Care Transitions Intervention
Model Concepts and Implementation through
Lehigh Valley Home Health Services
Vickie Cunningham, Tracey Wilds and Karen Panik
"Sometimes the questions are complicated and the answers are simple."
-Dr. Seuss
What is the Care Transitions
Intervention (CTI)?
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4-week program
Patients with complex care needs and
family caregivers
Specific tools
Transition Coach
Self-management skills
Why The Care Transitions
Intervention?
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Patients who received this program were significantly
less likely to be readmitted to the hospital, and the
benefits were sustained for five months after the end
of the one-month intervention.
■ Anticipated cost savings for 350 chronically ill adults
with an initial hospitalization over 12 months is
$295,594.
■ Patients who received this program were also more
likely to achieve self-identified personal goals around
symptom management and functional recovery.
CTI Model Pillars
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Medication self-management
Use of a dynamic patient-centered
record, the Personal Health Record
Timely primary care/specialty care
follow up
Knowledge of red flags that indicate a
worsening in their condition and how
to respond
CTI Model Encounters
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Hospital Visit
Home Visit
2-3 phone contacts
Key Attributes of a Coach
Ability to shift from a “doing” role to a
coaching role
■ Comfort with medication review
■ Understands the difference between
being persistent vs. pesty
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Outcomes Obtained in Initial
study
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Re-hospitalized 180 days
– 26 % Intervention 31 % control
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Re-hospitalized 90 days
– 17 %Intervention 23 % control
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Re-hospitalized 30 days
– 8 % Intervention 12 % control
Coleman, E.A., Parry, C, Chalmers, S., & Min,
S. (2006). The care transitions intervention
results of a randomized control trial. Archives of
Internal Medicine 166 1822-1828.
Care Transitions Intervention
Implementation at Lehigh Valley
Health Network
Market Analysis
Strengths
• CTI has been researched and was touted by Medicare
Innovations Collaborative (Med-IC) as one mechanism
to enhance older adult patient care while decreasing
rehospitalization (Medicare Innovations Collaborative,
2011).
• Patient transition to home from acute setting can be
fragmented and difficult to navigate
• If patient does not require traditional home based
services the patient may feel insecure about the
transition to home and return to the hospital creating
avoidable readmission
Medicare Innovations Collaborative (2011). Models of Care –
Transitional care. Retrieved from http://www.medic.org/pages/care.html
Market Analysis Continued
Weaknesses
– Need for
systematic culture
change within
healthcare
delivery system
– Research has not
been duplicated
by anyone other
than originator
Market Analysis Continued
Opportunities
• No current transitions
program to assist
patients that do not
receive traditional
home based services
within Lehigh Valley
Health Network
• No current
transitional care
delivery programs
within geographic
area (Lehigh, Carbon,
Northampton County)
Market Analysis Continued
Threats
– Lack of patient
interest
– Lack of direct
revenue which
could impact
sustainability
Market Analysis continued
Stakeholders
– Acute care hospitals who wish to decrease
uncompensated care
– Home health agencies who wish to enhance
home and community based services
– Third party payers who wish to decrease care
delivery costs
– Patients and caregivers who wish to improve
patient self management
– Physicians who wish to boost patient
compliance with treatment plans
Goals
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Ease transition from other levels of care to
home based services
Enhance collaboration and transitions
between home based service programs.
Improve continuity of care to patients with
chronic disease.
Decrease number and length of
hospitalizations for patients with chronic
disease
Setting the Stage
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Evaluate all transitions program
evidence
Training for care transitions coaching
Development of patient materials
including admission packet, Policies,
consent, documentation and patient
education
Spoke with Members of the MED- IC
initiative for guidance on roll out
Setting the Stage Cont.
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Small test of change using Coleman model
Evaluation of pilot and obtained grant funding
for Transitions Coach position
Developed job description
Coach hired
Developed referral mechanism using
Allscripts system
Developed home health mechanism for
referrals
Identified Inclusion Criteria
Inclusion Criteria
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Lehigh and Northampton Co
Hospitalized
Telephone
English Speaking
Adult
Alert and Oriented
At least 1 chronic condition
Service Delivery Plan
Follow criteria outlined by
the CTI to reduce
rehospitalization
– 4-week program
– Patients with complex
care needs and family
caregivers
– Specific tools
(Personal Health
record)
– Transition Coach
– Self-management
skills
Care Transitions Program (2007).
Business plan. Retrieved from
Colorado_Business_Plan_2009.pdf
Service Delivery Plan
Continued
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1 FTE Transitions coach per 25 patient
caseload (RN or MSW preferred)
0.25 FTE Clerical /office support per 25
patient caseload
Outcomes
CTI Outcomes 1/12/2011 – 3/2012
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Total referrals: 219
93 Refusals
46 Referral Inappropriate
75 Enrolled (signed a consent of
willingness to CTI participation)
30 day readmission 10.6% overall
– 0% of those who completed intervention
admitted 30 days post completion
Cost Benefit Analysis
$265 per day to maintain program
average cost of heart failure readmission
= $5497 (Whelan, Greiner, Schulman &
Curtis, 2010, p.37)
Prevention of 18 hospitalizations for HF
per year will recoup cost of program
Cost Benefit Analysis
Continued
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30 day readmission projection
• 365 patients per year at 12 % rehospitalization rate = 44
patients rehospitalized
• 365 patients at 8% rehospitalization rate = 29 patients
rehospitalized
• 16 patient decrease = $87,952 annualized savings
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90 day readmission projection
• 365 patients per year at 23% rehospitalization rate = 84
patients rehospitalized
• 365 patients at 18% rehospitalization rate = 62
• 22 patient decrease = $120,934 annualized savings
Coleman, E.A., Parry, C, Chalmers, S., & Min, S. (2006). The care transitions
intervention results of a randomized control trial. Archives of Internal Medicine 166
1822-1828.
Barriers
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Difficult to get patients to accept
program
– Overwhelmed
– Don’t need
– Have support
Lessons Learned
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Identify as a component of delivery system
Enhanced visibility in community
If developing other models that are similar
keep CTI data separate
Work with care providers in other arenas to
enhance program
Work with PCP and hospitalists together and
separate to enhance buy – in
Patient Perception
“Thank you for visiting me in my
home…this is a good, helpful
program“
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It's so nice to have all this support to
keep me in the comfort of my
home"
“Really helps me understand what my medications
are and if I need to talk to the Doctor about them”
“Thanks for helping me feel more confident in
making my doctor appts”
"Thank you so much for your time,
concern and patience…I've never
had this kind of support"
Conclusions
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CTI increases patient self management
CTI decreases hospital readmissions
CTI cost effective and simple to
implement
References
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Boling, P.A., (2009). Care transitions and home health care. Clinical Geriatric Medicine 25 135-148.
Care Transitions Program (2007). Business plan. Retrieved from Colorado_Business_Plan_2009.pdf
Care Transitions Program (2007). CTI Evidence and Adoptions. Retrieved from
http://www.caretransitions.org/documents/Evidence_and_Adoptions_2.pdf
Coleman, E.A., Parry, C, Chalmers, S., & Min, S. (2006). The care transitions intervention results of a
randomized control trial. Archives of Internal Medicine 166 1822-1828.
Coleman, E.A., Smith, J.D., Frank, J.C., Min, S. Parry, C. & Kramer, A.M. (2004). Preparing patients and
caregivers to participate in care delivered across settings the care transitions intervention. Journal
American Geriatric Association 52 1817-1825.
Colorado Foundation for Medical Care (2010). About the theme: opportunities for improving care
transitions. Retrieved from http://www.cfmc.org/caretransitions/about.html
Jencks, S.F., Williams, M.V. & Coleman, E.A. (2009). Rehospitalizations among patients in the Medicare
fee-for-service program. The New England Journal of Medicine 360(14) 1418-1428.
Medicare Innovations Collaborative (2011). Models of Care – Transitional care. Retrieved from
http://www.med-ic.org/pages/care.html
Parrish, M.M, O’Malley, K., Adams, R.I., Adams, S.R. & Coleman, E.A. (2009). Implementation of the
care transitions intervention sustainability and lessons learned. Professional Case Management 14(6)
282-293.
Whelan, D.J., Greiner, M.A., Schulman, K.A., & Curtis, L.H. (2010) Costs of inpatient care among
Medicare beneficiaries with heart failure, 2001 to 2004. Circ Cardiovasc Qual Outcomes 3 33-40.
Contact Information:
vickie.cunningham@lvh.org
tracey_awilds@lvh.org
Questions?