Post on 23-Dec-2015
transcript
Rush Enhanced Discharge Planning Program: A Model for Interdisciplinary Care Coordination
Robyn L. Golden, LCSWDirector, Older Adult ProgramsRush University Medical Center
Care Coordination Defined
• Client-centered• Assessment-based • Interdisciplinary • Integrating health care and social support
services• Care coordinator manages and monitors an
individual’s needs and preferences • Based on a comprehensive care plan
Rush EDPP: A Model for Care Coordination
• Rush Enhanced Discharge Planning Program (EDPP)– Short-term telephonic care coordination– Provided by Master’s-prepared social workers– From a biopsychosocial perspective– For older adults at risk for adverse events after an
inpatient hospitalization
© Rush University Medical Center, 2009
Rush University Medical Center
– Urban– Academic Medical Center– 676 staffed beds (72 rehab)– 27 patient care units– 30,012 admissions– 5.3 ALOS
4
Rush is located minutes from downtown Chicago in the West
Side Medical District
Primary Goals
EDPP operates with three guiding tasks to reach the goal of preventing avoidable adverse events post-discharge:1. Ensuring patients receive appropriate services in their home
post-discharge2. Connecting patients to their physician for follow-up
appointments3. Supporting caregivers to reduce stress and burden
© Rush University Medical Center, 2009
The Team
• EDPP Social Worker serves as primary care coordinator– Manages care coordination tasks– Facilitating inclusion of other team members
• Additional team members vary by client– Inpatient case manager and attending physician– Primary care physician– Pharmacist, therapists, other medical providers– Home health care provider– Community service providers
© Rush University Medical Center, 2009
Target Population
Must meet all the following criteria: Age > 65Returning home after discharge>7 medications prescribed Must also meet one additional criterion: Lives alone Without a source of emotional supportWithout a support system for care in placeDischarged with a service referral High falls riskInpatient hospitalization in past 12 monthsIdentified in-depth psychosocial needHigh risk medication prescribed
© Rush University Medical Center, 2009
Step 1: Referral
• Eligible patients referred through Rush’s electronic medical record, Epic
• Eligibility criteria based upon:– Review of literature– Trends observed during
program’s pilot– Feedback from Rush case
managers
© Rush University Medical Center, 2009
Step 2: Pre-assessment
• Upon receiving an electronic referral, the EDPP Social Worker:– Reviews the patient record for relevant information– Investigates previous hospitalizations– Identifies potential problem areas requiring in-depth
assessment– Generates a list of questions about potential problem
areas– Seeks information and clarification from inpatient
providers
© Rush University Medical Center, 2009
Step 3: Assessment
• EDPP Social Worker contacts the patient and/or caregiver by telephone within 2 business days of discharge– Basic assessment for all
patients– Targeted assessment of specific
problem areas
© Rush University Medical Center, 2009
Step 4: Intervention
EDPP Social Worker performs telephonic assessment
EDPP SW provides support, education, and information
Is follow-up with providers, caregivers, or
resources necessary?
Yes: Can patient or caregiver
contact necessary parties?
No: EDPP SW contacts parties on the patient’s behalf
Yes: EDPP SW provides contact information for parties to patient/caregiver
EDPP SW reconnects with patient
Yes: Patient and/or caregiver reconnects with EDPP SW
Does patient and/or
caregiver need more info or
support?
No: Provide local aging resource center’s contact information for future consult
EDPP Social Worker Intervenes until identified issues are resolved and situation is stable
© Rush University Medical Center, 2009
Step 4: Intervention
• The Patient’s Role– Patients and caregivers empowered to take an active role in
their care with the EDPP’s Social Worker’s support– Education on health care systems and self-management
provided– EDPP Social Worker performs coordination tasks on patient’s
behalf as necessary• Recognizing patients may be unable to do everything due to health
literacy and functional limitations
• The Team’s Role– Hospital and community team members engaged based upon
post-discharge issues– EDPP Social Worker facilitates team involvement© Rush University Medical Center,
2009
Impact
• EDPP’s impact measured in a randomized controlled trial– June 2009 to March 2010– n=740– Referrals generated through electronic
medical record at point of discharge– Participants randomized to intervention
and usual care groups
© Rush University Medical Center, 2009
Level of Intensity
Mean Std Dev Range
Duration of Intervention (Days) 5.8 11.3 1 72
Total calls 5.4 6.3 0 44
© Rush University Medical Center, 2009
• More than one call was needed for 254 of the 360 (70.6%) patients in this study– These patients had issues that needed intervention and
could not be resolved in the initial contact
Impact
• Post-discharge issues:– 300 of 360 (83.3%) of patients
had issues identified by an EDPP clinician upon discharge
– For 219 of 300 (73%) of these individuals, problems did not emerge until post-discharge
© Rush University Medical Center, 2009
Outcomes
© Rush University Medical Center, 2009
• Improvements in the Intervention Group from baseline to follow-up (p<.05)– Increased understanding of the purpose for taking their
prescribed medications• Baseline: 89.0%, Follow-Up: 95.3%, p=.002
– Decreased patient stress managing their health care needs• Baseline: 38.8%, Follow-up: 31.8%, p=.037
– Decreased caregiver stress managing patients’ health needs
• Baseline: 43.9%, Follow-Up: 32.2%, p=.003
Outcomes
© Rush University Medical Center, 2009
• The Intervention Group showed better outcomes at follow-up when compared to the Usual Care Group– Greater understanding of their responsibilities for
managing their health• Intervention Group: 93.3%• Usual Care Group: 87.9%• p=.011
– Better utilization of physician services post-discharge
Utilization
• Patients receiving the EDPP intervention were significantly more likely to:– Communicate with their PCP within 30 days of discharge– Schedule and attend their post-discharge appointments
(χ²=9.88, p=.001)
Patients scheduling and attending follow-up appointmentsIntervention Usual Care
Yes 239 (74.9%) 206 (57.4%)No 80 (25.1%) 153 (42.6%)
© Rush University Medical Center, 2009
Post-Intervention Contact
• 29.3% of intervention patients contacted the EDPP clinician for additional services or information after the case was closed– Suggests EDPP provides consistent point of access to
health care information– EDPP seen as trusted source of information and support
© Rush University Medical Center, 2009
Utilization
Readmissions to Rush University Medical CenterSince Discharge Intervention Usual Care p-value30 days 13.6% 16.1% .20160 days 20.8% 27.5% .031*90 days 26.4% 34.2% .018*120 days 30.8% 36.5% .078180 days 36.1% 42.5% .068
© Rush University Medical Center, 2009
*significant at the p<.05 level
Mortality at 30 days, p=0.03Overall (n=740) Intervention (n=360) Usual Care (n=380)
Alive 712 (96.2) 352 (97.8) 360 (94.7)
Dead 28 (3.8) 8 (2.2) 20 (5.3)
Systemic Impact
• Since concluding the research, EDPP has been integrated into pilots and projects that highlight the need for an interdisciplinary team– Interdisciplinary Care Model Pilot– Home Health Pilot– Illinois Transitional Care Consortium– Patient Centered Medical Home Pilot
© Rush University Medical Center, 2009
Implementation Issues
• Five key implementation questions must be answered for the program to be successful1. Who will perform the intervention?2. Who will manage the model’s administrative and
implementation tasks?3. How will patients be identified and referred to the
program?4. How will data be obtained, managed, and reported?5. How will hospital support be established for long-term
sustainability?
© Rush University Medical Center, 2009
EDPP, In Conclusion
• EDPP is an exciting and innovative model for providing transitional care– Addresses non-medical aspects of transition– Well-suited for integration into other initiatives– Further research in progress will strengthen evidence base,
understanding of model
© Rush University Medical Center, 2009
Thanks to…
• EDPP would not be possible without the support of:– Community Memorial Foundation– Sanofi Aventis– New York Academy of Medicine– Harry and Jeanette Weinberg Foundation– Michael Reese Health Trust– U.S. Administration on Aging
© Rush University Medical Center, 2009