commission for based: Care is delivered and chronic conditions.2,3,4 Too often, Case Manager Certification™. coordinated by the same these patients don’t receive the “The good news is that research advanced practice nurse care they need as they transition results are in, and they support the (APN), supported by a care through the health care system. value of proactive efforts designed team. The APN works with Among Medicare beneficiaries to improve care coordination and high-risk older adults within and readmitted to the hospital within care transitions.” across all health care settings (e.g., hospital, skilled nursing 30 days of a discharge, half have facility, home, etc.). no contact with a physician Naylor’s Transitional Care Model between discharge from their is one such effort. Continuity: The APN serves as initial hospitalization and the “point person” across the subsequent readmission.5 Understanding entire episode of care, starting transitional care with hospital admission. The APN makes regular home visits 1 Improving Care Transitions, Health Transitional care, Naylor explains, and provides ongoing tele- Affairs Health Policy Brief, Sept. 13, 2012 refers to a broad range of time- phone support for an average 2 Centers for Disease Control and of two months post-discharge. Prevention. The State of Aging and Health limited services designed to in America 2013. Atlanta, GA: US Dept ensure health care continuity and Early intervention: The model of Health and Human Services; 2013. avoid preventable poor outcomes www.cdc.gov/aging emphasizes early identification for at-risk patients as they move 3 Thorpe, K. “The Medicare Advantage of, and response to, health across care settings. As she noted Experience: Lessons for Reform to Original care risks and symptoms to Medicare.” December 2012 in Health Affairs, “The hallmarks of 4 Achieving Quality, Traditional Care transitional care are the focus on 6 Naylor MD, Aiken LH, Kurtzman ET, Olds Model http://www.transitionalcare.info/ highly vulnerable, chronically ill DM, Hirschman KB. “The care span: The 5 Care Transitions: Best Practices and patients throughout critical transi- importance of transitional care in achiev- Evidence-based Programs, Policy Paper, tions in health and health care, ing health reform.” Health Aff (Millwood). Center for Healthcare Research & 2011 Apr;30(4):746-54. http://content. Transformation, Jan. 15, 2014 the time-limited nature of services, healthaffairs.org/content/30/4/746.long

2 "Professional case managers recognize that transition points are the weakest links in the chain of care, and they also understand that better transitions and optimized care coordination can decrease those avoidable hospitalizations, improve health outcomes, lower costs and enhance the patient experience."

— PATRICE SMINKEY, CHIEF EXECUTIVE OFFICER, THE COMMISSION FOR CASE MANAGER CERTIFICATION

avoid the need for prevent- Collaboration: Strong collabo- In theory and in practice, TCM able acute care and improve ration and communication leads to: quality of life. Naylor notes that among patients, family care- symptom management is dif- givers and health care team Avoidance of hospital readmis- ferent from disease manage- members across episodes of sions for primary and compli- ment. The symptoms them- acute care and in planning cating conditions. TCM has selves—pain, shortness of for future transitions, such as resulted in fewer hospital read- breath, etc.—interfere with the palliative care is essential. missions for patients. Addition- patient’s quality of life. They ally, among those patients who need to be taken as seriously Evidence abounds are rehospitalized, the time as the condition itself. Why is this approach effective? between their discharge and readmission is longer and the Because TCM focuses on increas- Comprehensive, holistic number of days spent in the assessment: The APN assesses ing value over the long term— specifically, lowering costs and hospital is generally shorter the patient’s priority needs, than expected. goals and preferences. This bettering the quality of care, she 7,8,9,10 includes not only the reason for explains. Multiple studies Improvements in health the primary hospitalization, but demonstrate TCM’s positive outcomes after hospital also other complicating issues, impact on outcomes and costs. discharge. Patients who such as poverty, lack of trans- Early research—from the late ’90s received TCM services have portation or inability to under- through the mid-2000s—found reported reduction in symp- stand how and when to take that it increased access, reduced toms and improvements in the appropriate medications. errors, controlled costs and physical health, functional enhanced care experience. (See status and quality of life. Evidence-based: The APN uses Figures 1 and 2 on pages 4 and 5.) evidence-based protocols Enhancement in patient and supported by decision-support family caregiver experience. tools. 7 Naylor MD, et al. “Transitional Care of Overall patient satisfaction is Older Adults Hospitalized with Heart Failure: increased among patients Patient engagement: The care A Randomized, Controlled Trial.” Journal of the American Geriatrics Society, 52: 675–84. receiving TCM services. In plans align with each patient’s May 2004 ongoing studies, TCM also aims goals and needs, and involve 8 Naylor MD, et al. “THE CARE SPAN— to lessen the burden among active engagement and sup- The Importance of Transitional Care in family members by reducing port from patients and their Achieving Health Reform.” Health Affairs the demands of caregiving (Millwood), 30(4):746-754, 2011 families. Rather than imposing and improving family a care plan, the APN asks, 9 Naylor MD, et al. “Comprehensive discharge planning and home follow-up of functioning. “What matters to you? What hospitalized elders: a randomized clinical do you hope to achieve?” By trial.” JAMA. 1999;281:613-620 Overall lower costs. TCM was modifying the plan accord- 10 Naylor MD, Bowles KH, et al. associated with lower total ingly, she says, the APN is in a “High-value transitional care: translation of costs and lower average research into practice.” Journal of Evalua- per-patient costs. A 2004 study much better position to foster tion in Clinical Practice, Volume 19, Issue 5, lasting change. pages 727–733, October 2013 pegged the mean savings in

3 FIGURE 1. TCM's Impact on Readmission Preparation and training of Rates After Index Hospitalization TCM nurses, teams and sites Documentation and 70 quality monitoring, including 61% use of clinical information 60 TCM Group 56% systems 50 Control Group 48% Quality improvement

40 Evaluation

30 28% Naylor’s own institution, University 23% of Pennsylvania Health System,

Percent of Patients Percent 20 has adopted TCM. More broadly, 10% evidence generated from testing 10 this approach has informed how ACA innovations have unfolded. 0 1 2 3 at 6 weeks at 26 weeks at 52 weeks Her team at UPenn has developed Readmission After Hospital Discharge a web-based Foundations of Transitional Care seminar to orient 1 BasedBased on on 3 3NIH NIH funded funded RCTs: RCTs: Ann 1Ann Intern Intern Med, Med1994,, 1994, 120:999-1006; 120:999-1006; nurses and other health team 2 3 2JAMAJAMA,, 1999,1999, 281:613-620;281:613-620; 3J AmJ Am Geriatr Geriatr SocSoc,, 2004, 2004, 52:675-684 members to the model, and articulate the value and core So Naylor and her UPenn research components of TCM so they can total health care costs at nearly $5,000 per patient.11 team put the model in motion take it to their own institutions. themselves. They formed partner- Naylor and her team were thrilled ships with payers—including Aetna Variations on a theme with the results. “These were signifi- and Independence Blue Cross— cant findings. We published widely, and collaborating health systems When it’s put into practice, TCM’s in prestigious journals. And we to test real-world applications of benefits cease to be theoretical. waited.” In vain: The findings the research-based model of It enables patients and caregivers received considerable attention, care among high-risk seniors. to realize the desired results. Pre- but no one was putting the findings liminary findings from the Commis- into practice. They succeeded.12 Among the sion’s 2015 evidence-based Role results: improvements in all quality and Function Study also highlight From theory to practice measures, increased patient and the value of these very practical physician satisfaction, reductions in benefits, Sminkey says. “When you “The way we were talking about rehospitalizations and cost savings. see critical research support the delivering care—longitudinal, importance of transitions, and team-based care across different The key, Naylor and her team address how the health care team settings—was not the norm at the discovered, was building tools can best be engaged—the heart time. It wasn’t how payment incen- to translate evidence alone into of professional case manage- tives were structured and it wasn’t evidence-based practice. Tools ment—you know you are on the how health care professionals were include the following: cutting edge of transformational trained to act,” she explains. “We health care.” were confronting organizational, Patient screening and cultural and financial challenges.” recruitment Success comes through adapting and applying the evidence to a specific situation, says Naylor. 11 Journal of the American Geriatrics 12 Naylor MD, Bowles KH, et al. Journal of Society, op. cit. Evaluation in Clinical Practice, op. cit. “We aren’t the only ones to get it

4 right—local communities can take FIGURE 2. TCM's Impact on Total Health Care Costs* what we’ve developed and make it better.”

Part of adapting and interpreting $7,636 may involve systemic changes in $12,481 structures, care processes, and At 52 weeks*** health professionals’ roles and relationships to each other and the $3,630 TCM Group patients and families they support, $6,661 Control Group she adds. Several such “variations At 26 weeks** on a theme” projects are under- way. One explores how sites in health systems and communities $0 $3,000 $6,000 $9,000 $12,000 $15,000 across the country are implement- ing TCM. Another focuses on patient-centered medical *homes, Total costs were* calculatedTotal costs using were average calculated Medicare using reimbursements average Medicare for hospitalreimbursements readmissions, for hospital ED visits, physician visits and care comparing the outcomes ofprovided a by visitingreadmissions, nurses and ED other visits, health physician care personnel. visits and Costs care for provided TCM care by are visiting included nurses in the and intervention other group total. PCMH with TCM to outcomes** Naylor MD, Brootenhealth D, care Campbell personnel. R, Jacobsen Costs forBS, TCM Mezey care MD, are Pauly included MV, &in Schwartz the intervention JS. Comprehensive group total. discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-620. achieved by the PCMH alone in ** 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 preventing hospitalization*** for Naylor at-risk MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, & Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized,clinical controlledtrial. JAMA. trial. 1999;281:613-620. J Am Geriatr Soc. 2004;52:675-684. community-based older adults. *** Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, & Schwartz JS. Lessons learned will help advance Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. the larger-scale effort. J Am Geriatr Soc. 2004;52:675-684.

Translations, necessarily, vary with the nuances of different texts. Although the fundamentals remain a reminder that, as case manag- considered in the context of the same, each time the model is ers, our first concerns are to advo- whole-patient care. Working at the implemented it will be a little differ- cate for the client and protect the top of their license, case managers ent. Professional case managers consumer,” she says. “We do not can and must be part of the solu- can help accomplish successful work with cases. Actually, we have tion. “We can begin to mend the adaptations, she says. “Solving never worked with cases. We work broken system. The aims of these complex problems requires multi with people. And board-certified best practices for care transitions dimensional solutions. There’s no case managers are instrumental in are ones we can all agree on: cookbook.” protecting the public interest when improved health, better care and the focus changes, as it has with lower costs,” Sminkey says. The case manager’s role care transitions.” For her part, Naylor is eager to Board-certified case managers, Board-certified case managers, engage professional case manag- with their extensive education and brought in as part of the team at ers. There is, she says, a critical hands-on experience, are ideally the beginning of a complex hospi- need for case managers who are suited to the task of marrying con- tal admission, play an integral role following these patients on their cept to execution, research to in assessing the social, emotional journeys, aligning service availabil- practice, says Sminkey. It also aligns and physical needs of the patient ity with their goals and their needs. with the case manager’s focus on and the family caregiver beyond “It’s not simple, but it’s our future. the patient. “Much of the talk discharge, and bring a wealth of You are our future.” n about care transitions has been knowledge about how current about provider organizations. This is acute-care needs must be

5 About the Experts

Patrice Sminkey, Chief Executive Mary D. Naylor, PhD, FAAN, RN Officer, The Commission for Case Manager Certification Naylor is the Marian S. Ware professor in Gerontology and direc- Sminkey comes to the Commission tor of the NewCourtland Center from URAC, where she most for Transitions and Health at the recently served as senior director of sales. Prior to University of Pennsylvania School of Nursing. Since that, she was senior vice president, operations and 1989, Naylor has led an interdisciplinary program of client management, Patient Infosystems in Roches- research designed to improve the quality of care, ter, N.Y. She brings a proven track record in opera- decrease unnecessary hospitalizations, and reduce tions management in small and large operations, health care costs for vulnerable community-based multilevel services and cross-functional teams. She elders. Naylor is also the national program director for has extensive experience in client management the Robert Wood Johnson Foundation program, the and coordination, including marked improvement Interdisciplinary Nursing Quality Research Initiative, in client retention, timely and fiscally sound program aimed at generating, disseminating and translating implementation and an expanding book research to understand how nurses contribute to of business. quality patient care.

As chief executive officer, Sminkey oversees Naylor was elected to the National Academy of the management of all activities related to the Sciences, Institute of Medicine in 2005. She also is a Commission’s operations, including all programs, member of the RAND Health Board, the National products and services; and the provision of quality Quality Forum Board of Directors and is immediate services to and by the Commission. She is a direct past-chair of the board of the Long-Term Quality liaison to the Commission’s Executive Committee. Alliance. She was appointed to the Medicare She works with CCMC’s volunteer leadership to Payment Advisory Commission in 2010. evaluate and develop potential new products for implementation by CCMC, and she establishes and maintains communication and working relationships with other organizations, agencies, Join our community groups, corporations and individuals. of professional case managers! She holds a diploma of nursing from the Chester County School of Nursing.

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