1. Effectiveness and Cost of a Transitional Care Program for Heart Failure Arch Intern Med. 2011;171(14):1238-1243 September 11, 2012 Brett Stauffer MD MHS Director of Clinical Decision Support Center for Clinical Innovation Baylor Health Care System

2. © 2005 Baylor Health Care System Baylor’s Transitional Care Program Readmission increasingly the focus for evaluating the quality of care provided by hospitals, especially by CMS. Heart failure the largest contributor to readmissions for Medicare patients. BHCS felt implementation of a pilot program to reduce readmission was necessary to gain experience on methods of reducing readmission. 2

3. © 2005 Baylor Health Care System Evaluation of Programs for Pilot  Several different programs had been show to be efficacious in controlled research studies  Previous studies had shown the most effective care coordination programs had 2 crucial features:  Care coordinators interacted in person with patients and did not simply educate or assist them by telephone  Care coordinators collaborated closely with patients’ physicians to influence care 3

4. © 2005 Baylor Health Care System Implementation of Modified Naylor Transitional Care Model  Decision made to go with a transitional care model developed by Dr. Naylor at University of Pennsylvania  Uses Advance Practice Nurses to bridge care after discharge  Includes visits in the hospital, an initial home visit within 72 hours, and at least 8 home visits over a 3 month period  Telephone support is available 7 days a week 4

5. © 2005 Baylor Health Care System Analysis of Intervention  Intervention performed at Baylor Garland from August 2009 to April 2010  Study was a prospective observation study with concurrent controls  Analysis was intention to treat with outcome of interest being readmission within 30-days of discharge 5

6. © 2005 Baylor Health Care System Analysis of Intervention  Attempts were made to enroll all patients admitted with heart failure  Some patients were not identified while hospitalized to be enrolled  Some patients declined to participate in the program  Patients discharged to skilled nursing facilities or nursing homes 6

7. © 2005 Baylor Health Care System Analysis of Intervention 7

8. © 2005 Baylor Health Care System Analysis of Intervention 8

9. © 2005 Baylor Health Care System Financial Analysis Since current payment based on episodes of care (including readmission) and little reimbursement exists for costs associated with the program, the intervention -- while effective in the real world -- may not be financially sustainable long term without modifications to how hospitals are reimbursed for their care. 9

10. © 2005 Baylor Health Care System QUESTIONS? 10