1. SUSAN ALTFELD, PHD 1, ANTHONY PERRY, MD 2, VANESSA FABBRE, MSW 3, GAYLE SHIER, MSW 2, ANNE BUFFINGTON, MPH 1 AND ROBYN GOLDEN, AM, LCSW 2 1 UNIVERSITY OF ILLINOIS AT CHICAGO, 2 RUSH UNIVERSITY MEDICAL CENTER, 3 UNIVERSITY OF CHICAGO IMPROVING CARE TRANSITIONS FOR OLDER ADULTS: THE ENHANCED DISCHARGE PLANNING PROGRAM

2. DEVELOPING A DEEPER UNDERSTANDING OF CARE TRANSITIONS Patient and caregiver needs Intervention processes

3. WHAT IS TRANSITIONAL CARE? Coordination of care from one setting to another: Hospital to home Hospital to skilled nursing facility Skilled nursing to home Within hospital – unit to unit

4. IMPROVING CARE TRANSITIONS – WHY? 19.6% of Medicare patients are re hospitalized within 30 days of hospital discharge (Jencks, S. et al., (2009). Rehospitalizations among patients in the Medicare fee-for-service program, NEJM, 2009) 19% of patients experience an adverse event within 3 weeks of hospital discharge U.S. health care spending associated with potentially preventable readmissions estimated at $12 billion to $17.4 billion per year (MedPAC. (2007). Promoting Greater Efficiency in Medicare) 40-50% of hospital readmissions are linked to social problems and lack of community resources (Proctor et al, (2000) Adequacy of home care and hospital readmission for elderly congestive heart failure patients)

5. IMPROVING CARE TRANSITIONS Promote patient safety Enhance patient satisfaction Promote communication between care settings Prevent re-hospitalization by addressing major causes of adverse outcomes Psychosocial factors affecting the access to and utilization of quality post-discharge care

6. EVIDENCE-BASED INTERVENTIONS TO IMPROVE CARE TRANSITIONS BOOST (Williams) Project RED (Jack) Care Transitions Intervention (Coleman) Transitional Care Model (Naylor) Illinois Transitional Care Consortium Bridge (Altfeld, ITCC) Enhanced Discharge Planning Program (Altfeld, Golden, Rooney, Perry et al)

7. EVIDENCE-BASED INTERVENTIONS TO IMPROVE CARE TRANSITIONS BOOST Project RED Care Transitions Intervention Transitional Care Model Illinois Transitional Care Consortium Bridge Enhanced Discharge Planning Program How are they different?

8. EVIDENCE-BASED INTERVENTIONS BOOST – hospital based, discharge planning/teaching intervention Project RED - hospital based, discharge planning/teaching intervention Care Transitions Intervention – hospital to home, advanced practice nursing model, care coordination through home visits Transitional Care Model – hospital to home, transitions coach, enhanced communication across levels and between providers Illinois Transitional Care Consortium Bridge – social work coordination, emphasis on post d/c follow up Enhanced Discharge Planning Program

9. ENHANCED DISCHARGE PLANNING PROGRAM Telephone intervention Master’s level social workers Bio psychosocial focus Patient referrals based on electronic medical record Core intervention - 48 hour post discharge telephone assessment

10. ENHANCED DISCHARGE PLANNING PROGRAM Randomized controlled trial of 720 patients All patients older than 65 with medical and psychosocial risk factors Randomized to follow-up intervention or usual care Qualitative study Interviews with intervention social workers

11. ENHANCED DISCHARGE PLANNING PROGRAM INTERVENTION The mean duration of the intervention was 5.8 days (s.d.=11.3) Range 1 to 72 days. The mean number of contacts was 5.4 (s.d.= 6.3). Range 1 to 44 days

12. LOGISTIC REGRESSION ANALYSES – ADHERENCE OUTCOMES OUTCOMEOdds ratio95%CI Lower95% CI Upper Physician communication2.041.283.24 Physician appointment2.701.644.45 Physician appointment kept2.091.512.89 Physician appointment made and kept2.221.593.10 30 day mortality.38 0.16 0.88 Note: All models are adjusted for Admission type, prior admission in past year, coping, insurance except mortality which was adjusted for coping since other covariates not significant when included in the model

13. OUTCOMES – READMISSIONS AND ED USE Patient report re readmission/Emergency Department use not validated by hospital records Primary issue: recall of specific admission dates/intervals We are awaiting analysis of CMS data to explore readmissions and ED use

14. WHO WERE THESE PATIENTS? WHAT DID THEY NEED? WHAT DID EDPP DO?

15. PATIENT DEMOGRAPHICS Mean age=74.5 years 49.2% Caucasian/45.6% African American 59.4% Unmarried 62.6% Urban 91.1% Medicare 22.6% Medicaid 15

16. INTERVENTION GROUP 300 of 360 (83.3%) of patients had problems identified by an EDPP clinician upon assessment For 219 (73%) of these individuals, needs did not emerge until after discharge 16

17. NEED FOR POST-ASSESSMENT INTERVENTION 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.

18. NEEDS IDENTIFIED TRANSITIONAL CARE/HEALTH Delay in service – home health3610.0 Issues with coordination between care providers7019.5 Medication management issue5916.4 Challenges with management of post-d/c care10228.4 Challenges with management of new treatment/dx6317.6 Difficulties obtaining community services8523.7 Communication with service and medical providers5314.7 Difficulty understanding discharge plan of care6016.7 Transportation3610.0

19. NEEDS IDENTIFIED PSYCHOSOCIAL Caregiver burden12635.0 Coping with change12434.5 Psychiatric illness3910.8 Inadequate social support359.8 Insurance issues257.0 Bereavement and end of life concerns154.2 Suspected abuse and/or neglect; self- neglect10.3

20. QUALITATIVE INTERVIEWS Clinical intervention themes Broad view of the client system Patient, caregiver, health professionals/paraprofessionals Need to transcend institutional roles to resolve problems

21. QUALITATIVE INTERVIEWS Patient/caregiver themes “surprises” More stressful than anticipated Fatigue Suggests that better discharge planning is not the answer

22. POST-INTERVENTION CONTACT Almost 1/3 of intervention patients (29.3%) contacted the EDPP clinician for additional services or information after the case was closed 22

23. QUESTIONS AND COMMENTS For more information, contact: Susan Altfeld saltfeld@uic.edu 312-355-1134

24. Thank you to the Rush EDPP clinical team--- Madeleine Rooney, Debra Markovitz and Michele Packard--- for their dedication to patients and caregivers and their contributions to this research