Care Transitions Models
and Key Technologies for
Patients in the Home
Lynn Redington, DrPH, MBA
Senior Program Director
Center for Technology and Aging
lredington@techandaging.org
Remington’s 9th Annual
Forecasting Think Tank Summit
St. Pete, Florida March 13, 2011
Center for Technology and Aging
 Established in 2009 with funding from The SCAN Foundation,
located at the Public Health Institute
 Mission: Expand the use of technologies that help older
adults lead healthier lives and maintain independence
 Independent, non-profit resource center on issues related to
diffusion of technology for older adults
 Technology Diffusion Grants Programs
 e.g., Tech4Impact grant (Technologies for Improving
Post-Acute Care Transitions “Tech4Impact”)
Post-Acute Care Transitions & Re-admissions
• Avoidable Readmissions:
 Opportunity for better care, better health, lower costs
 1 in 5 patients readmitted within 30 days of discharge
 76% of readmissions are preventable
 A $25 billion savings potential
• Call to action:
 Improve care transitions (e.g., hospital to home)
 Improve care coordination, outreach, patient engagement and
support
References:
New England Journal of Medicine, Jencks S, et al “Rehospitalizations among patients in the Medicare
fee-for-service program” N England Journal of Medicine 2009; 360: 1418-28.
PricewaterhouseCoopers, 2008. The price of excess: Identifying waste in healthcare spending.
Many QI opportunities to reduce hospitalization . . .
Care Transitions Models Improve Processes,
Information Flows, and Capacity
• Evidence-based models include:
• Care Transitions Intervention
• Transitional Care Model
• Guided Care
• GRACE
• Others
The Care Transitions Intervention (CTI)
• “The Coleman Model”
• Qualifications: CTI Coach can be layperson
• Length of intervention: 30 days
• Average cost: $196 per patient
• Steps:
• Four pillars--Medication management; Patient-centered record;
Follow-up; Red flags
• Five encounters--Hospital/SNF Visit; Home Visit; 3 Follow-Up Calls
Transitional Care Model (TCM)
• “The Naylor Model”
• Qualifications: Transitional Care Nurses are advanced
practice nurses (BA-prepared nurses under study)
• Length of intervention: 1 to 3 months
• Average cost: $982 per patient
• Steps:
• Visit patient in hospital, home visit w/24 hours, accompany
patient to 1st doctor visit, facilitate clinician collaboration and
communications with patient/family, on call 7 days a week
Guided Care
• Developed at Johns Hopkins University since 2001
• Qualifications: Guided Care Nurse must be an RN
• Length of intervention: For life
• Average cost: $1743 per patient per year
• Steps:
• Conduct comprehensive home assessment, create care guide and
action plan for patient, provide monthly monitoring and selfmanagement coaching, coordinate care, facilitate access to
community services, engage/educate informal caregivers
GRACE: Geriatric Resources for
Assessment and Care of Elders
• “The Counsell Model”
• Qualifications: Nurse practitioner and social worker
• Length of intervention: Long term/indefinite
• Average cost: $1432 per patient per year
• Steps:
• In-home assessment, home visit after any hospitalization, one phone
or in-person follow-up per month, collaborate with PCP, hospital
discharge planner and others in a team-based approach
How Technologies May Support Care Processes
Video-Based
Telemedicine
Education
Smart Sensors
Wireless Broadband
Networks
Remote Patient Monitoring
Home
Medication
Management
Patient Health Records
Technology Usage Examples:
CTA Grantees that Aim to Reduce Hospitalizations
Medication Optimization Technologies
•American Society of Consultant Pharmacists
Foundation
•Caring Choices
•Connecticut Pharmacists Foundation
•VA Central California Health Care System
•Visiting Nurse Services of New York
Personal Health Records Technologies
State Units on Aging and ADRCs in:
•California
•Rhode Island
•Washington
Remote Patient Monitoring Technologies
•AltaMed Health Services, Stamford Hospital
•California Association of Health Services at
Home
•Centura Health at Home
•New England Healthcare Institute
•Sharp HealthCare Foundation
•HealthCare Partners
•Catholic Healthcare West
Evidence-Based Care Transitions QI
Evaluation Technologies
State Units on Aging and ADRCs in:
•Indiana
•Texas
ADRC = Aging and Disability Resource Center
Veterans Health Administration (Central CA)
CTA Grant Project
Focus Area
Medication Adherence, Remote Patient Monitoring (RPM)
Population
Vets with CHF, hospitalized within past 1-2 years
Technology
In-home RPM appliance using POTS,
Med Adherence Algorithm, weight scale, BP cuff
Expected
Benefits
Reduce hospital/ED visits; improve patient activation, QOL &
satisfaction
Workforce
Issues
Care coordinator (RN), MD oversight, Automated clinician alerts,
enabled patients/informal caregivers
Organizational
Readiness
VHA: world’s largest telehealth user, rural health = telehealth
(see next 2 slides for background)
POTS = Plain Old Telephone Service
The Early Adopter Experience:
Veterans Health Administration (1 of 2)
•
•
•
VHA has evaluated, piloted, reevaluated, and
deployed telehealth technologies in a
continuing process of learning and
improvement far beyond adoption in the
private sector
Largest national program--enables detailed
analyses
Home telehealth compared to traditional care
models:
– Studies conducted on patients enrolled in the
VA’s Care Coordination/Home Telehealth
program in 2006 and 2007 show:
• 25% reduction in bed days of care
• 20% reduction in numbers of admissions
• 86% mean satisfaction score rating
The Early Adopter Experience:
Veterans Health Administration (2 of 2)
Net cost = $1,600 / patient / year vs.
Age Distribution of all CCHT Patients
• VHA’s home-based primary care
services = $13,121 / patient / year
• Market nursing home care rates
average = $77,745 / patient / year
VHA takes “systems approach” to
integrate the elements of the CC/HT
program. This includes:
• Product selection
• Training
• Protocols for patient selection,
management
• Data analytics
Since VHA implemented CCHT in 2003, a total of
43,430 patients have been enrolled
Indiana State Unit on Aging
CTA Grant Project
Focus Area
Implementing GRACE care transitions model and technologies
into VAMC Indianapolis
Population
Older Vets at high risk for hospitalization and institutional care
Technology
Technologies that support GRACE protocols (EHR, automated
prompts, Web-access to protocols and other tools)
Expected
Benefits
improved performance on Assessing Care of Vulnerable Elders
(ACOVE) quality indicators, higher satisfaction, and decreased
hospital readmissions and long-term institutionalization
Workforce
Issues
Team-based approach coordinated by GRACE-trained nurse
practitioner and social worker, increased engagement of patients
and caregivers, local ADRC integrated into process
Organizational
Readiness
VA validates new innovations before taking nationwide; GRACE
intervention originated in Indiana; Counsell is leading project
Washington State Unit on Aging
CTA Grant Project
Focus Area
Improving communications, coordination, self-management
during care transitions
Population
Patients recently discharged from hospital that are participating in
the Care Transitions Intervention program
Technology
EHRs and PHRs
(Electronic Health Records, Personal Health Records)
Expected
Benefits
Reduce hospitalizations/re-hospitalizations, improve patient selfmanagement, improve communications
Workforce
Issues
CTI coach, connected clinicians, increased engagement of
patients and caregivers
Organizational
Readiness
An early adopter, Whatcom County, WA started project in 2001
Connecticut Pharmacists Foundation
CTA Grant Project
Focus Area
Remote Medication Therapy Management
Population
Older Cambodian-Americans w/ history of torture/trauma, high
incidence of chronic illness and low literacy rate
Technology
Video conferencing, spoken format technology, EMR
Expected
Benefits
Reduce hospital/ED visits; improve meds use; improve access to
culturally concordant providers
Workforce
Issues
Remote pharmacist visit, patient is accompanied by community
health worker. Few providers trained in special needs of this
population.
Organizational
Readiness
Connecticut partner, Khmer Health Advocates, is the only
Cambodian health organization in the US
Diffusion of Innovations
Lessons Learned
•Stakeholder readiness to adopt
•Business model/payment model
•Technology/Intervention model
• Evidence base/relative advantage
• Compatibility
• Complexity
•Policy issues
Center for Technology and Aging
www.techandaging.org