Transitions of Elders Between Long-Term Care and Hospitals
Mary D. Naylor, PhD, RN
Marian S. Ware Professor in Gerontology
University of Pennsylvania School of Nursing
Ellen T. Kurtzman, MPH, RN
Assistant Research Professor
George Washington University School of Medicine and Health
Sciences
Mark V. Pauly, PhD
Bendheim Professor
University of Pennsylvania Wharton School
Word Count (text plus endnotes): 3804 + 1296
Funding that supported preparation of manuscript: Paper
commissioned for “Building Bridges: Making a Difference in LongTerm Care” AcademyHealth Colloquium sponsored by The
Commonwealth Fund. Presented at 2007 Policy Seminar, February
14, 2007, Washington, D.C
First Author Contact:
420 Guardian Drive
Philadelphia, PA 19104-6096
Tele: 215-898-6088; Fax: 215-573-4225
Email: naylor@nursing.upenn.edu
Second Author Contact:
900 23rd Street, NW, Room 6195
Washington, DC 20037
Tele: 202-994-9439; Fax: 202-994-2777
Email: hspetk@gwumc.edu
Third Author Contact:
Colonial Penn Center
Philadelphia, PA 19104-6218
Tele: 215-898-2838
Email: pauly@wharton.upenn.edu
1
Abstract
Word Count = 100
Elderly long term care recipients who require acute
hospitalizations must navigate a fragmented system with poor
“hand-offs,” often resulting in negative outcomes. This paper
makes the case that reducing preventable hospitalizations and
improving transitions to and from hospitals will enhance health
care quality and outcomes among these elders. Immediate action
targeting diffusion of evidence-based care is recommended to
decrease avoidable rehospitalizations and achieve cost savings.
Policy changes are needed to address barriers to high quality
transitional care including deficits in health professionals’
and caregivers’ knowledge and resources, regulatory obstacles,
and lack of quality and financial incentives and clinical
information systems.
Key Words: transitions, long term care; acute hospital care;
frail elders
2
Introduction
In 2001, the Institute of Medicine (IOM) published a
landmark report, Crossing the Quality Chasm: A New Health System
for the 21st Century, outlining a transformational agenda that,
if achieved, could result in health care that is safer, more
effective, patient-centered, timely, efficient, and equitable
than available in the current system.1 One of the critical steps
proposed to achieve this transformation was the identification
of a limited number of conditions from which rapid improvements
could be achieved through evidence-based care, information
infrastructure, and other incentives. A subsequent IOM report
targeted 20 areas for improvement in health care quality based
on criteria such as impact, improvability, and inclusiveness.2
With the selection of similar health issues by other
organizations, consensus has been achieved among many health
care stakeholders on priorities for national action.3
Not surprisingly, care coordination and frailty associated
with old age are among the major areas in which substantial gaps
exist between evidence-based care and current services. This
paper documents the growing health care demands of elderly long
term care (LTC) recipients, the special problems that this
population faces when confronted with “hand-offs” in health
care, and the availability of evidence-based transitional care
models designed to improve outcomes of vulnerable elders. A
3
framework of policy and system changes is proposed that has
potential for decreasing preventable hospitalizations and
“hardwiring” sustained improvements in care coordination among
these LTC recipients.
Expanding Health Care Needs of an Aging Population
According to a recent U.S. Census Bureau report, the older
adult population, which grew from 3 to 35 million during the
last century, will increase substantially during the next few
decades when the first Baby Boomers turn 65.4 From 2010 to 2030,
the populations 65 years of age and older (the “older”
population) and 85 years of age and older (the “older-old”) are
both expected to double--from 36 to 72 million and 4.7 to 9.6
million, respectively.5
Rapid growth of the older adult
population, especially among the oldest-old, will substantially
increase the need for long-term care (LTC).6
LTC encompasses a broad range of health and social services
provided to frail elders for a prolonged period in a range of
settings including elders’ homes, assisted living facilities
[ALFs], and nursing homes [NHs].7 These typically low-tech
services help elders cope with physical and cognitive deficits
associated with chronic illnesses and major disabilities,
function as independently as possible, and maintain a high
quality of life.8 More than 60% of the 10 million persons in need
of LTC services in 2005 were older adults. In the next four
4
decades, the number of frail elders requiring LTC will more than
triple.9
Problems Associated with Transitions Among Frail Elders
Commonly occurring changes in health status among elderly
LTC recipients necessitate frequent transitions between the LTC
and acute care sectors of the health care system. These
transitions are often triggered by acute infections, adverse
events such as falls, acute episodes of chronic illnesses, or
uncontrolled pain and other distressing symptoms.10 About one in
six nursing home residents are hospitalized within any given
six-month period.11 Almost 40% of community-dwelling elderly LTC
recipients are hospitalized each year.12 Up to 40% of elders
receiving LTC are transferred to hospitals in the 30 days prior
to their deaths.13
Four overlapping categories of problems have been
associated with acute hospitalizations: poor communication,
preventable declines in health status, inadequate discharge
planning, and serious gaps in care during transfers to and from
hospitals.14 As a result of these system issues, the “hand-offs”
of hospitalized older adults among multiple providers and across
settings have been linked to adverse clinical events, serious
unmet needs, and poor satisfaction with care.15 For example, over
60% of community-based chronically ill elders experience
medication errors during transitions from hospitals to next
5
sites of care.16 Lengths of hospital stays, hospital charges and
mortality rates are higher among NH residents than their
community-dwelling counterparts.
More than one-quarter of the 600,000 elders hospitalized
for heart failure in 2005 were readmitted within 30 days. By 90
days, 50% had been rehospitalized. Among NH residents, a
relative increase of 50% in rehospitalizations at 30 days was
reported between 2000 and 2004.17 Between one-quarter to onethird of hospital readmissions among all chronically ill elders
are considered preventable.18 Rates of avoidable hospitalizations
among elderly LTC recipients are thought to be even higher.19
The Basis for Improvements in Transitional Care
Although few studies have specifically targeted transitions
among LTC recipients, clinical and health services researchers
have built on emerging insights about the needs of chronically
ill elders who often require acute services and designed and
tested innovations to enhance the quality of their care and
outcomes. Available evidence suggests that two promising
approaches to preventing avoidable hospitalizations and
improving continuity of care among elders receiving LTC are to
increase their access to selected primary, acute and palliative
care services within the LTC sector, and to improve their “handoffs” to and from acute care hospitals. Since assessments of
clinical innovations designed to prevent avoidable acute care
6
hospitalizations are generally lacking in scientific rigor and
there are few reported comparative studies, conclusions about
their potential in addressing the transitional care challenges
faced by elders receiving LTC are limited but, nonetheless,
instructive.
Decreasing Preventable Acute Care Hospitalizations.
Lessons from national, state and provider-led initiatives to
integrate acute and long-term care suggest that decreasing
preventable acute care hospitalizations for this population is a
desirable and achievable strategy.20 Evercare and the Day
Hospital are examples of transitional care models designed
specifically for frail elders to achieve this goal.
Evercare Model. At the core of the Evercare model is
enhanced primary care services to elders in NHs facilitated by
master’s prepared nurse practitioners (NPs). Residents are
enrolled in a risk-based HMO, with nursing home costs covered by
Medicaid or private insurance.21 One study of this model compared
Evercare residents to two sets of controls.22 The incidence of
hospitalizations was found to be twice as high among controls
compared to Evercare residents. This difference corresponded to
Evercare’s use of intensive NP service days within NHs.23
Assuming that the total compensation of an NP is $90,000
annually and that the NP’s caseload is approximately 85
patients, the authors estimated an annual savings in hospital
7
costs of $103,000 per NP. The report of this analysis did not
include other Evercare costs or the percentage reduction in
total hospital costs. Nonetheless, the estimated cost-reduction
in conjunction with improvements in some dimensions of family
satisfaction, suggest that the potential value of this approach
should be further investigated.24
The Day Hospital. Modeled after the program offered within
the British health care system, the day hospital is based in the
community with clinical services managed by a masters-prepared
geriatric nurse practitioner (GNP). The Collaborative Assessment
and Rehabilitation for Elders (CARE) program at the University
of Pennsylvania was an example of such an initiative.25 The CARE
program operated as a Medicare-certified comprehensive
outpatient rehabilitation facility (CORF).26 Older adults at risk
for hospitalization had access to a range of health, palliative,
and rehabilitation services for a few days each week up through
nine weeks.27 A quasi-experimental study revealed improved
function and decreased hospital use among the patients in the
study group.28 Notably, there were no differences in the size of
the improvement in outcomes between cognitively intact and the
more challenging group of cognitively impaired elders.29 More
rigorous assessment of the benefits and costs associated with
this model is needed.
8
Improving Transitions Between LTC and Acute Care Hospitals.
The few reported efforts to improve care transitions of
elders between the acute and LTC sectors are limited by small
sample sizes and other methodological concerns. However, among
the broader population of chronically ill elders transitioning
from hospital to home, nurse-led, interdisciplinary
interventions have demonstrated improved quality and cost
savings. These multidimensional interventions have typically
incorporated strategies intended to improve communication and
transfer of information, enhance discharge follow-up and
decrease gaps in care through the use of a single, consistent
provider. The Care Transitions “Coaching” Intervention and
Transitional Care Model are the more rigorously studied of these
approaches.
Care Transitions “Coaching” Intervention.
A
multidisciplinary team at the University of Colorado Health
Sciences Center has been testing an intervention designed to
encourage patients and their family caregivers to assert a more
active role during care transitions. A recent randomized
clinical trial (RCT) of this “coaching” intervention was
completed with community-based older adults hospitalized with
common health problems in an integrated delivery system. The
impact of a set of tools (e.g., personal health record) to
promote cross-site communication and continuity across settings
9
coupled with “coaching” from an advanced practice nurse were
examined.30 Study findings revealed that intervention patients
had lower all-cause rehospitalization rates through 90 days
compared to controls who received usual care. Mean hospital
costs were approximately $500 lower for intervention patients
compared to controls at six months post-discharge.31 This
analysis did not examine the cost of the intervention.
APN Transitional Care Model.
A multidisciplinary team
based at the University of Pennsylvania has been testing and
refining an innovative model of care delivered by APNs for high
risk older adults transitioning from hospitals to home. The
model incorporates state of the science interventions that focus
initially on monitoring and managing elders’ symptoms, and
subsequently, on preparing elders and their family caregivers to
better manage elders’ care. A master’s prepared nurse assumes
primary responsibility for optimizing patient’s health outcomes
during hospitalization, coordinating a follow-up plan of care in
collaboration with each elder’s physicians and other health team
members, and implementing the plan for a defined period of time
via home visits and seven day per week telephone availability.
Study findings from three RCTs have consistently
demonstrated the capacity of this model of care to improve
elders’ satisfaction, reduce rehospitalizations and decrease
health care costs relative to usual care.32 The most recently
10
reported multi-site RCT tested a protocol directed by APNs
designed to address the health problems and risks common among
elders throughout an acute episode of heart failure.33 When
compared to the control group, members of the intervention group
demonstrated enhanced physical function, quality of life and
satisfaction with care in the short-term and fewer total
rehospitalizations through 52-weeks post-discharge, resulting in
a mean savings of $5,000 per hospitalized elder.34
Need for Research and Independent Assessment of Models.
While the models described above and others have demonstrated
improvements in care transitions for this population, the
quality and strength of evidence is uneven. Increased federal
support is needed to rigorously assess the impact of models
designed to prevent acute hospitalizations of frail elders.
Private foundation investment is needed to test application of
proven transitional care models with the population of elders
receiving LTC. Both sets of studies should attempt to identify
the most effective elements of these multifaceted interventions,
and compare the benefits and costs.
Despite the pressing need to expand the base of evidence,
there is an adequate body of research to recommend convening a
federally sponsored independent review body charged with
critically evaluating available evidence and providing
11
recommendations to payers, purchasers, and the public about the
relative value of alternative transitional care models.
Policy Solutions to Improve Care Transitions
Results from studies of these models suggest common, key
components to improving care transitions for elderly LTC
recipients. A number of potential policy solutions for state and
federal governments, payers, accreditors, educators, and other
health care stakeholders can be derived from these findings.
Policy changes are needed to address major barriers to high
quality transitional care including deficits in health
professionals’ and family caregivers’ knowledge and resources,
lack of quality performance measures, patient-centered clinical
information systems and financial incentives, and regulatory and
reimbursement obstacles.
Provision of Evidence-based Care. The application of
evidence-based practices for common acute conditions and
palliative care is fundamental to enhancing transitions. Yet, a
significant barrier to effective care is that health care
professionals lack the knowledge and resources needed to address
LTC needs during elders’ hospital stays.35 For example, findings
from focus groups involving multidisciplinary teams of acute
hospital providers revealed that these clinicians typically do
not possess the skills or have the time to implement LTC
12
strategies such as feeding and walking and, thus, contribute to
nutritional and functional decline among these elders.36
Studies of LTC providers suggest similar challenges.37
Elderly LTC recipients often have limited contact with
physicians or nurse practitioners, making continuity of medical
management from the hospital to LTC setting difficult. High
turnover rates and inadequate investment in continuing education
of nursing assistants and home health aides, the primary
providers of most LTC services, also negatively influence the
quality of care delivered to this population.38 Effective
palliation is rare because providers are not adequately prepared
to identify and manage pain and other symptoms in the frail LTC
population, recognize terminal status, discuss advanced care
planning, or communicate elders’ wishes.39
Family caregivers play a if not the major role in
supporting community-dwelling elderly LTC recipients during
acute episodes of care. The lack of attention paid to
identifying and addressing their needs throughout these
transitions is a significant barrier to effective care.40 Not
surprisingly, caregivers consistently rate their level of
engagement in decision making about discharge plans and the
quality of their preparation to address their loved ones’ needs
following hospital discharge as poor.41
13
Positioning health professionals to prevent avoidable
transfers and improve care coordination will require new
investments in the preparation of existing and future health
professionals. There is some evidence that care of older adults
by nurses, physicians and other health disciplines who have
specialized preparation in geriatrics contributes to enhanced
functional outcomes among these elders and decreased avoidable
hospital transfers with minimal increases in health care costs.42
However, projections regarding the availability of these health
professionals suggest that this pool will be inadequate to
address the current and future complexities of organizing and
delivering care for older adults requiring acute and LTC
services.43
In a recent policy statement issued by the American
Geriatrics Society (AGS), “professional educational
institutions, specialty certification boards, licensing boards,
and quality improvement programs were encouraged to improve,
evaluate, and monitor health professionals' ability to
collaborate across settings in order to execute a common plan of
care”.44 In response to this “call to action,” policy changes are
needed to support increased emphasis on geriatrics, palliative
care, interdisciplinary team care, active engagement of family
caregivers, advance care planning and evidence-based
transitional care in the educational preparation of all health
14
professionals. Similarly, new investments in the preparation of
family caregivers for their roles during critical transitions
are needed.
Comprehensive assessment of family caregivers’
unique needs at time of elders’ hospital admissions is
essential.
Equally important, health professionals will require
new tools and time to coach family caregivers.
Policy-makers should work with educators to identify and
disseminate “best practices” in each of these content areas to
reach students in health professional schools and providers in
acute hospitals and LTC organizations nationwide. In some
content areas, large scale studies may be needed to ascertain
the “best practices”. Special emphasis should be placed on the
recruitment, staff development, and retention of
paraprofessionals who often are the primary caregivers in LTC.
Development of Performance Measures and Reporting Systems.
A significant clinical barrier to high quality care is the
dearth of performance measures that capture effective
transitions. Little is currently known about the natural history
of changes in quality of life and health among frail elders from
which to establish measures of quality care. Increased knowledge
of expected changes due to aging and increased frailty is an
antecedent to the development of measures that assess the
adequacy of care during health transitions.45 An ongoing NIH
15
funded longitudinal study of elders from the point they enter
into LTC should help to address these gaps in knowledge.46
The development of robust quality indicators and the
integration of these indicators into national performance
measurement sets also are hindered by the difficulty in
identifying the “accountable entity.” The majority of existing
standards reinforce health care delivery “silos” by focusing on
processes and outcomes within rather than across settings.47 Few
focus on the actual experiences of frail elders throughout acute
episodes of illness and none recognize the distinct role of
family caregivers during transfers.
Obviously, both acute and LTC providers share
responsibility for the care and outcomes of these elders, but
developing measures that capture their shared accountability and
inspire quality improvements in care transitions is a challenge
that researchers, government agencies, accrediting bodies and
other organizations that design measures must assume. The
development of overarching monitoring systems that focus on the
quality of care elderly LTC recipients receive across “silos”
will require resolution of these issues.
Use of Patient-Centered Clinical Information Systems. The
critical need to design communication systems that foster
information exchange between providers has been articulated in
recently developed policy statements independently issued by AGS
16
and the National Quality Forum (NQF).48 As proposed by these
organizations, current information from available sources about
a patient’s health status, including “all related activities,
services, and results” must be integrated into clinical
information systems. While compliance with federal law should be
in place to protect personal privacy, arrangements must be made
to ensure that all clinicians who require access to necessary
information have such access.
For these reasons, the development and use of clinical
information systems that allow hospital, primary care, LTC and
other health care professionals to access data related to
elders’ health status and care needs throughout transitions is
vital. The impact of the electronic health record to promote
cross-site communication and continuity, and enable quality
assessment and improvement activities, should be assessed. As
noted by NQF, important characteristics that must be
incorporated into electronic systems include seamless
interoperability; an evidence-based plan of care management;
efficient and effective integration of all patient information;
patient registries and population-based data; support for
quality improvement and safety; decision support tools; and
provider alerts and patient reminders.49 These priorities demand
the attention of information system and decision support
17
vendors, chief information officers, government agencies,
providers, and lawmakers.
Alignment of Incentives. Financial and other incentives are
needed to support the level and quality of staff within LTC
organizations essential to managing common acute conditions and
offering palliative care.
Although the cost savings associated
with reductions in avoidable high cost hospitalizations is
clear,50 conflicting payment incentives for providers of Medicaid
services, the primary payer of LTC, and Medicare services, the
primary payer of acute care, continue to exist. Increased
reimbursement to skilled nursing facilities (SNFs) for the postacute episode is just one example of such an incentive. Yet,
care coordination, which is essential to assure smooth
transitions, is not reimbursed in Medicare’s fee-for-service
system. The current reimbursement system and related policies
contribute to increased and often avoidable transitions from LTC
to acute care.51
Recent national attention on improved care coordination and
value-based purchasing are placing a spotlight on existing
financial barriers to improving health care quality and
decreasing costs for chronically ill elders. The Centers for
Medicare and Medicaid Services’ (CMS) care coordination
initiatives and campaigns to reduce avoidable hospitalizations
among hospital, home health and NH providers are examples of
18
innovations in this area. Selected states also have focused on
incentive remedies.
Massachusetts’ pay-for-performance system,
for example, provides additional Medicaid dollars to providers
that meet certain quality standards.52
While these efforts suggest some momentum, public and
private payers should be mobilized to increase flexibility in
reimbursement, adequately compensate for transitional care, and
develop and test effective incentives to improve the transition
of patients from one level of care to another or across
settings, and reduce costs. The immediate introduction by CMS of
bundled payments to cover health care costs over an acute
episode of illness would foster increased collaboration between
hospital and LTC providers to prevent rehospitalizations and
encourage LTC providers to reduce avoidable acute
hospitalizations.
Regulatory Reform.
There are substantial regulatory
barriers to assuring effective care coordination and
transitional care within the Medicare and Medicaid programs.
Traditional, fee-for-service Medicare regulations promote the
delivery, monitoring and payment of acute care services within
separate and distinct settings including hospitals, home health
care agencies and SNFs. Gaps in care are common in a system that
pays little attention to the continuing care needs of elders
19
moving across these silos as well as those of their family
caregivers.
Discontinuities are compounded when elders are also
receiving LTC services primarily reimbursed under Medicaid
programs. Beneficiary needs, eligibility, state and federal law,
financing models, and other factors influence the design of both
public and private health insurance benefits. Within and across
the acute and LTC sectors, different Medicare and Medicaid
eligibility rules, quality monitoring systems, criteria for
reimbursement, and funding streams create confusion and
sometimes conflicts for providers. Without question, the
confusion and conflict adds to the burden of family caregivers,
providers and administrators. For these reasons, the elimination
of regulatory barriers to evidence-based transitional care is
essential.
Payment reform is among the major policy implications
associated with increasing access to evidence-based approaches
to care for this population and addressing the needs of their
family caregivers. As proposed above, an independent review body
of stakeholders is needed to evaluate the evidence and provide
recommendations regarding reimbursement of the best evidencebased transitional care approaches to policy and other decisionmakers.53 This external review is key to preventing payment for
over-use of ineffective care and under-use of effective care.
20
The optimal use of palliative care services is dependent on
adequate funding and flexible reimbursement policies. In
addition to clinical improvements in care already discussed, the
narrowly defined Medicare Hospice benefit currently hinders
access to appropriate end-of-life care for these elders. For
this reason, modification to the Medicare Hospice benefit to
decrease constraints on use of available services for the
elderly LTC population is recommended.
Conclusions
Available evidence suggests that care to the rapidly
growing population of frail elders requiring acute and LTC
services will be enhanced by focusing health care stakeholders
on transitions in care. Strategies designed to reduce
preventable acute care hospitalizations and improve the
transitions to and from acute care for this population have
shown promising results. Health care leaders and private and
public purchasers need to recognize both the challenges to
optimizing quality outcomes for this population and the promise
of research-based care models.
In the five years since the IOM identified care
coordination and frailty associated with old age as priority
areas for quality improvement, very little progress has been
made in these areas as evidence by increasing rates of
hospitalizations among the NH and community-based frail elders.
21
Unquestionably, to optimize outcomes for this growing
population, continued investment in rigorous studies is needed
to understand the impact of transitions on frail elders,
identify the most effective and efficient models, and define the
quality and financial incentives that will foster adoption of
evidence-based practices. While awaiting these findings, steps
should be taken on a blueprint for immediate action that targets
diffusion of evidence-based care, removal of regulatory barriers
development of performance measures and information systems, and
alignment of quality and financial incentives.
22
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5. Ibid.
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23
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24
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16. M.D. Naylor
17. M.D. Naylor
18. M.D. Naylor, “A Decade of Transitional Care Research with
Hospitalized Elders;” and E.A. Coleman and C. Boult,
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19. Ibid.
20. R.A. Kane et al., “Quality Of Life Measures For Nursing Home
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R.L. Kane et al, “Effect of an Innovative Medicare Managed
25
Care Program on the Quality of Care for Nursing Home
Residents,” The Gerontologist 44, no. 1 (2004): 95-110.
21. R.L. Kane RL et al, “The Effects of Evercare on Hospital
Use,” Journal of the American Geriatrics Society 51, (2003):
1427-1434.
22. Ibid.
23. Ibid.
24. B. Leff et al, “Hospital At Home: Feasibility And Outcomes
Of A Program To Provide Hospital-Level Care At Home For
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10 (1995): 1155-60.
26. Ibid.
27. F. Yu, L.K. Evans, and E.M. Sullivan-Marx, “Functional
Outcomes For Older Adults With Cognitive Impairment In A
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the American Geriatrics Society 53, no. 9 (2005): 1624-6.
28. Ibid.
26
29. L.K. Evans and J. Yukow, “Balanced Budget Act of 1997,
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Elders,” Nursing Economics 17, no. 5 (1999): 279-280, 282;
and J.A. Sochalski, “Outcomes Of A Nurse-Managed Geriatric
Day Hospital,” The Gerontologist 41, no. Special Issue 1
(2001): 51.
30. E.A. Coleman et al, “Preparing patients and caregivers to
participate in care delivered across settings: the Care
Transitions Intervention,” Journal of the American Geriatrics
Society 52, no. 11 (2004): 1817-25.
31. Ibid.
32. M.D. Naylor et al, “Comprehensive Discharge Planning for the
Hospitalized Elderly: A Randomized Clinical Trial,” Annals of
Internal Medicine 120, (1994): 499-1006; M.D. Naylor et al,
“Comprehensive Discharge Planning and Home Follow-up of
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the American Medical Association 281, (1999): 613-622; and
M.D. Naylor et al, “Transitional Care Of Older Adults
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Trial,” Journal of the American Geriatrics Society 52, no. 5
(2004): 675-84.
33. M.D. Naylor et al, “Transitional Care Of Older Adults
Hospitalized With Heart Failure.”
27
34. Ibid.
35. M.D. Naylor et al, Transitional Care Of Hospitalized Nursing
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28
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30