American Case Management Association Virginia Chapter Robert M. Palmer, MD Glennan Center for Geriatrics and Gerontology Professor of Internal Medicine Eastern Virginia Medical School March 14, 2015 Geriatric-Population Management and Transitions of Care 1

 Identify the functional, cognitive, and psychosocial issues of older people that challenge case management  Describe the evidence-based models of transitional care that improve care management of vulnerable older people  List instruments (tools) that are useful in the case management of older people Learning Objectives 2

3 You just learned of a new admission (medical)  On your way to meet the patient (82 year old, probable pneumonia, no prior admission) ………  You ask yourself, “What do I need to know about this woman when I see her?”  “How can I get relevant information quickly and reliably? (I have a busy schedule)” 3

4 Lots to Think About Meds Complex, Costs? Family Support /strain? 4 Doctors Nurses Case Manager

 Does she have Medicare C or D coverage?  Does she qualify for an inpatient admission?  Does she have an advanced care plan (Living Will, Health Care proxy)? Code status?  Does she lack health literacy?  Are there issues of cultural sensitivity?  Does she have decisional capacity? Need to Know about her….more 5

 The challenges of the older hospitalized adult  The need for more than “multidisciplinary” care  Knowing the road map of hospitalization—and postacute care Getting Started 6

7 Healthy Mild Chronic Illness Advanced Chronic Illness Frail Usual (Acute) Care Model Chronic Disease Care Model Geriatric Care Model Matching Care to Patient Needs Dying Palliative/ Hospice Model Courtesy Jim Pacala, MD

 Sentinel event for seniors  Catastrophic vs. progressive disability for vulnerable elders  Medicare costs  Quality metrics linked to acute care and transitions—and hospital reimbursement. “Show me the Money!” Hospitalization as the Starting Point for Case Management 8

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10 Acute Care Hospitalization: Patients Age % of the American population, but: l 38% of discharges from acute hospitals l 43% of days of care l Longer hospital stays l Greater costs and adverse outcomes Buie VC et al. NHDS Vital Health Stat 13(168)

11 Outcomes at Discharge HHC=Home health Care %

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15 Virginia 15%

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17 Elderly are not just older adults: Admitting Evaluation  Acute and chronic diseases (high comorbidity)  CHF  COPD  Cardiovascular diseases  Cognitive impairment  Mobility difficulties  Social support insecurity  Home safety concerns (self-care competency)  Functional disabilities: ADL, IADL (medications) 17

18 Activities of Daily Living: (Needs personal assistance?) Basic ADL  Bathing  Dressing  Transferring  Toileting  Eating Instrumental ADL  Medications  Finances  Shopping  Cooking  Laundry  Household chores  Transportation 18

Elderly are not just older adults: Admitting Evaluation  Geriatric Syndromes (Issues)  Functional (ADL) disabilities  Cognitive impairment (dementia/delirium)  Frailty (homeostenosis)  Immobility and falls  Pressure ulcers  Nutritional concerns (undernutrition)  Polypharmacy 19

ADL From Admission To Discharge: 2-site cohort (n=300; n=736) -- Landefeld CS et al. NEJM 1995; 332: Counsell SR et al. JAGS 2000; 48:1572 Basic ADL: bathing, dressing, transferring from bed to chair, toileting eating 20 %

21 ADL Recovered or Not At One Month: Outcome At 12 Months % --Boyd CM et al. J Am Geriatr Soc 2008;56:2171 ADL RecoveredADL not recovered 21

22 Cognitive Impairment: “3 D’s”  Dementia  Delirium  Depression 22

Clock Draw Test (Screen for Impaired Cognition) 23 “Draw clock, show time 11:10”

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25 Delirium Features l Acute onset and fluctuating course l Inattention l Disorganized thinking l Altered consciousness l Cognitive impairment l Perceptual disturbances l Psychomotor disturbances l Altered sleep-wake cycle l Emotional disturbances (agitation, anxiety, apathy) Inouye SK. NEJM 2006; 354: Confusion Assessment Method

26 Depression Screen Patient Health Questionnaire-2 (PHQ-2) Over the past two weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things. 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day Feeling down, depressed, or hopeless. 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day Total point score: ______________ Score more than 4= 50% or more chance of major depression Score more than 4= 50% or more chance of major depression Kroenke K et al. Med Care 2003; 41:

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 Homeostatic decline (loss of physiologic reserve)  Multiple chronic conditions (“multimorbidity”)  Non-specific presentation of disease (old-old) Why Are Elders So Vulnerable? 28 Geriatric Syndromes

29 Homeostatic failure Aging (apoptosis) Immunosenescence Multimorbidity One organ system goes—so do the others Cumulative decline in many physiological systems during a lifetime Fedarko NS. The biology of aging and frailty. Clin Geriatr Med 2011;27:27

30 Homeostatic Failure-Pushing Back 30 Edge of precipice On surer ground

31 Story of Our Patient Lives alone (widow) Baseline, Indepedent in ADL and IADL Uses quad cane due to arthritis No memory loss or depression Medical history: HTN (controlled), mild CHF (controlled), Coronary artery disease, generalized osteoarthritis with slowed gait, and mild visual and hearing impairments Medications: Appropriate for her conditions

32  Does she have Medicare C or D coverage?  Does she qualify for an inpatient admission?  Does she have an advanced care plan (Living Will, Health Care proxy)? Code status?  Does she lack health literacy?  Are there issues of cultural sensitivity?  Does she have decisional capacity? Need to Know about her….more 32

33 The Functional Trajectory

34 “Why, When and Where?” Conversation with MD  “Why is the patient in the hospital?”  Inpatient diagnosis or reason for admission  Relevant comorbid conditions  “When is the patient ready for discharge/transition?”  Estimated length of hospital stay  Barriers to discharge?  “Where will patient go from hospital?”  Postacute needs and patient safety 34 The 3 W’s Day One Every Day

 Acute illness changes an elderly patients prognosis and quality of life  Interdisciplinary care paves the way for case management  Home, not a facility, is the goal of acute care But Does this work? Summary 35

36 Acute Care for Elders (ACE): Optimizing Efficiency and Quality Integrates geriatric assessment with continuous quality improvement l Better ADL function at discharge (mobility) l Fewer discharges to skilled nursing facilities or nursing homes l Shorter lengths of stay without increased readmissions l Higher physician and nursing satisfaction l Lower total costs of hospitalization Fox MT et al. J Am Geriatr Soc 2012;60:

37 Care Transitions: POTENTIAL PITFALLS  Fragmented care (poor handoffs)  Poorly coordinated discharge planning  Inadequate communication between health professionals  Confusing medication changes  Changes in patient cognition and functional status  Marginal social support network

38 Readmissions: Medical/Surgical Conditions (FFS Medicare) Jencks SF et al. NEJM 2009;360:1418 Days Since Discharge % Readmissions: Medical/Surgical Conditions (FFS Medicare) Jencks SF et al. NEJM 2009;360:1418 Days Since Discharge %

39 Jencks SF et al. N Engl J Med 2009;360: Rates of Rehospitalization within 30 Days after Hospital Discharge Virginia 18.8%

40 Highest Rates of Readmission Medical Condition l Heart Failure l Psychoses (delirium?) l COPD l Pneumonia Surgical Condition l Vascular surgery l Hip/femur surgery Rate (%) Rate (%) Jencks SF et al. N Engl J Med 2009;360:

41 Readmission rates falling but still high

42 Readmissions: More Than Meets the Eye Transitions of Care Readmissions to Acute Care Unplanned Readmissions Unplanned Admissions Avoidable Readmissions Avoidable Acute Care Transfers Avoidable Hospitalizations Preventable Hospitalizations Possibly Avoidable Hospitalizations Healthcare Reform

43 Taxonomy of Interventions to Reduce 30-day Rehospitalization Hansen L O et al. Ann Intern Med 2011;155:

44 Transitional Care Model: APN Advanced Practice Nurse Discharge Planning In Hospital Home care Up to 4 weeks Collaboration With physician Telephone availability Naylor ME et al. JAMA 1999;281:613

45 REDUCING READMISSIONS TO HOSPITAL ( Naylor ME et al. JAMA 1999;281:613) Intervention: Comprehensive discharge planning (APN) Home follow-up (APN) 24 Week Results p<.01

46 Coleman EA et al. JAGS 2004;52:

47 Care Transitions: Rehospitalizations * * * =Significant Days % Coleman EA et al. Arch Intern Med 2006; 166:1822

48 Eastern Virginia

49 Reengineering Discharge (RED):Nurse Advocate Coordinate discharge plan Educate and prepare patient for discharge PCP contact Date of appts Appt calendar Medication schedule List pending tests Describe dxs Jack BW et al. AIM 2009;150:178

50 Reengineering Discharge P=0.009 P=0.014 P=0.09 Jack BW et al. AIM 2009;150: % lower cost for intervention

51 Story of Our Patient Pneumonia resolves She remains alert and attentive Regains independence in ADL but is unsteady Discharged to home with home health care and transition coach and case management Daughter assists her with ADL--baseline at 30d Follow-up with PCP within one week She is not readmitted within 30 days of D/C

52 “Goal of Care”-of Case Management  Maintain or restore independence in ADL  Help enable patient to return to and remain at home (or lowest level) 52