1. Transitional Care in Skilled Nursing Facilities
Mark Toles, PhD, RN
November 6, 2016

2. research team Laura Hanson, MD, MPH (UNC-Chapel Hill)
Cathleen Colón-Emeric, MD, MHS (Duke University)
Mary Naylor, PhD, RN (University of Pennsylvania)
Morris Weinberger, PhD (UNC-Chapel Hill)
Josephine Asafu-Adjei, PhD (UNC-Chapel Hill)

3. acknowledgements
National Center for Advancing Translational Sciences, National Institutes of Health, through Grant 1KL2TR
The John A. Hartford Foundation
Atlantic Philanthropies

4. hospital to SNF to home 1.8 million older Americans / year (2015)
Medicare SNF benefit

5. a vulnerable population*
70% of SNF patients ≥ 75 years old
50% have limitations in 3 to 6 ADLs
40% are dually eligible for Medicare and Medicaid
Cognitive impairment, chronic illness, geriatric syndromes *

6. family caregivers (Toles, in progress)
Characteristic
Stat
Finding
Age
Mean
64 years
Female gender
(%) 80
Relation to patient
Spouse
41%
Child
39%
Friend or other
20%
Care days / week
5 days / week
Lives with patient
48%
Zarit burden score
3-4 / 5

7. “short term care” >15,000 facilities provide SNF care Nursing homes
Variable patient volume, mix and quality of care
Mean length of stay <25 days

8. discharge planning
referrals, patient teaching and medication administration instructions
provided by social workers, LPNs, and physicians
usually provided in the last hours of SNF stays

9. “bounce backs” after SNF discharge
Our team studied incidence and predictors of rehospitalization and ED use after SNF discharge
retrospective cohort design using Medicare claims data
NC and SC patients in 2010 and 2011 (N>200,000)
analysis using Survival Curves and Cox Proportional Hazard Models

10. patient outcomes (Toles, 2014)
22% in 30 days
38% in 90 days

11. predictors of bounce backs
male gender
African American race
combined Medicare and Medicaid eligibility
higher Charlson Comorbidity Index Score
admission for respiratory disease
care in a for profit SNF

12. transitional care (Naylor 2011)
“time-limited services designed to ensure health care continuity and avoid preventable poor outcomes among at risk populations as they move between providers and settings of care”

13. Taxonomy (Hansen, 2011) Domain Intervention Type Pre-discharge
Patient education
Discharge planning
Medication reconciliation
Appointment scheduled before discharge
Bridging the Transition
Transition coach
Patient-centered discharge instructions
Provider continuity
Post-discharge
Timely follow-up
Timely PCP communication
Follow-up telephone call
Patient hotline
Home visit

14. does transitional care work?
Key Meta-Analysis
Verhaegh, K. J., MacNeil-Vroomen, J. L., Eslami, S., Geerlings, S. E., de Rooij, S. E., & Buurman, B. M. (2014). Transitional care interventions prevent hospital readmissions for adults with chronic illnesses. Health Affairs, 33(9),

15. risk reduction: 30 day readmissions
All Interventions (N=26 RCTs) Days Risk Reduction ≤ 30 0 (OR: 0.76; 95% CI: 0.52, 1.10) % (OR: 0.77; 95% CI: 0.62, 0.96) % (OR 0.58; 95% CI: 0.46, 0.75) High Intensity Interventions (subgroup of 11 RCTs) ≤ 30 5% (OR: 0.59; 95% CI: 0.38, 0.92) % (OR: 0.69; 95% CI: 0.51, 0.92) % (OR: 0.57; 95% CI: 0.35, 0.92)

16. a closer look (Toles, 2016)
Our team completed case studies of transitional care in SNFs
Most recently, we examined care in 3 SNFs:
54 staff, patients and family caregivers
observations (N=235), interviews (N=66) and reviews of chart and SNF policies (N = 35).
thematic analysis to describe strategies for delivering effective transitional care in SNFs.

17. goal of care: preparedness for discharge
A SNF patient in Case 1
“They have been watching my Dilantin levels here…they have adjusted that medicine and my levels will return to normal. My doctor knows about that too.”
- SNF patient

18. case 1: strategies for success
Organizational support for staff
staff understood the need for transitional care
staff were skilled in preparing the patient to return home
a scheduled series of departmental, interdisciplinary, and staff/patient meetings were used to coordinate transitional care

19. case 1: strategies for success
Highly interactive patient care-teams
overlapping subgroups of staff and the patient relayed and refined clinical information
very inclusive decision-making activities
nonetheless - staff interactions rarely included family caregivers and community providers

20. Cases 1- 3: critical gap in care
evidence-based transitional care of SNF patients and caregivers

21. Systematic review of transitional care trials in SNFs (Toles, 2016)
Study findings were assessed
To identify whether transitional care interventions, compared to usual care, improved clinical outcomes such as mortality, readmission rates, quality of life or functional status;
to describe intervention characteristics, resources needed for implementation, and methodologic challenges.

22. Systematic review of transitional care trials in SNFs (Toles, 2016)
Of 1,082 unique studies, six studies meeting were reviewed.
The risk for bias was high across studies
Findings suggested that there is promising but limited evidence that transitional care improves clinical outcomes for SNF patients.

23. interventions and their impact on rehospitalization (Toles, 2016)
Study
Intervention R.
Newcomer, 2006
RN and SW, in SNF and at home No
Dolansky, 2011
RN, in the SNF and at home
Delate, 2008
Pharmacists, in call center
Tappen, 2001
RN, in the SNF and called at home
Park, 2012
NP, in a post discharge clinic visit
Yes
Berkowitz, 2013
SNF staff, in the SNF

24. connect-home* Tools, training and technical assistance
designed to help existing SNF staff
prepare patients and family caregivers to return home safely,
and remain at home without complications.
* National Center for Advancing Translational Sciences, National Institutes of Health, Grant # 1KL2TR001109

25. procedures for delivering transitional care
Step
Content 1
integrate assessments 2
convene caregiver meeting 3
schedule appointments
arrange outpatient services
educate the patient & primary caregiver
hand-off the transition plan to home care
provide written information to patient and PCP 4
call patients at home within 72 hours

26. tools to implement transitional care plans
Transition Plan of Care - a worksheet to guide multi-disciplinary assessment of patient and family caregiver needs and preferences
EMR template and cue sheets, supported with an implementation manual
Agendas and Scripts – guides for care plan meetings, using “teach back” and patient calls after discharge to home.

27. training and technical assistacne1
Group classroom activities (5 hours)
transitional care and care-team interactions
priority setting and telephone support 2
Audits of charts and staff feedback (6+ weeks)
integrated assessments
caregiver meetings
transfer of Discharge Summary Form
follow-up calls after discharge

28. measures Concept Measurement domains Transitional care
Patient and family caregiver experiences with care
Feasibility
Acceptability
Exploratory
PCP follow-up,
obtaining medicine
adverse events
ADL disability
ED and hospital use

29. connect-home: preliminary outcomes
Variable N
Cont.
Intvn.
Mean Ratio
CTM-3 score
133
66.8
76.1
p< .001
Care plan meeting
39%
58% -
Follow-up scheduled
21%
61%
Post-d/c call 66
51%

30. next step Sustainability Study in 3 SNFs
Efficacy Study in multiple SNFs
Scale-up for use in larger groups of SNFs
Intervention testing with new measures of patient outcomes