CMS National Conference
on Care Transitions
December 3, 2010
1
Implementation of the
Transitions of Care Model
in a Community Setting
Andrew Miller, MD, MPH
Director, Physician Services
Healthcare Quality Strategies, Inc. (HQSI)
2
New Jersey Care Transitions
Project Community
• Southwestern
New Jersey
• Main partner
organization:
Virtua
3
Virtua Home Care
• Implemented Transitional Care Model
(TCM)
• Key requirements for program
–Financial feasibility
–Sustainability
4
Role of Penn School
of Nursing Team
• Presentations to Virtua leadership
• Training
– Online training modules (reviewed
by Penn nurse trainer)
– Site visit by Virtua Home Care nurses
to Philadelphia
• Ongoing support
– Periodic case conferences
– Availability for telephone consultation
5
Adaptations
• To make the model feasible and
sustainable in a primarily Fee-forService, pre-Affordable Care Act
environment
– Enrolled only patients eligible for Medicare
home health services
– Baccalaureate nurses instead of Advanced
Practice Nurses (APNs)
6
Adaptations (cont’d)
– No visit in the hospital by the Transitional
Care Nurses (TCNs)
– TCN does not accompany patient to the
first follow-up visit to the physician
– Allowed enrollment of patients after
discharge from the hospital
• Initial refusals
• Patients identified by a home
health nurse
7
Additional Training
Provided to TCNs
• Management of patients with
congestive heart failure (CHF),
chronic obstructive pulmonary
disease (COPD), and diabetes
• Availability of community resources
for patients with chronic conditions
8
Pilot Project
• Started as a small pilot within Virtua
Home Care
• Four TCNs (2.4 FTE)
• Ultimate goal is spread throughout
the agency
9
Virtua Home Care’s Sense
of Ownership
• New name:
– Transitions of Care Program
• Potential concern:
– Loss of fidelity with the evidencebased TCM
10
Outcomes
Number of Hospitalizations
Transitions of Care
Program Enrollment
Number of
Hospitalizations
Average Hospitalizations
Per Patient (Range)
30 Days Prior
69
1.13 (1 – 2)
30 Days After
22
0.36 (0 – 3)
Number of
Hospitalizations
Average Hospitalizations
Per Patient (Range)
60 Days Prior
71
1.16 (1 – 2)
60 Days After
33
0.54 (0 – 4)
Transitions of Care
Program Enrollment
Number of Transitions of Care Program enrollments = 81
Analysis is limited to 61 patients with identifiable inpatient hospital claims
prior to enrollment.
11
Outcomes (cont’d)
30-Day Acute Care Hospitalization Rate
Number of
Patients Enrolled
in Program
Number of
Hospitalizations
Rate
2009 Q3
8
5
63%
2009 Q4
7
4
57%
2010 Q1
13
3
23%
2010 Q2
23
7
30%
2010 Q3*
10
3
30%
Quarter
*Q3 2010 data is incomplete. Result is preliminary.
12
Outcomes (cont’d)
30-Day Acute Care Hospitalization Post-TCM
Enrollment
Acute care hospitalization rate
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
2009Q3
2009Q4
2010Q1
2010Q2
2010Q3
13
Advice about Implementing
the Transitional Care Model
• It is as good as Dr. Naylor says it is
• Invest the time and resources
necessary to identify and train the
TCNs
• The TCM works very well in a
community-based setting
• Build at least a simple evaluation
system from the start
Role of the QIO (HQSI)
• Making the home health agency aware of
the TCM program
• Facilitating: bringing the agency together
with the Penn School of Nursing team
• Assisting with implementation: serving on
steering committee
• Funding support: for training provided by
Penn team
• Analytic support: for examining outcomes
15
For more information, contact:
• Andrew Miller, MD, MPH
Director, Physician Service
Healthcare Quality Strategies, Inc.
557 Cranbury Road, Suite 21
East Brunswick, NJ 08816-5419
732-238-5570, extension 2072
amiller2@njqio.sdps.org
16