CMS National Conference on Care Transitions December 3,

Implementation of the Transitions of Care Model in a Community Setting Andrew Miller, MD, MPH Director, Physician Services Healthcare Quality Strategies, Inc. (HQSI) 2

New Jersey Care Transitions Project Community Southwestern New Jersey Main partner organization: Virtua 3

Virtua Home Care Implemented Transitional Care Model (TCM) Key requirements for program –Financial feasibility –Sustainability 4

Role of Penn School of Nursing Team Presentations to Virtua leadership Training –Online training modules (reviewed by Penn nurse trainer) –Site visit by Virtua Home Care nurses to Philadelphia Ongoing support –Periodic case conferences –Availability for telephone consultation 5

Adaptations To make the model feasible and sustainable in a primarily Fee-for- Service, pre-Affordable Care Act environment – Enrolled only patients eligible for Medicare home health services – Baccalaureate nurses instead of Advanced Practice Nurses (APNs) 6

Adaptations (cont’d) – No visit in the hospital by the Transitional Care Nurses (TCNs) – TCN does not accompany patient to the first follow-up visit to the physician – Allowed enrollment of patients after discharge from the hospital Initial refusals Patients identified by a home health nurse 7

Additional Training Provided to TCNs Management of patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes Availability of community resources for patients with chronic conditions 8

Pilot Project Started as a small pilot within Virtua Home Care Four TCNs (2.4 FTE) Ultimate goal is spread throughout the agency 9

Virtua Home Care’s Sense of Ownership New name: – Transitions of Care Program Potential concern: – Loss of fidelity with the evidence- based TCM 10

Outcomes Number of Hospitalizations Number of Transitions of Care Program enrollments = 81 Analysis is limited to 61 patients with identifiable inpatient hospital claims prior to enrollment. 11 Transitions of Care Program Enrollment Number of Hospitalizations Average Hospitalizations Per Patient (Range) 30 Days Prior (1 – 2) 30 Days After (0 – 3) Transitions of Care Program Enrollment Number of Hospitalizations Average Hospitalizations Per Patient (Range) 60 Days Prior (1 – 2) 60 Days After (0 – 4)

Outcomes (cont’d) 30-Day Acute Care Hospitalization Rate *Q data is incomplete. Result is preliminary. 12 Quarter Number of Patients Enrolled in Program Number of HospitalizationsRate 2009 Q3 8563% 2009 Q4 7457% 2010 Q113323% 2010 Q223730% 2010 Q3 * 10330%

Outcomes (cont’d) 13

Advice about Implementing the Transitional Care Model It is as good as Dr. Naylor says it is Invest the time and resources necessary to identify and train the TCNs The TCM works very well in a community-based setting Build at least a simple evaluation system from the start

Role of the QIO (HQSI) Making the home health agency aware of the TCM program Facilitating: bringing the agency together with the Penn School of Nursing team Assisting with implementation: serving on steering committee Funding support: for training provided by Penn team Analytic support: for examining outcomes 15

For more information, contact: Andrew Miller, MD, MPH Director, Physician Service Healthcare Quality Strategies, Inc. 557 Cranbury Road, Suite 21 East Brunswick, NJ , extension