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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
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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
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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
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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.
Nu
mb
er
(in
million
s)
Nu
mb
er
(in
million
s)
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.
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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
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Transitions between LTC and Transitions between LTC and Acute Care HospitalsAcute Care Hospitals
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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
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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
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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
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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
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The Search for SolutionsThe Search for Solutions
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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
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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
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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
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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
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Mrs. Anderson: A Case StudyMrs. Anderson: A Case Study
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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
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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
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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
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Mr. Jenkins: A Case StudyMr. Jenkins: A Case Study
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Policy Policy RecommendationsRecommendations
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Leutz’s Conceptual Leutz’s Conceptual FrameworkFramework
LinkageLinkage
CoordinationCoordination
Full IntegrationFull Integration
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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
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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
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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
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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”
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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
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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