1. Rush Enhanced Discharge Planning Program: A Model for Interdisciplinary Care Coordination Robyn L. Golden, LCSW Director, Older Adult Programs Rush University Medical Center

2. 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

3. 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

4. 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

5. 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-discharge 2.Connecting patients to their physician for follow-up appointments 3.Supporting caregivers to reduce stress and burden © Rush University Medical Center, 2009

6. 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 © Rush University Medical Center, 2009

7. Target Population Must meet all the following criteria: Age > 65 Returning home after discharge >7 medications prescribed Must also meet one additional criterion: Lives alone Without a source of emotional support Without a support system for care in place Discharged with a service referral High falls risk Inpatient hospitalization in past 12 months Identified in-depth psychosocial need High risk medication prescribed © Rush University Medical Center, 2009

8. Process © Rush University Medical Center, 2009 Referral Pre- Assessment AssessmentIntervention

9. 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 © Rush University Medical Center, 2009

10. 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 © Rush University Medical Center, 2009

11. 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 © Rush University Medical Center, 2009

12. 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? 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 © Rush University Medical Center, 2009

13. 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

14. 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 © Rush University Medical Center, 2009

15. Level of Intensity MeanStd DevRange Duration of Intervention (Days)5.811.3172 Total calls5.46.3044 © Rush University Medical Center, 2009 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

16. 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 © Rush University Medical Center, 2009

17. Common Problems © Rush University Medical Center, 2009

18. Common Interventions © Rush University Medical Center, 2009

19. Outcomes © Rush University Medical Center, 2009 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

20. Outcomes © Rush University Medical Center, 2009 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

21. 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 appointments InterventionUsual Care Yes239 (74.9%)206 (57.4%) No80 (25.1%)153 (42.6%) © Rush University Medical Center, 2009

22. 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 © Rush University Medical Center, 2009

23. Utilization Readmissions to Rush University Medical Center Since DischargeInterventionUsual Carep-value 30 days 13.6%16.1%.201 60 days 20.8%27.5%.031* 90 days 26.4%34.2%.018* 120 days30.8%36.5%.078 180 days36.1%42.5%.068 © Rush University Medical Center, 2009 *significant at the p<.05 level Mortality at 30 days, p=0.03 Overall (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)

24. 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 © Rush University Medical Center, 2009

25. Implementation Issues Five key implementation questions must be answered for the program to be successful 1.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? © Rush University Medical Center, 2009

26. 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 © Rush University Medical Center, 2009

27. 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 © Rush University Medical Center, 2009

28. Questions and Comments For more information on this project, please contact: Robyn Golden, LCSW Robyn_L_Golden@rush.edu 312-942-4436