The Illinois Transitional Care Consortium (ITCC) presentation at the 2011 American Society on Aging Conference: the Bridge Model of transitional care.

1. Bridging Hospital to Home The Bridge ModelAn Innovative Social Work Approach to Transitional Care American Society On Aging Thursday April 28th, 2011 San Francisco, CA

2. Kristen Pavle, Health & Medicine Policy Research Group Good Morning!

3. Agenda ITCC, Transitional Care The Bridge Model Building Relationships: Hospital & Community Based Organizations Aging Resource Centers Business agreements/contracts Cultural Competency Research, Evaluation, and Data Q & A

4. Who we are… the Illinois Transitional Care Consortium ITCC was formed to more effectively address needs of older adults transitioning from the hospital to the community by linking hospital based services with the aging network through intensive care coordination.

5. ITCC members Community-based organizations Aging Care Connections Shawnee Alliance for Seniors Solutions for Care Hospitals Rush University Medical Center MacNeal Hospital Adventist LaGrange Memorial Hospital Herrin Hospital Memorial Hospital of Carbonda;e Research, Evaluation & Policy University of Illinois at Chicago, School of Public Health Health & Medicine Policy Research Group

7. 19% of patients experience an adverse event within 3 weeks of hospital discharge

9. The United States Health Care System Medicare Medicare Advantage Plans Private Insurance Co-Pays Deductibles In-Network Providers Rehabilitation Skilled Nursing Facilities In-Patient Hospital Stays Community-based Organizations Primary Care Physicians Specialist doctors Nurses Social Workers Preventive Care Long-term care Family Caregivers Medicaid Home care physicians Medical homes Accountable care organizations Direct-care workers: home health, home care

10. Perfect Storm Increasingly aged population Greater functionality with chronic conditions Living longer, yet sicker Bottom Line: people need better care and we need to offer high quality care while containing costs Photo courtesy of “striking_photography” on Flickr.com

11. Transitional Care Coordinating care from one care setting to another Hospital to home Hospital to nursing home Nursing home to home Home to nursing home Within hospital or nursing home Insurance transitions PCP transition Caregiver moving in or out

12. Advisory Board Jean Bohnhoff - Executive Director, Effingham County Committee on Aging Thomas Cornwell - Medical Director, HomeCare Physicians Bob Clapp - Senior Vice President, Hospital Affairs, Rush University Medical Center Jim Durkan - President/CEO, Community Memorial Foundation Karen Freda - Executive Director, Illinois Council of Case Coordination Units Michael Gelder - Senior Health Policy Advisory to Illinois Governor Pat Quinn Michael Koronkowski – Pharmacist and Geriatrics Professor, University of Illinois at Chicago Patricia Merryweather - Vice President, Illinois Hospital Association Jonathan Lavin - Executive Director, Age Options, Suburban Cook County Area Agency on Aging Marta Pereyra - Coalition of Limited English-Speaking Elderly Cheryl Schraeder - Director of Policy & Practice Initiatives, Institute for Healthcare Innovation, University of Illinois at Chicago College of Nursing Patricia Volland - Senior Vice President, Strategy & Business Development, The New York Academy of Medicine Rebecca Zuber - President, Rebecca Zuber, Inc.

13. Walter Rosenberg, Rush University Medical Center The Bridge Model

15. 75 years old

17. Discharged with home health care

19. http://blog.reflexstock.com/2009/12/a-selection-of-stunning-images/ The Bridge Model

20. The Bridge Model Overview of Components Social-worker Based: Bridge Care Coordinator Interdisciplinary Teams Hospital  Home Patient Focused, Community-Specific The Aging Resource Center Urban, Suburban, and Rural applicability

22. Family

23. SES

24. Race

25. Gender

26. Ethnicity

27. Religion

28. Mental Health

30. If non-hospital staff, requires access to the EMRReview of the electronic medical record, meeting with an interdisciplinary pre-discharge and fast tracking community services.

34. Any additional unmet needs

35. Building off of Aging Network Conducting Choices for Care Assessments and CCC Assessments Setting up CCP Interim Services and Interim Home Delivered Meals Providing and referring families for Caregiver Support Services and Respite Conducting Benefits Check-Ups Providing Information & Assistance to Patients and their families on site (i.e. Medicaid, Food Stamps, Circuit Breaker, Tax Freezes, Medicare Part D, Home Modification, FSS)

36. Bridge Care Coordinators http://commons.wikimedia.org/wiki/File:Provence_Winds_Compass_Rose.jpg

37. Bridge Care Coordinators Why Social Workers? Systems Theory Biopsychosocial framework Psychosocial determinants of health http://early-childhood-resources.com/2010/05/reflection

38. The Post-Discharge Environment http://amandabauer.blogspot.com/2010/03/romantic-circles-by-kandinsky.html

39. Psychosocial Issues Social isolation Depression Difficulty coping with change Financial stressors Language barriers Health literacy barriers Older generations taught to be “good patients” 40-50% of readmissions linked to psychosocial issues and lack of community resources

40. Calculating the Cost What is the REAL cost? Staff allocation Overhead Training Case load efficiency http://www.boston.com/ae/theater_arts/exhibitionist/2007/06/salaries_of_sym.html

41. Sustainability Can’t do good without doing well Who’s money are you saving? Who is your audience? Business case options Readmissions Higher yield patients Patient Satisfaction The “3026 RFP” Grants http://www.thinkgeek.com/gadgets/tools/a396/

42. Building Relationships Ilana Shure, Aging Care Connections Esther Izaguirre, Solutions for Care

43. Aging Resource Center

44. The Role of the ARC Symbol of hospital-community collaboration Greater ability to interface with the community Promotes the notion of “systems” approach to discharge planning. Maximizes the opportunity for a servable moment.

47. Community-Hospital Partnerships Aging Care Connections (CCU - Suburban Chicago) Adventist LaGrange Memorial Hospital Shawnee Alliance for Seniors (CCU – Rural, downstate Illinois) Memorial Hospital of Carbondale Herrin Hospital Solutions for Care (CCU – Suburban Chicago) Mac Neal Hospital Central West (CMU – Chicago) Rush University Medical Center

48. Aging Network: National  State

49. Illinois Aging Services Network

50. Establishing a Connection to the Aging Network Many older adults seen at the hospital by Bridge Care Coordinators have yet to get connected to resources available through their community 54% of ARC clients had no previous interaction with their local Care Coordination Unit (N=399) Bridge Care Coordinators connect older adults to the aging network 49% of ARC clients utilized services offered through their local Care Coordination Unit for the first time after their encounter with a Bridge Care Coordinator (N=399)

51. Establishing an ARC Time frames for developing the ARC Outreach to hospital Through existing programs or contracts already established Begin contacting individuals at the hospital who are supportive of the model.

52. Establishing a Partnership Evaluate Potential Partners Make the “ASK” Identify what you are asking the partner to contribute Establish the basic structure of the partnership prior to launching the project Keep parameters loose enough to allow for growth development An MoU at a minimum should be in place prior to the start date of the project

53. Establishing a Partnership Cont. Legal agreements should be created broadly defining the service provision, the recipient of the service and duties of each partner in the relationship including: Purpose of the program Responsibilities of both parties Individual responsibilities of the partners Financial liabilities Confidentiality and data sharing Termination Annually review agreement! http://www.fortklock.com/signatures.htm

55. Cultural Competency Continued Assess clients and caregivers in their language and coordinate and link them to services BCC are able to participate in the important aspects of culture, value and belief systems All printed material are in Spanish including Consent forms

56. Cultural Competency Continued Support Groups for Spanish Speaking Caregivers Chronic Disease Self Management Classes taught in Spanish -Take Charge of your Health Outreach Program to target cultural linguistically isolated individuals in the communities

57. Susan Altfeld, University of Illinois at Chicago – School of Public Health Research & Evaluation

58. The Bridge Model Evidence Base The Bridge Model is an adaptation of the Enhanced Discharge Planning Program (EDPP) EDPP is an evidence-based model developed and evaluated with a randomized-controlled trial at Rush University Medical Center (ITCC partner) Bridge implements the evidence based components of EDPP and best practices developed by ITCC partner sites Bridge is a hospital and community partnership

59. Rush University Medical Center Study Randomized controlled trial of 720 patients All patients older than 65 with multiple medical conditions Half received follow-up intervention, half were in the “usual care” group Qualitative study Interviews with intervention social workers

60. What did we learn from the Rush study? 83% of the patients in the intervention group had problems identified by the social worker during the assessment at 2 days post-discharge For ¾ of these individuals, problems did not emerge until after discharge – “surprises”

61. Needs Identified at 2 day post discharge contact* - Rush study *select variables

62. Randomized Controlled Trial Outcomes at 30 day follow up – patient follow up/adherence

63. Adverse Outcomes –30 days post discharge

64. Post-Intervention Contact- Rush RCT Almost 1/3 of patients (29.3%) contacted the Bridge social worker for additional services or information after the case was closed 49

65. Evaluation of the Bridge Model Important variables from our previous work and other evidence based care transitions interventions Patient characteristics Health status Patient stress Caregiver stress Understanding of responsibilities for managing health Medical follow up Hospital readmissions Mortality Satisfaction

66. Evaluation data collection- ITCC Bridge Intake assessment 2 day post discharge assessment 30 day follow up assessment Satisfaction survey Both “patient” and “caregiver” versions of the assessment surveys Telephone Email /telephone satisfaction surveys

67. Evaluation of the Bridge Model Who are our participants? 1766 participants at 5 sites across Illinois from May 2010-March 2011

68. Bridge client demographics preliminary data 5/10-3/11 Male 39.7% 75+ 52.2% Frail 64.8% Living alone 41.5% Social need 87.2% Non-English speaking 8.4% Minority/”non-White” 35.7% At risk for nursing home placement 37.6%

69. 2-day post-discharge assessment Older adult client’s health At this time, how is your health?/ how is (Mr./Ms. patient last name)'s health? (N=117) Excellent 4.3% Very good 15.4% Good 47.0% Fair 19.7% Poor 11.1%

70. 2 day post discharge assessment Older adult (patient) stress Since I left the hospital, managing my needs has been stressful for me/ Since he/she left the hospital, managing his/her needs has been stressful for him/her (N=109) Yes 50.5% No 49.5%

71. 2 day post discharge assessment Caregiver stress Since I left the hospital managing my needs has been stressful for my family or other caregivers/ Since he/she left the hospital managing his/her needs has been stressful for you. (N= 102) Yes 57.8% No 42.2%

72. 2 day post discharge assessment Understand medications I understand the purpose of each of my medications and how to take each of them (N= 118) Yes 98.3% No 2.7%

73. 2 day post discharge assessment Understand symptoms/”red flags” I understand what symptoms I need to watch out for and who to call if they occur(N= 118) Yes 94.9% No 5.1%

74. 2 day post discharge assessment Problems/“Surprises” Are things more difficult than you expected since leaving the hospital, less difficult or about what you expected? (N=110) More difficult 30.0% Less difficult 10.9% As expected 59.1%

75. 30 day outcomes patient follow up/adherence Physician communication- 95.1% Physician visit -95.3%

76. 30 day outcomes adverse events Rehospitalized within 30 days of d/c- 8.9% Mortality - 2.0%

77. Satisfaction survey Decision making The assistance or information you received from the Bridge Program helped you (or your loved one) make decisions about your care Strongly agree 40.1% Agree 59.1% Disagree 0% Strongly Disagree 0%

78. Satisfaction survey Links to community services The assistance or information you received from the Bridge Program helped you (or your loved one) connect to services and resources. Strongly agree 42.1% Agree 57.9% Disagree 0% Strongly Disagree 0%

79. Satisfaction survey Patient stress Bridge Program helped to make the hospital discharge experience less stressful for you (the patient). Strongly agree 39.1% Agree 52.2% Disagree 4.3% Strongly Disagree 4.3%

80. Satisfaction survey Caregiver stress The Bridge program helped to make the hospital discharge experience less stressful for family or other loved ones Strongly agree 31.8% Agree 59.1% Disagree 4.5% Strongly Disagree 4.5%

81. Satisfaction survey Bridge Care Coordinator - knowledge The Bridge social workers were knowledgeable. Strongly agree 47.8% Agree 47.8% Disagree 4.3% Strongly Disagree 0%

82. Satisfaction survey Satisfaction I would recommend this program to others Strongly agree 41.0% Agree 59.0% Disagree 0% Strongly Disagree 0%

83. Satisfaction Survey - Quotes Satisfaction Unmet needs/anything you would change/what did you like about the Bridge Program? “I like everything about the Bridge Program.” “You are providing a great service.” “I would like it to be much more advertised for everyone wherever they live.” “It would be nice for everyone to receive the services like my father.” “I cannot think what else the social worker could have done additionally since she was very helpful throughout ….”

84. http://tinyurl.com/4kfm4ep Questions?

85. Contact Information Susan Altfeld (saltfeld@uic.edu) Esther Izaguirre (eizaguirre@solutionsforcare.org) Kristen Pavle (kpavle@hmprg.org) Walter Rosenberg (walter_rosenberg@rush.edu) Ilana Shure (ishure@agingcareconnections.org)