National Advisory Council on Nurse Education and Practice Health Resources and Services Administration

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

May 21, 2019

1 2 3 4 Penn Team

Mary D. Naylor Mark V. Pauly Kathy McCauley Karen Hirschman Alex Hanlon Lead Architect Lead Economist Lead Clinician Lead Implementer Lead Biostatistician

Marian S. Ware Professor Bendheim Professor in Professor of Research Associate Professor of Practice in Gerontology and Health Care Management, Cardiovascular Nursing Professor and Department of Statistics Director of the Economics, and Public and former Associate NewCourtland Term Virginia Tech NewCourtland Center for Policy at the University of Dean at the University of Chair in Health Transitions and Health at Pennsylvania, Wharton Pennsylvania School of Transitions Research at the University of School of Business Nursing the University of Pennsylvania School Pennsylvania School of of Nursing Nursing

20+ dedicated TCM team members and affiliates covering nursing, healthcare economics, social work, biostatistics and medicine

5 Transitional Care Population Health

6 TCM’s Core Components

• Targets older adults in the community or hospital Screening who are at risk for poor outcomes.

• Uses APRNs to assume primary responsibility for care Staffing management throughout episodes of acute illness and oversee/support longitudinal follow-up.

Maintaining • Establishes and maintains trusting relationships with Relationships older adults and family caregivers.

Engaging Patients and • Engages older adults and family caregivers in design and implementation of plans of care aligned with Caregivers individuals’ preferences, values and goals. 7 TCM’s Core Components

Educating/Promoting • Prepares older adults and family caregivers to prevent or identify and respond quickly respond to Self-Management worsening health and social needs.

• Promotes consensus on plans of care between older Collaborating adults and members of the care team.

• Prevents breakdowns in care by having same APRN Promoting Continuity help older adult and family caregivers navigate multiple clinicians, health and community sectors.

• Promotes communication and connections between Fostering Coordination healthcare and community-based care staff.

8 Sample TCM Protocol: Intensive Phase (Hospital to Home)

st CONFIRM ELIGIBILITY 1 APN VISIT IN HOSPITAL ADMISSION Within 24hrs of enrollment: APRN conducts DAILY APN VISIT IN HOSPITAL APRN reviews screening results Throughout hospitalization: APRN visits Patient (≥65yo) comprehensive assessment, including and EHR, and then engages patient and collaborates with health care admitted to patient’s and caregiver’s goals and needs, patient and caregiver (if team members to design and coordinate and initiates collaboration with health care hospital. available). evidence-based transitional care plan. team.

If Patient is rehospitalized within the 90-day period, APRN conducts same visit pattern.

WEEKLY APN VISIT st APRN implements care plan through 90 days: continually 1 APN VISIT IN HOME Within 24 hrs of discharge: APRN reviews TRANSITION TO PCP reassessing status and plan of care with patient, caregiver care plan in home, reassess goals and needs At day ~90: APRN transitions patient and health care team. APRN accompanies patient to first with patient, caregiver and health care team. to primary care/health system. follow-up physician visit. Weekly home visits during 1st APRN will conduct at least 8 home visits month; bi-monthly during 2nd and 3rd months; additional during 90-day intervention. visits based on patient’s needs.

Longitudinal Follow-Up Level 1: Patient is stable following acute episode of illness. APRN collaborates with patient, caregiver, and care team to Level 2: Patient is unstable following acute episode of illness. determine level of follow-up care (up to 12 months). Level 3: Patient is nearing end-of-life. Sample TCM Protocol: Longitudinal Follow-up

Level 1 Level 2 Level 3

STABLE FOLLOWING ACUTE UNSTABLE FOLLOWING NEARING END OF LIFE EPISODE OF ILLNESS ACUTE EPISODE OF ILLNESS APRN continues to collaborate APRN engages registered nurses APRN continues to conduct home with PCP and community-based or community health workers visits and other forms of outreach staff. with emphasis on meeting palliative care needs.

10 TCM Design and Testing with At Risk Older Adults and Their Caregivers

Hospital to Home Primary Care Long-term Care

RCT/CER CER Observational 11 Older Adults’/Caregivers’ Outcomes

Decreased symptoms, Improved function, Enhanced quality of life, BETTER Reduced caregiver burden§ CARE

BETTER Improved access, Reduced errors, HEALTH Increased time to first rehospitalization or death, Enhanced care experiences

(Based on 4 NIH funded RCTs and CER: Ann Intern Med, 1994, 120:999-1006; JAMA, 1999, 281:613-620; J Am Geriatr § Soc, 2004, 52:675-684; J Comp Eff Res, 2014,3:245-257, specific to CER trial. J Comp Eff Res, 2013, 2(5):457-468.) 12 Health Resource Use and Cost Outcomes

TCM Group § 70% $5000 $3000§ Control Group 61% § 60% 56% $3500 Hospital Nurse 50% 48% 48% Intervention 45%

40% 38%

30% 28%

% of patients patients of % 23% 20% 10% 10%

0% at 6 weeks* 1994 at 26 weeks** 1999 at 52 weeks*** 2004 at 26 weeks 2014 High-Risk Multiple High-Risk Multiple High-Risk Heart Failure High-Risk Patients with Chronic Conditions Chronic Conditions Cognitive Impairment

(4 NIH funded RCTs and CER: *Ann Intern Med, 1994, 120:999-1006; **JAMA, 1999, 281:613-620; ***J Am Geriatr Soc, 2004, 52:675-684; J Comp Eff Res, 2014, 3(3):245- § 257; J Comp Eff Res, 2018, 7(9):913-922. Estimated total savings per older adult after accounting for TCM costs.) 13 Examples of TCM Implementation with Partnering Health Systems/Communities

14 Overarching Recommendations

• Accelerate widespread use of the TCM to maximize on the contributions of nurses in addressing the challenges of the rapidly growing population of older adults with complex health and social needs. • Expand testing of the TCM to older adults living in rural/underserved communities (e.g., non-English speaking) who have not been a focus of prior efforts. • Test technological innovations designed to broaden access of the TCM to a much wider population of older adults with complex care needs. 15 Overarching Recommendations (cont.)

•Position the existing and emerging nursing workforce with the competencies, tools and resources essential for high quality implementation of evidence-based transitional care and population health. •Test the older adult, family caregiver and cost outcomes achieved by implementing the TCM using BSN prepared nurses compared to MSN/DNP prepared nurses.

16 Upstream: Primary Care + TCM Strategy for “At Risk” Older Adults

Screening Monitoring Engaged older Implementation of adults/caregivers, care plan improved health and Community-based older collaboratively social outcomes, adults and family developed by older prevention of caregivers adults/caregivers, hospitalizations/ED PCPs, APRNs and visits CBOs

AT-RISK STABLE

17 Downstream: Intensive and Longitudinal Phases for Acutely Ill Older Adults

Transitional Care

Level 1 Older Adults’/caregivers’ (primary care, goals met; Population CBO) Post Long- improved health and social of Level 2 illness Hospital Acute/ Term outcomes; reduced Acutely Ill (RN/CHW) Phase Rehab Follow-up hospitalizations+ED visits; At Risk Phase death with dignity Older Adults Level 3 life (palliative care/hospice) Palliative Care

18 Thank You!

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