rush enhanced discharge planning program: a model for interdisciplinary care coordination robyn l....

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


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


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


Process


Referral Pre-Assessment Assessment Intervention

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


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


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


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


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


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


• 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


Common Problems


Common Interventions


Outcomes


• 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


• 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%)


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


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


*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


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?


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


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


Questions and CommentsFor more information on this project, please contact:

Robyn Golden, [email protected]

312-942-4436

rush enhanced discharge planning program: a model for interdisciplinary care coordination robyn l....

Documents

rush edpp

medical district slide

care coordination tasks

comprehensive care plan

primary care coordinator

patient care units

assessment edpp social

indepth assessment