Transitional Care: A Transitional Care: A Focal Point for Health Focal Point for Health Care ReformCare Reform

Mary D. Naylor, PhD, RNMary D. Naylor, PhD, RNMarian S. Ware Professor in GerontologyMarian S. Ware Professor in GerontologyDirector, NewCourtland Center for Transitions and Director, NewCourtland Center for Transitions and HealthHealthUniversity of Pennsylvania, School of NursingUniversity of Pennsylvania, School of Nursing July 11, 2008

Transitional Care (TC)Transitional Care (TC)

Transitional careTransitional care – range of time – range of time limited services and environments limited services and environments designed to ensure health care designed to ensure health care continuity and avoid preventable continuity and avoid preventable poor outcomes among at risk poor outcomes among at risk populations as they move from populations as they move from one level of care to another, one level of care to another, among multiple providers and/or among multiple providers and/or across settings. across settings.

Acute Care Episode: Acute Care Episode: Context for Transitional CareContext for Transitional Care

Adapted from the National Quality Forum committee on Measurement Framework: Evaluating Efficiency across Episodes of Care

The Case for Transitional The Case for Transitional CareCare

• High rates of medical errors High rates of medical errors

• Serious unmet needsSerious unmet needs

• Poor satisfaction with carePoor satisfaction with care

• High rates of preventable High rates of preventable readmissionsreadmissions

• Tremendous human and cost burdenTremendous human and cost burden

ScreeninScreeningg

CollaboratingCollaborating

Quality Cost Quality Cost Transitional Care Model (TCM)Transitional Care Model (TCM)

Engaging Engaging Elder/CaregiverElder/Caregiver

Managing Managing SymptomsSymptoms

Educating/Educating/Promoting Promoting

Self-ManagementSelf-Management

Assuring Assuring ContinuitContinuit

y y

CoordinatinCoordinatingg

CareCare

MaintainingMaintainingRelationshipRelationship

Unique FeaturesUnique Features

Care is delivered and Care is delivered and coordinatedcoordinated……by same advanced practice by same advanced practice nursenurse

……across settingsacross settings

……7 days per week 7 days per week

……using evidence-based using evidence-based protocolprotocol

……with focus on long term with focus on long term outcomesoutcomes

Findings from Randomized Findings from Randomized Clinical TrialsClinical Trials

Funding: National Institutes of Health, National Institute of Nursing Funding: National Institutes of Health, National Institute of Nursing Research, National Institute on Aging (1990-2010)Research, National Institute on Aging (1990-2010)

Barriers to AdoptionBarriers to Adoption

• Organization of current Organization of current system of caresystem of care

• Lack of quality and financial Lack of quality and financial incentivesincentives

• Culture of careCulture of care

Translating TCM into Translating TCM into PracticePractice

Penn research team formed Penn research team formed partnerships with Aetna partnerships with Aetna Corporation and Kaiser Permanente Corporation and Kaiser Permanente to test “real world” applications of to test “real world” applications of research-based model of care for research-based model of care for high risk elders.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

Progress to Date & Next Progress to Date & Next Steps Steps

• TCM proposed for expansion as TCM proposed for expansion as part of Aetna’s 2009 Strategic Planpart of Aetna’s 2009 Strategic Plan

• Kaiser enrollment complete; data Kaiser enrollment complete; data collection ongoingcollection ongoing

• University of Pennsylvania Health University of Pennsylvania Health System has adopted TCM; Blue System has adopted TCM; Blue Cross will reimburse for its Cross will reimburse for its membersmembers

Next Steps for Penn TeamNext Steps for Penn Team

• Continue efforts to promote Continue efforts to promote widespread adoption of TCMwidespread adoption of TCM

• Use findings to promote needed Use findings to promote needed policy changespolicy changes

• Continue to build the scienceContinue to build the science

RWJF Interdisciplinary Nursing RWJF Interdisciplinary Nursing Quality Research Initiative Quality Research Initiative

(INQRI)(INQRI)

Purpose: Purpose: To generate, disseminate and translate research that describes how nurses contribute to and can improve the quality and safety of patient care.

INQRI Supports INQRI Supports

Interdisciplinary Teams toInterdisciplinary Teams to::

• Develop + test quality measures Develop + test quality measures • Establish causal linkages Establish causal linkages

between nursing care and safety, between nursing care and safety, quality and cost outcomesquality and cost outcomes

• Define nursing’s contributions to Define nursing’s contributions to health systems’ performance health systems’ performance

INQRI Program ContactsINQRI Program Contacts

Mary Naylor, Program DirectorMary Naylor, Program Director

Mark Pauly, Program Co-DirectorMark Pauly, Program Co-Director

Lori Melichar, RWJF Senior Lori Melichar, RWJF Senior Program OfficerProgram Officer

Visit our website at www.INQRI.org

Thank You!Thank You!