Transitions in Long-Term Care:
The Policy Implications
Building Bridges: Making a Difference in Long-Term Care
2007 Policy Seminar
Sponsored by The Commonwealth Fund
AcademyHealth
Washington, D.C.
Mary D. Naylor, Ph.D., R.N.
Marian S. Ware Professor in Gerontology
University of Pennsylvania School of Nursing
Goals
 Make
the case that health care quality
among elderly long-term care (LTC)
recipients who require acute care
services may be enhanced by:
–avoiding preventable acute
hospitalizations; and,
–improving transitions to and from
hospitals when such transfers are
needed
Goals
 Offer
policy recommendations to
prevent avoidable hospitalizations
and enhance necessary care
transitions
 Propose
a research agenda to inform
future changes in standards of care
Number (in millions)
Elders 85 and Older: One among the
fastest growing age groups in the U.S.
SOURCE: Nursing Staff in Hospitals and Nursing Homes: Is it adequate?, 1996; page 33.
Acute Hospitals vs. LTC
short-term services
dominated by
medical model
 providers choose +
deliver services
 high tech
 limited family
involvement
 Payor: Medicare

long-term health,
social and housing
services
 providers help with
ADLs +IADLs
 low tech
 family equal
partners
 Payor: Medicaid

Transitions between LTC and
Acute Care Hospitals
Nature of Problems
 Poor
communication
 Negative
effects of
hospitalization
 Inadequate
 Gaps
discharge planning
in care during transfers
Consequences
 High
rates of acute clinical
events
 Serious
unmet needs
 Poor
satisfaction with care
 High
hospital readmission rates
Clinical Barriers to Addressing
Problems with Transitions
 Providers’
resources
 Limited
 Dearth
knowledge, skills and
use of palliative care
of quality performance
measures
Non-Clinical Barriers to
Addressing Problems with
Transitions
 Regulatory
 Financial
challenges
constraints
 Pressures
from families and
health care administrators
The Search for Solutions
Related Areas of Inquiry
 Efforts
LTC
to fully integrate acute and
 Transitional
care interventions
targeting chronically ill elders
 Innovative
care models
Lessons from Integration Efforts
 Described
the unique issues and
challenges confronting acutely ill,
frail elders
 Highlighted
the benefits of avoiding
preventable hospitalizations
Lessons from Integration Efforts
 Suggested
value of:
–Early identification of acute care
needs
–Increased access to selected
primary, acute and palliative care
services within LTC
–Flexible funding and benefits
Care Models Designed to Avoid
Preventable Hospitalizations
 Evercare
 Hospital
 The
at Home
Day Hospital
 Palliative
Care Program in LTC
Mrs. Anderson: A Case Study
Lessons Learned from
Transitional Care Interventions
 Identified
individual and system
barriers to effective transitions
 Highlighted
importance of
multidimensional strategies targeting
problems common during “hand-offs
Lessons Learned from
Transitional Care Interventions
 Suggested
value of:
–Nurse-led, interdisciplinary teams
–Streamlined care delivery
–Information systems that span
settings
–Quality measures and other
incentives
Care Models Designed to
Improve Care Transitions
 Care
Transitions “Coaching”
Intervention
 Advanced
Practice Nurse (APN)
Transitional Care Model
Mr. Jenkins: A Case Study
Policy
Recommendations
Leutz’s Conceptual
Framework
 Linkage
 Coordination
 Full
Integration
Key Assumptions
 The
financing and delivery of
acute and LTC will continue to be
characterized by a patchwork of
public and private services and
funding
Key Assumptions

There is an adequate evidence base to
justify:
– increasing access to primary care,
management of common conditions and
palliative care within LTC; and,
– use of nurse directed interdisciplinary
teams, guided by evidence-based
transitional care protocols
Proposed Structures, Incentives to
Enhance Coordination of Care Delivery
 Design,
testing and integration of
quality measures and monitoring
systems
 Development
of information systems
that span settings
Proposed Structures, Incentives to
Enhance Coordination of Care Delivery
 Preparation
of current + future
providers emphasizing…
– geriatrics
– palliative care
– interdisciplinary team care
– advance care planning
– transitional care/care coordination
 Dissemination
of “best practices”
Proposed Structures, Incentives to
Improve Coordination of Care Benefits
 Create
incentives to foster adoption of
evidence-based models of on-site
primary or palliative care and
transitional care
 Modify
Medicare’s Hospice benefit to
minimize barriers for use within LTC
Research Agenda
 Describe
impact of transitions
 Identify
most effective and efficient
models to:
– avoid preventable hospitalizations
– improve care coordination, continuity
and transitions
 Define
financial and other incentives
to optimize quality and cost
outcomes