1. Reducing Re-hospitalizations: The ICU Survivors Follow-Up Care Program Shirley F. Jones, MD Scott & White Healthcare/Texas A&M Health Science Center

2. Nature of the problem Older ICU survivors are at increased risk of mortality 1 and poor outcomes 2 Rehospitalizations among Medicare beneficiaries are common 3 Reasons? Complex discharge instructions Lack of follow-up with PCP Patients are not fully engaged in their health Separation of hospital and ambulatory care Care coordination Complexity of medical conditions (ICU survivors) 1 NEJM 2003 3 NEJM 2009 2 JAMA 2010

3. Results of Environmental Scan Reengineered Hospital Discharge Program Discharge Advocate Care Transitions Intervention Post ICU clinics Variability (structure, population) Outcome measures (QOL, etc.) Availability Single versus Combined Interventional Strategy Employ, Examine, Create and Integrate existing and new strategies to reduce rehospitalizations, improve care coordination and delivery

4. Approach to the Problem ICU Survivors Follow-Up Care Program Two parts: Care Transitions Intervention ICU survivor specialty clinic Target population: Older patients (>55 yo) Admission to MICU Survival to be discharged home Mechanical ventilated Delirium Residents of Bell County (expansion potential)

5. ICU Survivors Follow-Up Care Program 12345678910 Identify at risk patient Establish rapport Check-In/ Visits DischargePost ICU Clinic Visit PCP Follow-up Needs Interaction MD/SW Communication PCP Home Visit Transfer to floor ICU Admission

6. ICU Survivors Follow-Up Care Program CTI Home Visit ICU Follow-Up Clinic PCP Follow-Up Hospital Discharge Within 3 Days from Discharge Within 7 Days From Discharge Within 14 Days From Discharge 23 June Transitional Couch

7. Process and Outcome Measures RE-AIM Evaluation Plan Reach--% of eligible who participate; demographics Effectiveness Rehospitalizations @ 180 days ED visits @ 180 days % of patients with PCP visit within 14 and 30 days Comparisons between program vs control Adoption- % of PCP unwilling to discuss treatment plans Implemenation- missed to sched appts; # coach contacts; audit of program records; dates of appointments Maintenance- interest by leadership, new costs incurred —

8. Project Timeline July 2010-Nov 2010—set up operations, fill positions, buy-in from primary care, hospitalists, case managers Meetings with Clinic and Hospital Quality & Patient Safety Committees Nov 2010--Program opens Jan 2011—Review 60 day progress & and implement necessary changes May 2011—6 month interim analysis of effectiveness May 2011-Oct 2011—continue project implementation and changes necessary Nov 2011-Jan 2012—12 month interim analysis; prepare abstracts and manuscripts for presentation based on preliminary data Feb 2012-July 2012—Examine and propose (if possible) financial sustainability of program July 2012-onward—Explore a powered test of effectiveness

9. Implementing the Program Alignment with Scott and White Healthcare Mission Statement “To provide the most personalized, comprehensive, and highest quality health care, enhanced by medical education and research.” Piggybacking of Program Pilot Projects Discharge Advocacy Program on Aging and Care—Care Transitions Key Stakeholders Physicians (PCP, Hospitalists, and Intensivists) Case Managers Committee and Individual meetings with leadership Appointment of PCPs as Key Project Personnel—feedback Detailed Program tracking as evidence to Stakeholders

10. Perceived Facilitators/Barriers Leadership support DOM Chair Division Chief of Pulmonary Program on Aging and Care PCF Program Accepting Change Patients-willingness to go to “another MD” PCP-territory battles Hiring and retaining personnel “Research” perception Exclusion of other patients who may benefit

11. Sustaining the Program Presentation of detailed program cost and effectiveness data to Hospital and Clinic Leadership Discuss with S&W Health Plan to include program for members Grant proposals—AHRQ, NIH Foundation support Abstracts and manuscripts to disseminate ideas Presentations at national meetings

12. What I Have Learned Things don’t always go as planned… Operational cost limit hiring new personnel Discharge plans not smooth Not systemized—no follow-up scheduled for many patients Join collaborative pilot projects Getting to know others Learning how to work within the system—networking, contacts, collaboration