the care transitions intervention - a valued voice care transitions intervention ... – the four...

The Care Transitions

Intervention®

Kimberly Irby, MPH

Colorado Foundation for Medical Care

www.cfmc.org/integratingcare

Acknowledgments: Eric A. Coleman, MD, MPH

• To provide an overview of the Care Transitions

Intervention® (Developer: Eric Coleman, MD,

MPH; http://www.caretransitions.org/)

– Preparing patients and caregivers to participate in care

delivered across settings

– The Four Pillars

– Coaching vs. Doing

– Stories from the field

• To discuss the importance of patient activation

Objectives

“Silent” Care Coordinators

• Older patients and family caregivers function as their own care coordinators

• First line of defense for transition related errors

• CTI model explicitly recognizes their role as integral members of the interdisciplinary team

http://www.caretransitions.org/

Eric A. Coleman, MD, MPH

The Care Transitions Intervention

• Self-management model

• Encourages patients and caregivers to take a more active role during transitions

• Key Elements:

– Transition Coach®

– Personal Health Record

– Medication Discrepancy Tool (MDT)®

– The Four Pillars®



Intervention Details: Transition

Coach®• Hospital Visit

• Nursing Home Visit*

• Home Visit (ideally within 48 hours of discharge)

• 3 Phone Calls

*when applicable



Personal Health Record

• Patient-owned and operated

• Record of medical history and associated

warning signs

• Medication list

• Advance directives

• Space for patient questions and concerns

• Should be portable, readable, easy to locate

and update



Medication Reconciliation

From the MDT:

50% System

1/3 discharge instructions incomplete, illegible or inaccurate

1/3 conflicting information

1/6 duplicate meds

50% Patient

2/3 non-intentional non-adherence

Coleman EA, Smith JD, Raha D, Min S. Posthospital Medication Discrepancies Prevalence and Contributing Factors. Arch Intern

Med. 2005;165:1842-1847

You’re Only

Old Once! A

Book for

Obsolete

Children,

Dr. Seuss

The Four Pillars®

1. Medication self-management

2. Use of a dynamic patient-centered

record, the Personal Health Record

3. Timely primary care/specialty care

follow up

4. Knowledge of red flags that indicate

a worsening in their condition and

how to respond



Coaching vs. Doing

• A coach helps the patient set goals

• A coach helps the patient anticipate barriers and plan for their resolution

• A coach strategizes with the patient ways to take action to meet goals

• A coach does not do it for the patient

• A coach is not a caregiver

• A coach is not an educator



Coaching and Readmissions

48% ↓ 30 days

44% ↓ 90 days

43% ↓ same-diagnosis 180 days

Evidence of Effectiveness:

Results of A Randomized

Controlled Trial

J Am Geriatr Soc 52:1817-1825, 2004

Variable Intervention Control P-Value

Age (years) 76.0 76.4 0.52

Female (%) 48.2 52.3 0.26

Married (%) 58.2 53.8 0.23

Lives alone (%) 30.9 30.8 0.99

Sad or Blue (%) 30.3 26.4 0.24

CHF (%) 16.5 12.9 0.17

COPD (%) 17.0 18.5 0.61

Arrhythmia (%) 12.8 19.0 0.02

CAD (%) 14.1 13.5 0.81

Chronic Disease

Score

6.8 7.1 0.31



Variable Intervention Control P-Value

Prior Hosp (%)

1+ past 6 mo

29.3 26.1 0.36

Prior ED (%)

1+ past 6 mo

40.3 38.9 0.69

D/C Destin.

Home (%)

Homecare (%)

SNF (%)

Other (%)

50.8

24.7

21.0

3.5

52.9

25.9

19.3

1.9

0.71

Friday D/C (%) 14.6 16.5 0.48



Variable Intervention Control

Adjusted

P-value

Re-hospitalized

w/in 30 days

8 % 12 % 0.05

Re-hospitalized

w/in 90 days

17 % 23 % 0.03

Re-hospitalized

w/in 180 days

26 % 31 % 0.09



Variable Intervention Control

Adjusted

P-value

Readmit for Same Dx

w/in 30 days

3 % 5 % 0.04

Readmit for Same Dx

w/in 90 days

5 % 10 % <0.01

Readmit for Same Dx

w/in 180 days

9 % 14 % <0.01



Variable Intervention Control P-value

Non-elective mean hospital

costs 30 days

$784 $918 0.03


costs 90 days

$1519 $2016 0.01


costs 180 days

$2058 $2546 0.03



Anticipated Cost Savings

For 350 chronically ill older adults with

an initial hospitalization, anticipated

net costs savings over 12 months:

$295,574



Care Transitions Measure (CTM®)

• The hospital staff took my preferences and those of

my family or caregiver into account in deciding what

my health care needs would be when I left the

hospital.

• When I left the hospital, I had a good understanding

of the things I was responsible for in managing my

health.

• When I left the hospital, I clearly understood the

purpose for taking each of my medications.

Implementation Considerations

• Community-based implementation

• Hospital-specific implementation

• Providers as coach

• Volunteers as coach

• Partnerships with AAA and ADRC

• Local adaptations

Measurement Considerations

Process MeasuresProximal Outcome

MeasuresUtilization Measures

Care Transitions

Intervention

(CTI)

• Count of patients

coached

• Count of

medication

discrepancies

• PAM scores

• Patient Activation

Assessment

scores

• Readmission rates

• Admission rates

• Emergency

department

utilization rates

Stories from the field

“I feel that I must tell someone

about how greatly I benefited from and appreciate the services of the

nurse who follows up on patients discharged from your hospital.

She comforted me and helped

make several forceful phone calls, and soon all was well. What a

great help! What a relief! Thanks.”

Mr. H: A patient story

The personal impact

• Coleman et al. (2006): Lower 30-day

readmission; lower readmission at 90 days

and 180 days.

• Coleman et al. (2004): Lower readmission for

same diagnosis at 90 days and 180 days.

• Additional articles of interest

– http://caretransitions.org/publications.asp

23

Further Evidence

Patient Activation

Patient Activation Measure (PAM®)

http://www.insigniahealth.com/solutions/

patient-activation-measure

Blah blah blah, blah blah. Any questions?

No I’m good to

go. Whatever

you say is what

we’ll do Doctor

What’s he saying? I

sure hope my wife is

getting this..

How can you

tell?

Patient Activation

Measure(PAM ®) -

Integration with the CTI

• A 13 item measure used to guide clinical interventions that

support patient activation to maximize outcomes

• Developed by Judith Hibbard, Jean Stockard, and Martin Tusler at the University of Oregon and Eldon R. Mahoney at PeaceHealth.

• The PAM is a copyright protected instrument and is the property of the Insignia Health

• Use of the PAM must be arranged by contacting Insignia Health

Patient Activation Measure (PAM®)

Stage 1 – Believes Active Role Important:

• Taking an active role in my own health care is the most important factor in determining my health and ability to function.

Stage 2 – Confidence and Knowledge to Take Action:

• I am confident that I can follow through on medical treatments I need to do at home.

Stage 3 – Taking Action:

• I am able to handle symptoms of my health condition on my own at home.

• I have made the changes in my lifestyle like diet and exercise that are recommended for my health condition.

Stage 4 – Staying the Course Under Stress:

• I am confident I can figure out solutions when new situations or problems arise with my health condition.

• I am confident that I can maintain lifestyle changes like diet and exercise even during times of stress.

PAM Stages of Activation

PAM questions assess three core domains – knowledge, skills and

confidence, that drive health behavior and outcomes

28

Sample

Questions:#1: “When all is

said and done, I am

the person who is

responsible for

taking care of my

health.”

#12: “I am

confident I can

figure out solutions

when new

problems arise

with my health”

The PAM is scored on a 100 point continuum.

Most patients score between 35 and 80

Can We Measure Activation?

Does Activation correlate with important

outcomes?

29

Is Activation Changeable?

What Interventions change it?

Activation is developmental

15-20% 20-30% 30-35% 20-30%

31

Medicare Segmentation

Activation level insights guide support toward what is

realistic and achievable for a given level

PAM-Tailored Coaching Process If readmitted, continue to build confidence and do not let

this derail the patient

33

• Coleman CTI℠ model1

• >300 patients coached

• Measurement

– Patient Activation

Measure® (PAM®; Insignia

Health)2

NW Denver longitudinal data (sample size: 49)

http://www.insigniahealth.com/solutions/patient-activation-measure

Outcomes

PAM tailored coaching

Critical Success Factors

Patients will complete the PAM, and do so accurately. Proper

administration is critical. Convey caring and not evaluation

The low activated (L1/L2) are 2 – 3x more likely to be readmitted

Help the low activated focus on just a couple important tasks in their first

two weeks following discharge

Help patients build competency and confidence. Competency comes from

confidence over time – it’s a journey. Best practice/evidence-based self-

care is achieved by those at L3 & L4

Allocate more resource to the low activated (L1 & L2), while shifting from

the most activated (L4)

L3 and 4 do not require intense support, but they do require appropriate

support or they will ignore you

This material was prepared by CFMC (PM-4010-092 CO 2011), the

Medicare Quality Improvement Organization for Colorado, under

contract with the Centers for Medicare & Medicaid Services (CMS), an

agency of the U.S. Department of Health and Human Services. The

contents presented do not necessarily reflect CMS policy.

Kimberly Irby, [email protected]

www.cfmc.org/integratingcare

Questions

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