bridge model asa 2012
TRANSCRIPT
The Bridge ModelAn Innovative Social Work Model of Transitional Care
Aging in America ConferenceWashington, D.C. – March 29th, 2012
AgendaI. Welcome and IntroductionsII. Bridge Model Overview and ProcessIII. Research and EvaluationIV. Unique Components of the Bridge ModelV. Rural ImplementationVI. Policy and Health Systems Implications
The Illinois Transitional Care Consortium 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 Carbondale
Research, Evaluation & Policy University of Illinois at Chicago, School of Public Health Health & Medicine Policy Research Group
Bridge Model Overview & Process
Walter Rosenberg, Rush University Medical Center – Health & Aging
Basic Definitions What is care
coordination? What is transitional
care? What is social work?
Core competencies Engagement and
assessment Resource linkage Self-management
support and education
Counseling Team interaction Care coordination
Why Social Work? Why do readmissions take place?
Root cause analysis Medical Psychosocial Existing resources or redundant resources?
Geriatric Interdisciplinary Team Training (GITT) Rush post-graduate course “The Glue”
Reintroduction to healthcare Putting social work back on the map
Root Cause Analysis Hospital-level
Chart reviews Interdisciplinary focus groups Individual interviews
Community-level Identify community providers Interdisciplinary focus groups Individual interviews
Bird’s eye viewPre-Discharge
• Referral• Assessme
nt• Informatio
n gathering
• Community resources
Post-Discharge
• Assessment
• Connection to providers
• Psychosocial support
30-day follow-up
• Confirm long-term support structure
• Collect data
• Decreased readmissions• Decreased mortality• Increased physician follow-up• Increased understanding of medications and discharge plan of care• Decreased patient and caregiver stress
Quick information Telephonic 5-6 calls over a period of 5-6 days Calls made to:
Client/caregiver Primary care Hospital of origin Pharmacy Community-based organizations
Target Population Must have all of the below
60+ Chronic condition Previous hospitalization
within 6 months Must have at least one of
the below Discharged with home health Living alone Discharged to a skilled
nursing facility Current practice
Expanded demand and realistic pressures
Assessment domains Common Problem
Areas Transition/Discharge
Plan Home Health Follow-up Medical Care Medication
Management Self-Management Psychosocial
Pre-discharge
Hospital Admissio
n
Referral(Target
Population)
Pre-Discharg
e Assessment and
Intervention
The participant enters the hospital with more than an
illness.
•Caregiver•Family•SES•Race•Gender•Ethnicity•Religion•Mental Health•Personal Values and Beliefs
Referrals can originate from an electronic medical record, a discharge planner, the patient or a family member.
•Risk screen built in to the EMR•If non-hospital staff, requires access to the EMR•Balance between consistency and flexibility
Preparation for discharge must
include as broad a picture of the
patient/consumer as possible
•Discharge plan of care•Community resources•Systemic challenges•Community physicians•Interdisciplinary team•Essential information
Post-discharge
Back Home
Post-Discharg
e Assessment and
Intervention
30-day Follow-up
Walking through the house doors,
one walks back into their real life
•Caregiver•Family•SES•Race•Gender•Ethnicity•Religion•Mental Health•Personal Values and Beliefs
The map is not the territory. What
changed? How can we help?
•Understanding of discharge plan of care•Understanding of medications•Follow-up on community resources•Ensure physician follow-up•Caregiver support•Emotional support
Longer term involvement to
ensure the patient/consumer
remains connected
•Still connected to necessary resources?•Quality assurance•Emotional support (30% re-contacts post-intervention)
A Case Example Mrs. Harrison– Widowed– 75 years old– Has diabetes and COPD
Admitted through the ED after a fall– Hospitalized for 5 days– Discharged with home health care– 10 medications prescribed
Mrs. Harrison’s two children can’t agree how to best manage
their mother’s medical needs.
Mrs. Harrison at HomeCommunity PCP
doesn’t know Mrs. Harrison was
admitted to the hospital.
Mrs. Harrison’s primary caregiver is
overwhelmed and has to return to work.The Home Health
Care Agency doesn’t arrive on time.
Mrs. Harrison has no transportation to her
follow-up medical appointments.
Mrs. Harrison doesn’t know which
medications to resume and which to stop taking at home.
Mrs. Harrison’s Community Services
are delayed
Mrs. Harrison has questions about her
medical bill and doesn’t know what her insurance will
cover.
Mrs. Harrison can’t afford her
medications anyway.
Mrs. Harrison is having difficulty coping with her
mobility changes.
Mrs. Harrison is feeling depressed
because she can’t get around anymore like
she used to.
Mrs. Harrison is feeling isolated now
that she’s homebound.
Mrs. Harrison is afraid she will fall again and have to return to the
hospital.
Is this the worst case scenario,
or is it a typical
transition?
Mrs. Harrison’s two children can’t agree how to best manage
their mother’s medical needs.
Community PCP doesn’t know Mrs.
Harrison was admitted to the
hospital.
Mrs. Harrison’s primary caregiver is
overwhelmed and has to return to work.The Home Health
Care Agency doesn’t arrive on time.
Mrs. Harrison has no transportation to her
follow-up medical appointments.
Mrs. Harrison doesn’t know which
medications to resume and which to stop taking at home.
Community Services were delayed
Mrs. Harrison has questions about her
medical bill and doesn’t know what her insurance will
cover.
Mrs. Harrison can’t afford her
medications anyway.
Mrs. Harrison is having difficulty coping with her
mobility changes.
Mrs. Harrison is feeling depressed
because she can’t get around anymore like
she used to.
Mrs. Harrison is feeling isolated now
that she’s homebound.
Mrs. Harrison is afraid she will fall again and have to return to the
hospital.
Contact Community PCP to inform of Mrs. Harrison’s hospital
stay.
Support caregiver and listen to concerns. Link to community
resources.
Communicate with children to plan for
immediate care needs. Refer to care
management.
Call Home Health Care Agency to
troubleshoot scheduling issues.
Facilitate communication with
pharmacy, prescribing physician, and home
health nurse.
Facilitate home evaluation by Home Health Care Agency.
Communicate with CCU case manager to
ensure prompt resumption or start of
services
Connect to pharmacy assistance program.
Screen for supportive mental health
programs or ongoing counseling services.
Link Mrs. Harrison to medical
transportation resources and assist
in scheduling services.
Refer Mrs. Harrison to patient access
immediately and connect to Senior Health Insurance Program (SHIP)
Counselor
Work with Home Health Care Agency
and physician to identify therapy
needs.
Refer and connect to local friendly visiting
program.
How does Bridge help?Mrs. Harrisonat Home
Research & Evaluation
Susan Altfeld, University of Illinois at Chicago – School of Public Health
Preliminary data As of December 2011 Midway through project DO NOT QUOTE OR CITE WITHOUT
PERMISSION OF ILLINOIS DEPARTMENT ON AGING, ILLINOIS TRANSITIONAL CARE CONSORTIUM AND SUSAN ALTFELD
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 Illinois Department on Aging and AgeOptions
partnership for Community Based Care Transitions through Administration on Aging
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
Evaluation data collection - ITCC Bridge Intake assessment 2 day post discharge assessment 30 day follow up assessment Satisfaction survey
Both “patient” and “caregiver” versions of the assessment surveys Telephone Email /telephone satisfaction surveys
Readmissions and mortality data from Medicare through the Quality Improvement Organization in Illinois
Evaluation of the Bridge Model Who are our participants?
3090 participants at 5 sites across Illinois May 2010-December 2011
Bridge client demographics Preliminary data May 2010-December 2011 Research sample (N=519)
Male 29.7%75+ 63.5%Living alone 44.7%Non-English speaking 12.3%Minority/”non-White” 29.1%
2-day post-discharge assessment Older adult client’s health
At this time, how is your health?/ how is (Mr./Ms. patient last name)'s health?)
Excellent 2.2%Very good 18.3%Good 46.8%Fair 26.2%Poor 6.4%
2-day post-discharge assessment Older adult (patient) stress
“Since I left the hospital, managing my needs has been stressful for me”
34.4%
2-day post-discharge assessment Caregiver stress
“Since (older adult patient) left the hospital, has managing his/her needs been stressful for you?”
52.2%
2-day post discharge assessment Understand medications
“I understand the purpose of each of my medications and how to take each of them”
95.5%
2-day post discharge assessment Understand symptoms/”red flags”
“I understand what symptoms I need to watch out for”
95.5%
2-day post discharge assessment Cue to action
“I understand who to call if these symptoms occur”
98.0%
2-day post discharge assessment Problems/“Surprises”
“Are things more difficult than you expected since leaving the hospital, less difficult or about what you expected?”
More difficult 23.5%Less difficult 12.1%As expected 64.4%
30-day outcomes patient follow up/adherence
Physician visit within 30 days of discharge
84.7%
30-day outcomes adverse events
Mortality
1.7%
30-day outcomes adverse events
Readmissions
Awaiting report
30-day outcomes adverse events
Nursing home placement
3.0%
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.”
84.7%
Satisfaction survey Links to community services
“The assistance or information you received from the Bridge Program helped you (or your loved one) connect to services and resources.”
77.9%
Satisfaction survey Patient stress
“The Bridge Program helped to make the hospital discharge experience less stressful for you/ (the patient).”
90.9%
Satisfaction survey Caregiver stress
“The Bridge program helped to make the hospital discharge experience less stressful for family or other loved ones.”
97.8%
Satisfaction survey Satisfaction
“I would recommend this program to others.”
89.5%
Satisfaction Survey - QuotesSatisfactionUnmet needs/anything you would change/what did you like about the Bridge Program?
“I like everything about the Bridge Program.”
“You are providing a great service.”
“I would like it to be much more advertised for everyone wherever they live.”
“It would be nice for everyone to receive the services like my father.”
“I cannot think what else the social worker could have done additionally since she was very helpful throughout ….”
Unique Components of the Bridge Model
Ilana Shure, Aging Care Connections – Aging Resource Center
Unique Components of the Bridge Model Social work model Builds off of the aging network Bridge requires a true partnership between
the community-based organization and the hospital The community-based organization is in the
leadership role
Bridge Care Coordinator Qualifications Master’s in social work Expertise in geriatric field Strong clinical and advocacy skills Experience in both community and hospital
settings Knowledge of state, federal and community
resources
Aging NetworkAoA •Administration on Aging & Older Americans Act
SUA •State Unit on Aging
AAA •Area Agency on Aging
CCU •Care Coordination Unit (Unique to Illinois)
AAAs are Your Community Service Experts
Medicaid Waiver
Program
•Adult Day Care•Case Management•Emergency Home Response•In-home Services
Older Americans Act
Services
•Home Delivered Meals•Caregiver Support Services•Transportation•Information and AssistancePrivate
and /or Volunteer Services
•Counseling•Ethnic Resources•Community-specific and local
Area Agencies on Aging
Connecting to Community-based Services
Assessment of need
Set-up services based on assessment (eligibility and application); including caregiver support
Benefits Check-Ups (receiving all eligible benefits)
Provide information & assistance for older people and their families
Aging Network – a critical tool in the Bridge toolkit Identifying older adults in the hospital who are
at-risk for potential adverse events post-discharge
Connecting the hospital and the older adult to the existing Aging Network (home and community-based resources)
Reduce the risk of adverse events reduce re-hospitalizations
Complementing the Aging Network The Aging Network provides an important
safety net. Here are other areas critical to successful transitions addressed by Bridge: Transition/Discharge Plan complications Home Health – systemic and client-level issues Follow-up Medical Care Medication Management Self-Management Psychosocial complications
Who are Your Transitional Care Partners?
AAA
Hospital
Primary Care
Physician
Home Health
Community Based Agencies
Caregivers
Skilled Nursing Facility
Pharmacy
Non-traditional Resources
Hospital – Aging Network
collaboration
Working Together Recognize the differences between cultures We come from different perspectives and have
different languages What does MI mean to you? Working together you encounter a lot of “
Why a Duck?” situations… Address concerns early and troubleshoot
problems together Share both successes and challenges
Culture Change is a Challenge Integrate at all levels
of the hospital system Front desk reception to
Regional Director Be patient and
persistent Guest versus Team
Member Troubleshoot
challenges before they become barriers
Learn both cultures and languages Network, network,
network
The Aging Resource Center (ARC) On-Site at the Hospital Physical office space for the Bridge Care Coordinators
(BCCs) to receive referrals and access hospital and community records
A library of resources for Bridge clients and caregivers Space for the BCCs to collaborate with the
interdisciplinary team A location for the BCC to meet with Bridge clients and
their families to discuss community-based resources available The ARC is an on-site hospital location for the Bridge Program. The establishment of an ARC symbolizes the
commitment of both partners to sustaining Bridge.
The Role of the ARC Symbol of hospital-community collaboration Greater ability to interface with the community Promotes the notion of “systems” approach to
discharge planning Maximizes the opportunity for a servable moment
Benefits of the ARC Time and expertise to focus on participant and the
transitional process Community expertise The transition happens fast and the BCC has
to know how to put all of the pieces together in an expedited manner to ensure a safe transition home.
Not only does the BCC need to know the unique language, values, and perspectives of the client and family but also what services and resources
are available to the individual.
Rural Implementation of the Bridge Model
Amanda Groaning, Shawnee Alliance for Seniors
Shawnee Alliance for Seniors Shawnee Alliance for Seniors, an Illinois Care
Coordination Unit, serves the southernmost counties of Illinois An entirely rural area roughly 4,557 square miles The largest community, Carbondale, has 20,000 residents 20.5 % of population in the lower 13 counties is over the age of
60
Shawnee Alliance for Seniors (con’t) Shawnee utilizes BCCs with experience
working in the rural area and have a sensitivity to and awareness of issues specific to rural elders, including: Limited access to care Literacy and Language Barriers Geographic and Social isolation Extended family such as neighbors and friends often must step
in when the elder has no family members living in the immediate area
Problems Facing Seniors in Rural Areas Limited Access to Care
Distance 5 out of the 13 counties do not
have hospitals Most seniors face at least a 30
minute drive to access basic services
Limited public transportation services
Lack of Resources Smaller populations means less
funding for services Emergency and Specialty needs
referred out of the area
Literacy and Language Barrier Limited Education
Due to need to work Gender bias Disability
Language Barrier Limited access to interpreters Few resources and materials Reliance on Family as translator
Geographic and Social Isolation Pros
Community support Extended family Better communication
and relationships between agencies who are sharing clients
Cons Isolation from resources,
family, and friends Dependence on non-
family supports that are not always reliable
Higher risk for burn-out and caregiver stress
Role of the Bridge Care Coordinator What does a BCC bring to the table?
Integration of community resources in the hospital
On site materials and direct access to the Bridge Care Coordinator
Expanded access to care for clients and caregivers
Education to hospital staff Breadth of post-discharge support
Initial Bridge Assessment Medical record review Patient set up with in home services to assist with
care Home delivered meals were arranged for 5 days a week Health education for his diabetes Medication management Transportation
2-day follow-up Medications management Health Education for diabetes Concerns over bathing, possible need for DME New financial concerns over electrical bill
30-day follow-up Transportation Possible financial exploitation
Policy and Health Systems Implications
Kristen Pavle, Health & Medicine Policy Research Group – Center LTC Reform
Transitional Care: Integrating Medical and Social Models of Care
Medical models of care do not sufficiently cover an individual’s comprehensive needs, but health care is typically categorized and reimbursed as a medical commodity Culture Change Systems Change Bridging silos of care
http://amandabauer.blogspot.com/2010/03/romantic-circles-by-kandinsky.html
http://magicofteams.wordpress.com/2010/12/02/silos-firm-they-stand/
A Systemic Look at a Transitional Care
Event
Hospital
How do I
bill for this?
Community
Can we connect to the EMR?
Health Insurer
What is the
code for
pyschosocial?
How do we coordinate this
care transition?!
Care Coord
-inator
Transitional Care, Health Reform, and Community Involvement Affordable Care Act
Aging & Disability Resource Center Care Transitions Grant Providing Aging & Disability Resource Centers
(community-based organizations) an opportunity to participate in a nation-wide care transitions network Sharing best-practices Highlighting community (ADRC) and hospital partnerships
Provisions 3025 & 3026 (next slide)
Affordable Care Act Provisions 3025 and 3026 Section 3025 - The
“Stick” Withholding total Medicare
reimbursement rates up to 3% for high readmission rates.
Section 3026 Community-based Care Transitions Program – The “Carrot” Contracting with CMS to
provide fee-for-service care transition services through Medicare
$500 Million, several contracts/projects already accepted
http://hrfishbowl.com/2010/12/your-carrot-needs-more-stick/
3026 Impact on Integrating Medical & Social Over the next 5 years, Mathematica and the
Lewin Group will be evaluating the Community-based Care Transitions Program through a contract with CMS
Will this opportunity contribute to a change in the health care system as we know it? Bridging silos? Bridging hospital and community?
Holding different entities across the care continuum accountable for quality outcomes in care?
Bridge Model and 3026 The Bridge Model has been used in two
Community-based Care Transitions Program proposals that have been accepted Illinois: “Bridge Transitional Care Partnership”
Illinois Transitional Care Consortium partnership with AgeOptions (suburban Cook County AAA/ADRC)
Pennsylvania: “Philadelphia Bridge Care Transition Program, North Philadelphia Safety Net Partnership”. Philadelphia Corporation for Aging, Einstein Medical
Center Philadelphia, Temple University Hospital
Opportunities for Bridge Model Training The Illinois Transitional Care Consortium offers
a training package to agencies/hospitals interested in replicating the Bridge Model Full-day, in-person training Follow-up consultation via conference calls over 3-
months post-trainingBridge Model
http://edutechnow.sharepoint.com/Pages/Training.aspx
http://www.eci.com/blog/archives/2011-10.html
Thank You to Our Funders & Partners
Contact InformationSusan Altfeld ([email protected])Amanda Groaning ([email protected])Kristen Pavle ([email protected])Walter Rosenberg ([email protected])
Ilana Shure ([email protected])
www.transitionalcare.org