Leading Healthcare Practices and
Training: Defining and Delivering
“Disability-Competent Care”
This is the text version of Leading Healthcare Practices and Training: Defining
and Delivering “Disability-Competent Care”, Session VI: Managing Transitions,
which contains the same information as the slide presentation and was prepared
to meet 508 compliance standards.
Slide 1
Leading Healthcare Practices and Training: Defining and Delivering
“Disability-Competent Care”
Session VI: Managing Transitions
Presented to individuals working with persons with disabilities, particularly those
working in long-term care, inpatient, and home care settings
November 5th, 2013
Health Care and Human Services Policy, Research, and Consulting – With RealWorld perspective
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Resources for Plans and Providers for Medicare-Medicaid Integration. This slide
contains three stock photos from The Lewin Group of physicians and caregivers
helping adults with disabilities.
Slide 2
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screen shot of the online page that webinar participants use to interact during the
presentation, with highlighted boxes to indicate where participants can ask a
question and where they can download the slide deck. This slide contains the
official logo of Resources for Integrated Care. This slide contains a link to the
website for Resources for Integrated Care:
https://www.resourcesforintegratedcare.com
Slide 3
Overview of Webinar Series
This is a continuation of the 3-part webinar series presented in September.
The second part of this series will explore:
-“Disability-Competent Primary Care” 10/22/2013
-“The Individualized Plan of Care” 10/29/2013
-“Managing Transitions” 11/5/2013
-“Flexible Long Term Services and Supports” 11/12/2013
Each presentation is about 45 minutes with 15 minutes reserved for Q&A
Webinars are recorded; video and PDFs are available for use after each session
at:
https://www.resourcesforintegratedcare.com/
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https://www.resourcesforintegratedcare.com
Slide 4
Goals of Disability-Competent Care Webinar Series
What We Will Explore in This Series:
-The unique needs and expectations of individuals with disabilities
-Disability care competency
-Person-centered care and interactions
-Preparing to achieve the Triple Aim goals of improving the health and
participant experience of health care delivery while controlling costs in all
work with adults with disabilities
What We’d Like From You:
-How best to target future Disability-Competent Care webinars to specific
groups of healthcare professionals involved in all levels of the healthcare
delivery process
-Feedback on these topics as well as ideas for other topics to explore in these
webinars and subsequent resources related to Disability-Competent Care
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website for Resources for Integrated Care:
https://www.resourcesforintegratedcare.com
Slide 5
Introductions
Presenters
Lynne Morishita
Nurse Practitioner, Geriatric & Disability Health Consultant
Mary D. Naylor, RN, PhD
Marian S. Ware Professor in Gerontology
Director, NewCourtland Center for Transitions & Health
Elizabeth Shaid, RN, MSN, CRNP
Advanced Practice Nurse
University of Pennsylvania School of Nursing
Deborah A. Streletz, MD
Primary Care Physician
Bryn Mawr Family Practice
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Resources for Integrated Care. This slide contains a link to the website for
Resources for Integrated Care: https://www.resourcesforintegratedcare.com
Slide 6
Webinar Agenda
-Understand transitional care
-Transitional Care Model (TCM)
-Understanding the model
-Learning form the research
-Applying the model
-TCM in the real world
-Applying the model to adults with disabilities
-Case study
-Audience questions
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official logo of Resources for Integrated Care. This slide contains a link to the
website for Resources for Integrated Care:
https://www.resourcesforintegratedcare.com
Slide 7
Learning from Geriatric Studies
Discipline and study of geriatrics has 30+ years of experience; while the study of
the care of persons with disabilities is very limited
Populations comparable clinically, though life experiences and expectations vary
significantly requiring changed practices
Transitional Care in particular has been developing since the 1970’s, starting with
early work focusing on populations defined as ‘frail older adults’
Presenters will discuss experience of translating and applying the Transitional
Care Model (TCM) to younger adults with disabilities at the Inglis Program in
Philadelphia
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Slide 8
Understanding Transitional Care
Transitional care is a range of time limited services and environments that are
designed to:
-Ensure health care continuity and,
-Avoid preventable poor outcomes
Target:
-At-risk populations as they move from one level of care to another,
among multiple health care team members and across various settings,
such as hospitals to homes
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Slide 9
Understanding Transitional Care
Published evidence:
-21 RCTs of diverse “hospital to home” innovations targeting primarily
chronically ill older adults
-In 9 studies, a positive impact was shown on at least one measure of rehospitalization plus other health outcomes
-Effective interventions:
Multidimensional span settings
Use of inter-professional teams with primarily nurses, as “hubs”
Source: Naylor, et al. 2011. The Care Span – The Importance of Transitional
Care in Achieving Health Reform. Health Affairs, 30(4):146-154.
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Slide 10
Transitional Care
Evidence-Based Interventions
Different goals of evidence-based interventions targeting transitional care:
-Address gaps in care and promote effective “hands-off”
-Address “root causes” of poor outcomes with focus on longer-term value
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Slide 11
Transitional Care Model (TCM)
-Screening
-Engaging Adults with Disabilities and Caregivers
-Managing Symptoms
-Educating/Promoting Self-Management
-Collaborating
-Assuring Continuity
-Coordinating Care
-Maintaining Relationship
Source: www.transitionalcare.info
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the center with text bubbles surrounding the picture; each text bubble contains
one of the points listed above. This slide contains a number in the lower right
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presentation. This slide contains the official logo of Resources for Integrated
Care. This slide contains a link to the website for Resources for Integrated Care:
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Slide 12
TCM – Unique Features
Care is delivered and coordinated:
-By same advanced practice nurse (APN) supported by team
-In hospitals, SNFs, and homes
-Seven days per week
-Using evidence-based protocol
-Supported by decision support tools
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Slide 13
TCM – Understanding the Model
Core components:
-Holistic, person/family-centered approach
-Nurse-coordinated, team model
-Protocol guided, streamlined care
-Single “point person” across episode of care
-Information/decision support systems that span settings
-Focus on increasing value over long term
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Slide 14
TCM – Understanding the Model
Moving from the Hospital to the Home
Better Care:
-Enhanced access
-Reduced errors
-Enhanced care experience
Better Health:
-Decreased symptoms
-Improved function
-Enhanced quality of life
Source: Ann Intern Med, 1994, 120:999-1006; JAMA, 1999, 281:613-620; J Am
Geriatr Soc, 2004, 52:675-684
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Slide 15
TCM – Learning from the Research
Impact of TCM on Readmission Rates:
Time after Discharge: 6 weeks
TCM Group 10%
Control Group 23%
Time after Discharge: 26 weeks
TCM Group 28%
Control Group 56%
Time after Discharge: 52 weeks
TCM Group 48%
Control Group 61%
Source: www.transitionalcare.info
[Images] This slide contains a bar graph that depicts the figures listed above; it
illustrates that readmission rates are lower for participants in the TCM group
versus those in the control group. This slide contains a number in the lower right
hand corner of the slide to indicate that this is the fifteenth slide in the
presentation. This slide contains the official logo of Resources for Integrated
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Slide 16
TCM – Learning from the Research
TCM’s Impact on Total Health Care Costs:
At 26 weeks post-discharge
TCM group $3,630
Control group $6,661
At 52 weeks post-discharge
TCM group $7,636
Control group $12,481
Source: www.transitionalcare.info
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above; it illustrates that total health care costs after hospital discharge are lower
for participants in the TCM group versus those in the control group. This slide
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Slide 17
TCM – Applying the Model
Barriers to widespread adoption:
-Organization of care
-Regulatory challenges
-Quality and financial incentives
-Culture of caring
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Slide 18
TCM – Applying the Model
Penn research team formed partnerships with Aetna Corporation and Kaiser
Permanente to test “real world” applications of research-based models of care
among high risk elders.
Funded by the Commonwealth Fund and the following foundations: Jacob and
Valeria Langeloth, The John A. Hartford, Gordon & Betty Moore, and California
HealthCare; guided by National Advisory Committee (NAC)
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Slide 19
TCM – Applying the Model
Tools of Translation:
-Patient screening and recruitment
-Preparation of TCM nurses and teams (e.g. online seminar)
-Documentation and quality monitoring (clinical information system)
-Quality improvement (case conferences grounded in root cause analysis)
-Evaluation
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Slide 20
TCM – Applying the Model
Project Goals (Aetna):
-Test TCM in defined market
-Document facilitators and barriers
-Present findings to Aetna decision makers
-Widely disseminate findings
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Slide 21
TCM – Applying the Model
Findings (Aetna project):
-Improvements in all quality measures
-Increased patient and physician satisfaction
-Reductions in re-hospitalizations through 3 months
-Cost savings through one year
-All significant at p<0.05
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Slide 22
TCM in the Real World
Cognitively Impaired Adults
Would cognitively impaired hospitalized older adults and their caregivers benefit
from TCM?
Funding provided by the Marian S. Ware Alzheimer Program, and the National
Institute on Aging, R01AG023116 (2005-2011)
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Slide 23
TCM in the Real World
Cognitively Impaired Adults
Time to First Readmission (N=407)
Lower Dose Interventions:
RNC = Resource Nurse Care
ASC = Augmented Standard Care
30 days post-discharge:
TCM group 93.4% not readmitted
ASC/RNC group 78.6% not readmitted
90 days post-discharge:
TCM group 79.8% not readmitted
ASC/RNC group 63.7% not readmitted
180 days post-discharge
TCM group 67.9% not readmitted
ASC/RNC group 53.1% not readmitted
Source: Marian S. Ware Alzheimer Program, and the National Institute on Aging,
R01AG023116 (2005-2011)
[Images] This slide contains a graph that depicts the figures listed above; it
illustrates that participants in the TCM group had lower rates of readmission
compared to those in the lower dose intervention group (ASC/RNC). This slide
contains a number in the lower right hand corner of the slide to indicate that this
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Slide 24
TCM in the Real World
Cognitively Impaired Adults
Mean Number of All-Cause Re-Hospitalizations
APN = Advanced Practice Nurses
RNC = Resource Nurse Care
ASC = Augmented Standard Care
30 days post-discharge:
APN group 0.09 re-hospitalizations
ASC/RNC group 0.19 re-hospitalizations
90 days post-discharge
APN group 0.07 re-hospitalizations
ASC/RNC group 0.12 re-hospitalizations
150 days post-discharge
APN group 0.06 re-hospitalizations
ASC/RNC group 0.07 re-hospitalizations
[Images] This slide contains a graph that depicts the figures listed above; it
illustrates that the APN group had a lower mean number of all-cause rehospitalizations compared to those in the lower dose intervention group
(ASC/RNC). This slide contains a number in the lower right hand corner of the
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Slide 25
TCM in the Real World
LTC Recipients
What do we know about effects of transitions among elderly long-term care
recipients over time?
Funding provided by the National Institute on Aging, National Institute of Nursing
Research, R01AG025524, (2006-2011)
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Slide 26
TCM in the Real World
LTC Recipients
Bothersome physical symptoms present at baseline*
Aching: 64%
Shortness of breath: 56%
Pain: 41%
*Symptom Bother Scale
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Slide 27
TCM in the Real World
LTC Recipients
Depressive Symptoms* Through One Year
Categorized Depression Score Distribution Over Time
At 0 months:
Score 0-4
63%
Score 5-9
26%
Score 10+ 11%
At 3 months:
Score 0-4
61%
Score 5-9
32%
Score 10+ 7%
At 6 months:
Score 0-4
63%
Score 5-9
30%
Score 10+ 6%
At 9 months:
Score 0-4
65%
Score 5-9
28%
Score 10+ 6%
At 12 months:
Score 0-4
63%
Score 5-9
32%
Score 10+ 5%
*GDS-SF
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Slide 28
TCM in the Real World
PCMH
Does the TCM add value to the Patient Centered Medical Home (PCMH)?
Funding provided by the Gordon and Betty Moore Foundation, Rita and Alex
Hillman Foundation, and the Jonas Center for Nursing Excellence (2011-2014)
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Slide 29
TCM in the Real World
PCMH
Study Aims:
In collaboration with Patient Centered Medical Homes and guided by an Advisory
Committee, the Penn team is:
-Comparing outcomes of PCMH and TCM, a new care delivery approach,
to those achieved by the PCMH only
-Using lessons learned and findings to advance larger scale effort
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Slide 30
TCM in the Real World
PCMH
Modifications to TCM for PCMH
-Collaboration (co-management) with PCMH
-Focus on patient’s and family caregiver’s goals
-Emphasis on prevention of acute resource use (ED visit, index
hospitalization) and continuity of care when acute event occurs
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Slide 31
TCM Overview
The Transitional Care Model:
-Focuses on transitions of high-risk cognitively intact and impaired older
adults across all settings
-Has been “successfully” translated into practice
-Has been recognized by the Coalition for Evidence-Based Policy as an
innovation meeting “top-tier” evidence standards
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Slide 32
TCM: Implementation Progress
-Aetna – expansion of TCM proposed as part of Aetna’s Strategic Plan
-University of Pennsylvania Health System – adopted TCM; IBC and Aetna
reimbursing for services
-Other health care systems and communities – adoption or adapting
-Informing ACA implementation
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Slide 33
TCM for Adults with Severe Disabilities
Special considerations for transitions of adults with disabilities:
-Multiple healthcare providers in acute and primary settings with minimal
communication
-Finding providers with willingness and experience working with
consumers with disabilities
-Finding providers with accessible surroundings or in-home services
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Slide 34
TCM for Adults with Severe Disabilities
Special considerations continued:
-Attendant care that is not directed / reliable
-Assuring back-up plan for attendant illness or absence
-Identification of family caregiver or additional persons for contact
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Slide 35
TCM for Adults with Severe Disabilities
Special considerations continued:
-Multiple unmet needs that have not been addressed for months / years:
emotional, housing, social, legal, physical, equipment, and supplies
-Source(s) of supplies that are not customer driven
-Assuring transportation
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Slide 36
TCM for Adults with Severe Disabilities
Special considerations continued:
-Working with homecare specialists
-Communication
-Understanding treatment / life goals
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Slide 37
TCM for Adults with Severe Disabilities
Partnerships with Inglis House
50 community dwelling adults, age 20-55
Pre- / post-test of APN intervention based on TCM
Improved functional status: trend toward decreased hospitalizations, ED visits
Source: Naylor et al., 2007. Community-Based Care for High Risk Adults with
Severe Disabilities. Home Health Care Management & Practice, 19(6):255-266
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Slide 38
Case Study: Mrs. Smith
75-year old, female
Retired – domestic work
Lives alone, in two-story home (grand-daughter vacated)
1 son, 3 daughters
Church
Documented history of non-adherence to therapeutic regimen
History of depression
20 chronic medical conditions (including Parkinson’s Disease, diabetes with
ophthalmic and renal manifestations, arthropathy, heart disease, hearing loss)
18 prescribed medications
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Slide 39
Case Study: Mrs. Smith’s Goal
Patient identified:
-Working motorized chair, with a ramp installed
-Poly-pharmacy and non-adherence
-Navigating the medical community
New Issue: Section 8 Housing required relocation
-Family support – son found apartment, close to him and daughters
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Slide 40
Case Study: Mrs. Smith’s Plan
Motorized chair
Medication adjustments, from 18-12 (education, stressing compliance)
Diabetes education
Bladder and bowel program
Advanced directives
Follow-up visit schedule (provide master list)
Fall prevention education
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Slide 41
Case Study: After Transition
Issues to consider after transition:
-Medically stable?
-Continued housing
-Social / family (network)
-Emotional (depression)
-Functional (pain)
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Slide 42
Key Lessons
Solving complex problems will require multidimensional solutions
Evidence is necessary but not sufficient
Change is needed in structures, care processes, and health professionals’ roles
and relationships to each other and the people they support
Carpe Diem!
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Slide 43
Audience Questions
Webinar Evaluation Survey
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Slide 44
Next Webinars
“Flexible Long Term Services and Supports”
Tuesday, November 12th, 2013
2:00 – 3:00PM Eastern
Session VII will focus on:
- Integrating and coordinating all health care services and supports
- Understanding the roles and responsibilities of the disability-competent
interdisciplinary care team
Targeted audience:
- Individuals who work with persons with disabilities, in particular home
and community-based service providers
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Slide 45
Thank You for Attending
For more information contact:
Lynne Morishita at [email protected]
[email protected]
Chris Duff at [email protected]
Jessie Micholuk at [email protected]
Kerry Branick at [email protected]
Disability-Competent Care Self-Assessment Tool available online at:
https://www.resourcesforintegratedcare.com/
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Slide 46
Resources & References
The Transitional Care Model
www.transitionalcare.info
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to indicate that this is the forty-sixth slide in the presentation. This slide contains
the official logo of Resources for Integrated Care. This slide contains a link to the
website for Resources for Integrated Care:
https://www.resourcesforintegratedcare.com
Slide 47
Disability-Competent Care Self-Assessment Tool
[Images] This slide contains a screenshot of the Disability-Competent Care SelfAssessment Tool that is available at the Resources for Integrated Care website.
This slide contains a number in the lower right hand corner of the slide to indicate
that this is the forty-seventh slide in the presentation. This slide contains the
official logo of Resources for Integrated Care. This slide contains a link to the
website for Resources for Integrated Care:
https://www.resourcesforintegratedcare.com
