Transitions in Long-Term Care: Transitions in Long-Term Care: The Policy ImplicationsThe Policy Implications

Building Bridges: Making a Difference in Long-Term CareBuilding Bridges: Making a Difference in Long-Term Care2007 Policy Seminar2007 Policy Seminar

Sponsored by The Commonwealth FundSponsored by The Commonwealth FundAcademyHealthAcademyHealth

Washington, D.C.Washington, D.C.

Mary D. Naylor, Ph.D., R.N.Mary D. Naylor, Ph.D., R.N.

Marian S. Ware Professor in GerontologyMarian S. Ware Professor in Gerontology

University of Pennsylvania School of NursingUniversity of Pennsylvania School of Nursing

GoalsGoals Make the case that health care quality Make the case that health care quality

among elderly long-term care (LTC) among elderly long-term care (LTC) recipients who require acute care recipients who require acute care services may be enhanced by:services may be enhanced by:– avoiding preventable acute avoiding preventable acute

hospitalizations; and,hospitalizations; and,– improving transitions to and from improving transitions to and from

hospitals when such transfers are hospitals when such transfers are neededneeded

GoalsGoals

Offer policy recommendations to Offer policy recommendations to prevent avoidable hospitalizations prevent avoidable hospitalizations and enhance necessary care and enhance necessary care transitionstransitions

Propose a research agenda to inform Propose a research agenda to inform future changes in standards of carefuture changes in standards of care

Elders 85 and Older: One among the Elders 85 and Older: One among the fastest growing age groups in the U.S. fastest growing age groups in the U.S.

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SOURCE: SOURCE: Nursing Staff in Hospitals and Nursing Homes: Is it adequate?,Nursing Staff in Hospitals and Nursing Homes: Is it adequate?, 1996; page 33. 1996; page 33.

Acute Hospitals vs. LTCAcute Hospitals vs. LTC

short-term services short-term services dominated by dominated by medical modelmedical model

providers choose + providers choose + deliver servicesdeliver services

high techhigh tech limited family limited family

involvementinvolvement Payor: MedicarePayor: Medicare

long-term health, long-term health, social and housing social and housing servicesservices

providers help with providers help with ADLs +IADLsADLs +IADLs

low techlow tech family equal family equal

partnerspartners Payor: MedicaidPayor: Medicaid

Transitions between LTC and Transitions between LTC and Acute Care HospitalsAcute Care Hospitals

Nature of ProblemsNature of Problems

Poor communicationPoor communication

Negative effects of Negative effects of hospitalizationhospitalization

Inadequate discharge planningInadequate discharge planning

Gaps in care during transfersGaps in care during transfers

ConsequencesConsequences

High rates of acute clinical High rates of acute clinical eventsevents

Serious unmet needsSerious unmet needs

Poor satisfaction with carePoor satisfaction with care

High hospital readmission ratesHigh hospital readmission rates

Clinical Barriers to Addressing Clinical Barriers to Addressing Problems with TransitionsProblems with Transitions

Providers’ knowledge, skills and Providers’ knowledge, skills and resourcesresources

Limited use of palliative careLimited use of palliative care

Dearth of quality performance Dearth of quality performance measuresmeasures

Non-Clinical Barriers to Non-Clinical Barriers to Addressing Problems with Addressing Problems with

TransitionsTransitions

Regulatory challengesRegulatory challenges

Financial constraintsFinancial constraints

Pressures from families and Pressures from families and health care administratorshealth care administrators

The Search for SolutionsThe Search for Solutions

Related Areas of InquiryRelated Areas of Inquiry

Efforts to fully integrate acute and Efforts to fully integrate acute and LTCLTC

Transitional care interventions Transitional care interventions targeting chronically ill elderstargeting chronically ill elders

Innovative care modelsInnovative care models

Lessons from Integration Efforts Lessons from Integration Efforts

Described the unique issues and Described the unique issues and challenges confronting acutely ill, challenges confronting acutely ill, frail eldersfrail elders

Highlighted the benefits of avoiding Highlighted the benefits of avoiding preventable hospitalizationspreventable hospitalizations

Suggested value of:Suggested value of:

– Early identification of acute care Early identification of acute care needsneeds

– Increased access to selected Increased access to selected primary, acute and palliative care primary, acute and palliative care services within LTCservices within LTC

– Flexible funding and benefitsFlexible funding and benefits

Lessons from Integration EffortsLessons from Integration Efforts

Care Models Designed to Avoid Care Models Designed to Avoid Preventable HospitalizationsPreventable Hospitalizations

EvercareEvercare

Hospital at HomeHospital at Home

The Day HospitalThe Day Hospital

Palliative Care Program in LTCPalliative Care Program in LTC

Mrs. Anderson: A Case StudyMrs. Anderson: A Case Study

Lessons Learned from Lessons Learned from Transitional Care InterventionsTransitional Care Interventions

Identified individual and system Identified individual and system barriers to effective transitionsbarriers to effective transitions

Highlighted importance of Highlighted importance of multidimensional strategies targeting multidimensional strategies targeting problems common during “hand-offsproblems common during “hand-offs

Lessons Learned from Lessons Learned from Transitional Care InterventionsTransitional Care Interventions

Suggested value of:Suggested value of:

– Nurse-led, interdisciplinary teamsNurse-led, interdisciplinary teams

– Streamlined care deliveryStreamlined care delivery

– Information systems that span Information systems that span settingssettings

– Quality measures and other Quality measures and other incentivesincentives

Care Models Designed to Care Models Designed to Improve Care TransitionsImprove Care Transitions

Care Transitions “Coaching” Care Transitions “Coaching” InterventionIntervention

Advanced Practice Nurse (APN) Advanced Practice Nurse (APN) Transitional Care ModelTransitional Care Model

Mr. Jenkins: A Case StudyMr. Jenkins: A Case Study

Policy Policy RecommendationsRecommendations

Leutz’s Conceptual Leutz’s Conceptual FrameworkFramework

LinkageLinkage

CoordinationCoordination

Full IntegrationFull Integration

Key AssumptionsKey Assumptions

The financing and delivery of The financing and delivery of acute and LTC will continue to be acute and LTC will continue to be characterized by a patchwork of characterized by a patchwork of public and private services and public and private services and fundingfunding

Key AssumptionsKey Assumptions

There is an adequate evidence base to There is an adequate evidence base to justify:justify:

– increasing access to primary care, increasing access to primary care, management of common conditions and management of common conditions and palliative care within LTC; and,palliative care within LTC; and,

– use of nurse directed interdisciplinary use of nurse directed interdisciplinary teams, guided by evidence-based teams, guided by evidence-based transitional care protocolstransitional care protocols

Proposed Structures, Incentives to Proposed Structures, Incentives to Enhance Coordination of Care DeliveryEnhance Coordination of Care Delivery

Design, testing and integration of Design, testing and integration of quality measures and monitoring quality measures and monitoring systemssystems

Development of information systems Development of information systems that span settingsthat span settings

Proposed Structures, Incentives to Proposed Structures, Incentives to Enhance Coordination of Care Delivery Enhance Coordination of Care Delivery

Preparation of current + future Preparation of current + future providers emphasizing…providers emphasizing…– geriatricsgeriatrics– palliative carepalliative care– interdisciplinary team careinterdisciplinary team care– advance care planningadvance care planning– transitional care/care coordinationtransitional care/care coordination

Dissemination of “best practices”Dissemination of “best practices”

Proposed Structures, Incentives to Proposed Structures, Incentives to Improve Coordination of Care BenefitsImprove Coordination of Care Benefits

Create incentives to foster adoption of Create incentives to foster adoption of evidence-based models of on-site evidence-based models of on-site primary or palliative care and primary or palliative care and transitional care transitional care

Modify Medicare’s Hospice benefit to Modify Medicare’s Hospice benefit to minimize barriers for use within LTCminimize barriers for use within LTC

Research AgendaResearch Agenda Describe impact of transitions Describe impact of transitions

Identify most effective and efficient Identify most effective and efficient models to:models to:

– avoid preventable hospitalizationsavoid preventable hospitalizations

– improve care coordination, continuity improve care coordination, continuity and transitions and transitions

Define financial and other incentives Define financial and other incentives to optimize quality and cost to optimize quality and cost outcomesoutcomes