TRANSITIONS IN LONG TERM CARE
Building Bridges: Making a Difference
in Long-Term Care
AcademyHealth Colloquium
Sponsored by
The Commonwealth Fund
Mary D. Naylor, PhD, RN
Marian S. Ware Professor in Gerontology
University of Pennsylvania School of Nursing
Objectives
• Demonstrate that health care quality among
elders receiving LTC can be enhanced by:
– avoiding preventable acute care
transitions; and,
– improving transitions across acute + LTC
when needed.
• Propose a research agenda to inform
needed changes
• Offer policy recommendations to prevent or
enhance care transitions
Mrs. Anderson: A Case Study
Number (in millions)
Mrs. Anderson: One among the fastest
growing age group (85 and older) in the U.S.
Figure 2-2, Nursing Staff in Hospitals and Nursing Homes: Is it adequate? Institute of Medicine, 1996.
SOURCE: Bureau of the Census, 1993a.
Mrs. Anderson: One of ~15% of NH
residents with multiple preventable
hospitalizations each year
Figure 3-2, Priority Areas for National Action: Transforming Health Care Quality. Institute of Medicine, 2003.
Source: Gerard Anderson, Ph.D.
Blurred Boundaries, No
Connections, Cultural Clashes
Acute
• short-term services
dominated by medical
model
• providers choose +
deliver services
• high tech
• limited family
involvement
• Payor: Medicare
vs.
LTC
• long-term health,
social and housing
services
• providers help with
ADLs + IADLs
• low tech
• family equal partners
• Payor: Medicaid
Initiatives to Integrate
Acute + LTC
• Multiple models (federal, state, provider)
• Effective for a few, but do not address
needs of many
• Hampered by:
– different goals, services
– fragmented financing
– lack of knowledge and skills
– questions re: economic value
Lessons Learned from Integration
Efforts
• Need for increased experimentation with
care coordination focused on:
– high risk groups receiving acute + LTC
services
– managing transitions across existing
acute + LTC structures
Lessons Learned from Integration
Efforts (con’t)
• Need for care coordination characterized by:
– interdisciplinary teams guided by “point
person”
– evidence-based protocols
– information systems
– care delivery that spans traditional “silos”
– quality control with single point of
accountability
– flexible benefits and funding
Transitions of Elders Between
Acute and LTC:
State of the Science
• Limited research re: patterns of use,
reasons, unique challenges and
effects of transitions
• Knowledge of transitions among
chronically ill elders has implications
for those receiving LTC
Major Findings
• Number and nature of transitions
• Factors associated with preventable
acute care transitions
• Factors associated with breakdowns
in care across settings
• Human and economic consequences
Research Agenda
• Examine over time number, reasons, unique
challenges (for elders and caregivers) and
effects of acute care transitions (targetcommunity-based elders)
• Identify profile of elders at highest risk for
transitions and poor outcomes
• Explore factors associated with + and –
outcomes
Summary
• Transitions of elders b/t acute + LTC are
increasing at a rapid rate.
• High proportions of acute care
transitions may be preventable.
• Poor and costly outcomes are the norm.
• Few studies have explored elders’ and
caregivers’ unique issues re: acute +
LTC transitions
TRANSITIONAL CARE:
Transitional Care
• Transitional care – broad range of
time limited services and
environments designed to ensure
health care continuity and avoid
preventable poor health outcomes
among high risk populations as they
move from one level of care to
another or across settings.
Innovations in Transitional Care:
State of the Science
• Limited research re: benefits + costs
of innovations designed to prevent
acute care transitions
• Findings from interventions targeting
chronically ill elders transitioning from
hospital to home have helped to
define core elements of effective
transitions
Major Findings
• Innovations designed to:
–avoid preventable acute care
transitions
–improve transitions between
acute + LTC
• Core elements of effective
transitions across settings
Methodological Challenges
• Studying multidimensional interventions
in complex settings
• Determining the core elements of
interventions
• Defining severity and risk adjustment
measures
• Identifying the most sensitive and
influential measures
• Examining impact of the context of care
Challenges to Adoption of
Proven Interventions
• Defining the best context for services
• Securing financial and other incentives
that promote…
– adoption of “best practices” by LTC
– collaboration between hospitals + LTC
in improving care transitions
• Changing the culture of current practice
Measuring the Quality of
Transitions in Care
• Lack of measures, a major barrier to
improving quality
• Promising recent efforts
• Ongoing challenges:
– defining appropriate process and
outcome measures
– identifying accountable providers and
organizations
Research Agenda
• Define population best served
• Compare benefits + costs of alternative
models
• Identify most efficacious elements of
interventions
• Design and test quality measures + other
incentives
• Evaluate “real world” applications of
evidence-based models
Summary
• Nurse led, multidimensional,
multidisciplinary interventions have
demonstrated great promise.
• Core elements are emerging.
• Translation of evidence is key.
• Future research should emphasize
avoiding preventable acute care
transitions.
Policy Implications
• Financial and other incentives needed to:
– assure adequate #s of prepared staff
– develop integrated information systems
– encourage delivery of health services
within LTC to avoid preventable
transitions
– promote use of evidence-based models
– reward high quality
Policy Implications (con’t)
• Integration of robust measures into
information systems and national
performance standards is priority
• Increased research support to
address knowledge gaps is essential