1. Bridging Hospital to Home The Bridge ModelAn Innovative Social Work Approach to Transitional Care American Society On Aging Thursday April 28th, 2011 San Francisco, CA
3. Agenda ITCC, Transitional Care The Bridge Model Building Relationships: Hospital & Community Based Organizations Aging Resource Centers Business agreements/contracts Cultural Competency Research, Evaluation, and Data Q & A
4. Who we areโฆ the Illinois Transitional Care Consortium ITCC was formed to more effectively address needs of older adults transitioning from the hospital to the community by linking hospital based services with the aging network through intensive care coordination.
5. ITCC members Community-based organizations Aging Care Connections Shawnee Alliance for Seniors Solutions for Care Hospitals Rush University Medical Center MacNeal Hospital Adventist LaGrange Memorial Hospital Herrin Hospital Memorial Hospital of Carbonda;e Research, Evaluation & Policy University of Illinois at Chicago, School of Public Health Health & Medicine Policy Research Group
6.
7. 19% of patients experience an adverse event within 3 weeks of hospital discharge
8.
9. The United States Health Care System Medicare Medicare Advantage Plans Private Insurance Co-Pays Deductibles In-Network Providers Rehabilitation Skilled Nursing Facilities In-Patient Hospital Stays Community-based Organizations Primary Care Physicians Specialist doctors Nurses Social Workers Preventive Care Long-term care Family Caregivers Medicaid Home care physicians Medical homes Accountable care organizations Direct-care workers: home health, home care
10. Perfect Storm Increasingly aged population Greater functionality with chronic conditions Living longer, yet sicker Bottom Line: people need better care and we need to offer high quality care while containing costs Photo courtesy of โstriking_photographyโ on Flickr.com
11. Transitional Care Coordinating care from one care setting to another Hospital to home Hospital to nursing home Nursing home to home Home to nursing home Within hospital or nursing home Insurance transitions PCP transition Caregiver moving in or out
12. Advisory Board Jean Bohnhoff - Executive Director, Effingham County Committee on Aging Thomas Cornwell - Medical Director, HomeCare Physicians Bob Clapp - Senior Vice President, Hospital Affairs, Rush University Medical Center Jim Durkan - President/CEO, Community Memorial Foundation Karen Freda - Executive Director, Illinois Council of Case Coordination Units Michael Gelder - Senior Health Policy Advisory to Illinois Governor Pat Quinn Michael Koronkowski โ Pharmacist and Geriatrics Professor, University of Illinois at Chicago Patricia Merryweather - Vice President, Illinois Hospital Association Jonathan Lavin - Executive Director, Age Options, Suburban Cook County Area Agency on Aging Marta Pereyra - Coalition of Limited English-Speaking Elderly Cheryl Schraeder - Director of Policy & Practice Initiatives, Institute for Healthcare Innovation, University of Illinois at Chicago College of Nursing Patricia Volland - Senior Vice President, Strategy & Business Development, The New York Academy of Medicine Rebecca Zuber - President, Rebecca Zuber, Inc.
20. The Bridge Model Overview of Components Social-worker Based: Bridge Care Coordinator Interdisciplinary Teams Hospital ๏ Home Patient Focused, Community-Specific The Aging Resource Center Urban, Suburban, and Rural applicability
30. If non-hospital staff, requires access to the EMRReview of the electronic medical record, meeting with an interdisciplinary pre-discharge and fast tracking community services.
35. Building off of Aging Network Conducting Choices for Care Assessments and CCC Assessments Setting up CCP Interim Services and Interim Home Delivered Meals Providing and referring families for Caregiver Support Services and Respite Conducting Benefits Check-Ups Providing Information & Assistance to Patients and their families on site (i.e. Medicaid, Food Stamps, Circuit Breaker, Tax Freezes, Medicare Part D, Home Modification, FSS)
37. Bridge Care Coordinators Why Social Workers? Systems Theory Biopsychosocial framework Psychosocial determinants of health http://early-childhood-resources.com/2010/05/reflection
39. Psychosocial Issues Social isolation Depression Difficulty coping with change Financial stressors Language barriers Health literacy barriers Older generations taught to be โgood patientsโ 40-50% of readmissions linked to psychosocial issues and lack of community resources
40. Calculating the Cost What is the REAL cost? Staff allocation Overhead Training Case load efficiency http://www.boston.com/ae/theater_arts/exhibitionist/2007/06/salaries_of_sym.html
41. Sustainability Canโt do good without doing well Whoโs money are you saving? Who is your audience? Business case options Readmissions Higher yield patients Patient Satisfaction The โ3026 RFPโ Grants http://www.thinkgeek.com/gadgets/tools/a396/
44. The Role of the ARC Symbol of hospital-community collaboration Greater ability to interface with the community Promotes the notion of โsystemsโ approach to discharge planning. Maximizes the opportunity for a servable moment.
45.
46.
47. Community-Hospital Partnerships Aging Care Connections (CCU - Suburban Chicago) Adventist LaGrange Memorial Hospital Shawnee Alliance for Seniors (CCU โ Rural, downstate Illinois) Memorial Hospital of Carbondale Herrin Hospital Solutions for Care (CCU โ Suburban Chicago) Mac Neal Hospital Central West (CMU โ Chicago) Rush University Medical Center
50. Establishing a Connection to the Aging Network Many older adults seen at the hospital by Bridge Care Coordinators have yet to get connected to resources available through their community 54% of ARC clients had no previous interaction with their local Care Coordination Unit (N=399) Bridge Care Coordinators connect older adults to the aging network 49% of ARC clients utilized services offered through their local Care Coordination Unit for the first time after their encounter with a Bridge Care Coordinator (N=399)
51. Establishing an ARC Time frames for developing the ARC Outreach to hospital Through existing programs or contracts already established Begin contacting individuals at the hospital who are supportive of the model.
52. Establishing a Partnership Evaluate Potential Partners Make the โASKโ Identify what you are asking the partner to contribute Establish the basic structure of the partnership prior to launching the project Keep parameters loose enough to allow for growth development An MoU at a minimum should be in place prior to the start date of the project
53. Establishing a Partnership Cont. Legal agreements should be created broadly defining the service provision, the recipient of the service and duties of each partner in the relationship including: Purpose of the program Responsibilities of both parties Individual responsibilities of the partners Financial liabilities Confidentiality and data sharing Termination Annually review agreement! http://www.fortklock.com/signatures.htm
54.
55. Cultural Competency Continued Assess clients and caregivers in their language and coordinate and link them to services BCC are able to participate in the important aspects of culture, value and belief systems All printed material are in Spanish including Consent forms
56. Cultural Competency Continued Support Groups for Spanish Speaking Caregivers Chronic Disease Self Management Classes taught in Spanish -Take Charge of your Health Outreach Program to target cultural linguistically isolated individuals in the communities
57. Susan Altfeld, University of Illinois at Chicago โ School of Public Health Research & Evaluation
58. The Bridge Model Evidence Base The Bridge Model is an adaptation of the Enhanced Discharge Planning Program (EDPP) EDPP is an evidence-based model developed and evaluated with a randomized-controlled trial at Rush University Medical Center (ITCC partner) Bridge implements the evidence based components of EDPP and best practices developed by ITCC partner sites Bridge is a hospital and community partnership
59. Rush University Medical Center Study Randomized controlled trial of 720 patients All patients older than 65 with multiple medical conditions Half received follow-up intervention, half were in the โusual careโ group Qualitative study Interviews with intervention social workers
60. What did we learn from the Rush study? 83% of the patients in the intervention group had problems identified by the social worker during the assessment at 2 days post-discharge For ยพ of these individuals, problems did not emerge until after discharge โ โsurprisesโ
61. Needs Identified at 2 day post discharge contact* - Rush study *select variables
64. Post-Intervention Contact- Rush RCT Almost 1/3 of patients (29.3%) contacted the Bridge social worker for additional services or information after the case was closed 49
65. Evaluation of the Bridge Model Important variables from our previous work and other evidence based care transitions interventions Patient characteristics Health status Patient stress Caregiver stress Understanding of responsibilities for managing health Medical follow up Hospital readmissions Mortality Satisfaction
66. Evaluation data collection- ITCC Bridge Intake assessment 2 day post discharge assessment 30 day follow up assessment Satisfaction survey Both โpatientโ and โcaregiverโ versions of the assessment surveys Telephone Email /telephone satisfaction surveys
67. Evaluation of the Bridge Model Who are our participants? 1766 participants at 5 sites across Illinois from May 2010-March 2011
68. Bridge client demographics preliminary data 5/10-3/11 Male 39.7% 75+ 52.2% Frail 64.8% Living alone 41.5% Social need 87.2% Non-English speaking 8.4% Minority/โnon-Whiteโ 35.7% At risk for nursing home placement 37.6%
69. 2-day post-discharge assessment Older adult clientโs health At this time, how is your health?/ how is (Mr./Ms. patient last name)'s health? (N=117) Excellent 4.3% Very good 15.4% Good 47.0% Fair 19.7% Poor 11.1%
70. 2 day post discharge assessment Older adult (patient) stress Since I left the hospital, managing my needs has been stressful for me/ Since he/she left the hospital, managing his/her needs has been stressful for him/her (N=109) Yes 50.5% No 49.5%
71. 2 day post discharge assessment Caregiver stress Since I left the hospital managing my needs has been stressful for my family or other caregivers/ Since he/she left the hospital managing his/her needs has been stressful for you. (N= 102) Yes 57.8% No 42.2%
72. 2 day post discharge assessment Understand medications I understand the purpose of each of my medications and how to take each of them (N= 118) Yes 98.3% No 2.7%
73. 2 day post discharge assessment Understand symptoms/โred flagsโ I understand what symptoms I need to watch out for and who to call if they occur(N= 118) Yes 94.9% No 5.1%
74. 2 day post discharge assessment Problems/โSurprisesโ Are things more difficult than you expected since leaving the hospital, less difficult or about what you expected? (N=110) More difficult 30.0% Less difficult 10.9% As expected 59.1%
76. 30 day outcomes adverse events Rehospitalized within 30 days of d/c- 8.9% Mortality - 2.0%
77. Satisfaction survey Decision making The assistance or information you received from the Bridge Program helped you (or your loved one) make decisions about your care Strongly agree 40.1% Agree 59.1% Disagree 0% Strongly Disagree 0%
78. Satisfaction survey Links to community services The assistance or information you received from the Bridge Program helped you (or your loved one)ย connect to services and resources. Strongly agree 42.1% Agree 57.9% Disagree 0% Strongly Disagree 0%
79. Satisfaction survey Patient stress Bridge Program helped to makeย the hospital discharge experience less stressful for you (the patient). Strongly agree 39.1% Agree 52.2% Disagree 4.3% Strongly Disagree 4.3%
80. Satisfaction survey Caregiver stress The Bridge program helped to makeย the hospital discharge experience less stressful forย family or other loved ones Strongly agree 31.8% Agree 59.1% Disagree 4.5% Strongly Disagree 4.5%
81. Satisfaction survey Bridge Care Coordinator - knowledge The Bridge social workers were knowledgeable. Strongly agree 47.8% Agree 47.8% Disagree 4.3% Strongly Disagree 0%
82. Satisfaction survey Satisfaction I would recommend this program to others Strongly agree 41.0% Agree 59.0% Disagree 0% Strongly Disagree 0%
83. Satisfaction Survey - Quotes Satisfaction Unmet needs/anything you would change/what did you like about the Bridge Program? โI like everything about the Bridge Program.โ โYou are providing a great service.โ โI would like it to be much more advertised for everyone wherever they live.โ โIt would be nice for everyone to receive the services like my father.โ โI cannot think what else the social worker could have done additionally since she was very helpful throughout โฆ.โ
85. Contact Information Susan Altfeld (saltfeld@uic.edu) Esther Izaguirre (eizaguirre@solutionsforcare.org) Kristen Pavle (kpavle@hmprg.org) Walter Rosenberg (walter_rosenberg@rush.edu) Ilana Shure (ishure@agingcareconnections.org)
Editor's Notes
ITCC is a result of collective experience in the field of aging, and visionary leadership
Kristen โ Iโve mentioning this a lot on presentations โ when you get to the 40-50% make it clear that it does not imply that social workers can only prevent 40-50% of readmissions because social workers can intervene on numerous medical issues by connecting the right silos of care together. Things like medication regimen or discharge instruction confusion, etc.
ilana
Pre-discharge: referrals in one of a few ways (emr, walk-ins, d/c planners), assessment in one of a few ways (emr, interdisciplinary team, d/c-planner, family/patient)
Post-discharge: 48 hr. assessment and intervention (in-depth piece, follow up on important non-resource issues like pcp f/u, regimen understanding, caregiver burden, unmet needs, home health, etc. )
Key word: advocacy
Bring up own experience when possible (tell them a little story)โgood patientโ is a big reason why the situation changes post discharge. Weโre all taught to respect doctors and we nod and say yes, but do we really understand? So even with good coaching, however (coleman, naylor), things will go wrong at d/c
Note that not all participants live in areaโฆthis is just a snapshot from one CCU
Building on what we have learned
Not a discharge planning issue but UNANTICIPATED SURPRISES!
Integrating intervention and data collection to minimize burden for pts and staff
Data on a much smaller sample --- designing data measures, irb approvals, hospital approvals, coordination
(point out on slide the name of the variable ---and then how the question was asked)
Marketing!
Walter and ilanaTell them that more details on BCCs and data is still coming
