1. TransitionaL Care (TLC) Partners for Older Veterans at Home VISN 6, Durham VAMC GRECC Ambulatory Care/HBPC Cristina Hendrix, DNS, NP (program leader) Peggy Becker, LCSW Sara Tepfer, MSW, LCSW (program co-leader) Jeanette Stein, MD Kenneth Schmader, MD Susan Rakley, MD Cathleen Colon-Emeric, MDJames Galkowski, PA S. Nicole Hastings, MD Ellie McConnell, PhD, CNSOT Helen Hoenig, MD Social WorkJim Mathues, MOT, OTR/L Gregory Hughes, LCSW

2. The Durham VAMC TLC Partner Program Clinical demonstration program Administered through a competitive RFP process by the Office of Geriatrics and Extended Care (GEC) Transformation-21 (T-21) initiative to promote the growth and dissemination of patient-centric alternatives to institutional extended care.

3. VA Statistics At A Glance Percentage of Male vs Female 1 US Census Bureau, 2009 2 National Center for Veterans Analysis & Statistics, 2010

4. VA Statistics At A Glance Racial Distribution 1 US Census Bureau, 2009 2 National Center for Veterans Analysis & Statistics, 2010

5. In 2008, almost 14% of people in the US were 65 or older, whereas almost 40% of US veterans were 65 or older. Projected Number of Living WW II Veterans (as of 9/30/2009): 2,272,000

6. Percent Distribution of Inpatient Care By Age* *2001 National Survey of Veterans (NSV)

7. Older veterans admitted to Durham VAMC Risk for complicated home discharge TLC NP/PA conducts hospital visit(s) before discharge Determines if OT/SW home visits are needed Low High Usual discharge care TLC NP/PA conducts home visits within 2-3 days of discharge and PRN OT and/or SW visit within 5 days of discharge and PRN OT/SW visits needed? TLC NP/PA conducts home visits within 2-3 days of discharge and PRN TLC Partner Program* Handoff to PCP, HBPC, etc after 30 days of hospital discharge YesNo * Based on Naylor’s Transitional Care Model (LDI Issue Brief, 9(6): 1-4, 2004 Apr-May

8. Older veterans admitted to Durham VAMC Risk for complicated home discharge TLC NP/PA conducts hospital visit(s) before discharge Assesses goals and needs of patients/caregivers Determines if OT/SW home visits are needed Low High Usual discharge care TLC NP/PA conducts home visits within 2-3 days of discharge and PRN OT and/or SW visit within 5 days of discharge and PRN OT/SW visits needed? TLC NP/PA conducts home visits within 2-3 days of discharge and PRN TLC Partner Program* VISN 6, Durham VAMC GRECC/HBPC Handoff to PCP and/ or HBPC after 30 days of hospital discharge YesNo

9. Anticipated Program Outcome Phase 1: Identify risk factors for complicated home discharge among hospitalized older veterans Successful implementation of alert system and consult mechanism Good predictive value of identified risk factors

10. Anticipated Program Outcome Phase 2: Implement and evaluate a post- hospital care model for patients and their caregivers using TLC partners Reduction in ED visits; readmission to hospitals; hospital bed days of care; and institutionalized care Increase in patient and family satisfaction Increase in caregiving preparedness and reduce caregiving burden

11. Sustainability of the TLC Program 1 in 5 older adults will be readmitted within 30 days of hospital discharge Using Durham VAMC data, this translates to 12 out of 60 readmission within 30 days Naylor and colleagues have demonstrated a 25% decrease in readmission (0-3 months) and 55% SNF admission (0-3 months)

12. Cost Savings Ave hospital LOS: 4 days Ave hospital cost per day: $2,500 Reduce readmission by 3 patients per month In one year, reduce cost by $360,000 Ave LOS at CLC: 83 days Ave CLC cost per day: $438.36 Reduce admission by 5 patients per year In one year, reduce cost by $181, 919. 40 $541,919.40 - $358,877.00 (operating cost of TLC in 1 year) = $183,042.40 (savings)

13. TLC Update Begin hiring of staff Pull data for analysis of risk factors Meet regularly with the team Partner with IT to establish consult mechanism Disseminate information to hospitalists Begin patient/caregiver enrollment in August

14. Thank you