The Bridge Program (ITCC)
- 1. Bridging Hospital to HomeThe Bridge ModelAn Innovative Social Work Approach to Transitional CareAmerican Society On AgingThursday April 28th, 2011San Francisco, CA
- 2. Kristen Pavle, Health & Medicine Policy Research GroupGood Morning!
- 3. AgendaITCC, Transitional CareThe Bridge ModelBuilding Relationships: Hospital & Community Based OrganizationsAging Resource CentersBusiness agreements/contractsCultural CompetencyResearch, Evaluation, and DataQ & A
- 4. Who we are… the Illinois Transitional Care ConsortiumITCC 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 membersCommunity-based organizationsAging Care ConnectionsShawnee Alliance for SeniorsSolutions for CareHospitalsRush University Medical CenterMacNeal HospitalAdventist LaGrange Memorial HospitalHerrin HospitalMemorial Hospital of Carbonda;eResearch, Evaluation & PolicyUniversity of Illinois at Chicago, School of Public HealthHealth & Medicine Policy Research Group
- 6. So, why transitional care?19.6% of Medicare beneficiaries are readmitted in 30 days
- 7. 19% of patients experience an adverse event within 3 weeks of hospital discharge
- 8. 76% of 30 day readmissions are “highly preventable”Older Adults and Care TransitionsOlder adults are particularly vulnerable to poor transition outcomesMultiple medical conditions, medications, and care providersPhysical and cognitive limitationsHealth literacyBurdened caregiversPhoto courtesy of “auntjojo” on Flickr.com
- 9. The United States Health Care SystemMedicareMedicare Advantage PlansPrivate InsuranceCo-PaysDeductiblesIn-Network ProvidersRehabilitationSkilled Nursing FacilitiesIn-Patient Hospital StaysCommunity-based OrganizationsPrimary Care PhysiciansSpecialist doctorsNursesSocial WorkersPreventive CareLong-term careFamily CaregiversMedicaidHome care physiciansMedical homesAccountable care organizationsDirect-care workers: home health, home care
- 10. Perfect StormIncreasingly aged populationGreater functionality with chronic conditionsLiving longer, yet sickerBottom Line: people need better care and we need to offer high quality care while containing costsPhoto courtesy of “striking_photography” on Flickr.com
- 11. Transitional CareCoordinating care from one care setting to anotherHospital to homeHospital to nursing homeNursing home to homeHome to nursing homeWithin hospital or nursing homeInsurance transitionsPCP transitionCaregiver moving in or out
- 12. Advisory BoardJean Bohnhoff - Executive Director, Effingham County Committee on AgingThomas Cornwell - Medical Director, HomeCare PhysiciansBob Clapp - Senior Vice President, Hospital Affairs, Rush University Medical CenterJim Durkan - President/CEO, Community Memorial FoundationKaren Freda - Executive Director, Illinois Council of Case Coordination UnitsMichael Gelder - Senior Health Policy Advisory to Illinois Governor Pat QuinnMichael Koronkowski – Pharmacist and Geriatrics Professor, University of Illinois at ChicagoPatricia Merryweather - Vice President, Illinois Hospital AssociationJonathan Lavin - Executive Director, Age Options, Suburban Cook County Area Agency on AgingMarta Pereyra - Coalition of Limited English-Speaking ElderlyCheryl Schraeder - Director of Policy & Practice Initiatives, Institute for Healthcare Innovation, University of Illinois at Chicago College of NursingPatricia Volland - Senior Vice President, Strategy & Business Development, The New York Academy of MedicineRebecca Zuber - President, Rebecca Zuber, Inc.
- 13. Walter Rosenberg, Rush University Medical CenterThe Bridge Model
- 14. A Case ExampleMrs. HarrisonWidowed
- 15. 75 years old
- 16. Has diabetes and COPDAdmitted through the ED after a fallHospitalized for 5 days
- 17. Discharged with home health care
- 18. 10 medications prescribedIs this the worst case scenario, or is it a typical transition?Mrs. Harrison at HomeCommunity PCP doesn’t know Mrs. Harrison was admitted to the hospital.Mrs. Harrison’s primary caregiver is overwhelmed and has to return to work.Mrs. Harrison is afraid she will fall again and have to return to the hospital.Mrs. Harrison doesn’t know which medications to resume and which to stop taking at home.The Home Health Care Agency doesn’t arrive on time.Mrs. Harrison’s two children can’t agree how to best manage their mother’s medical needs.Mrs. Harrison is feeling depressed because she can’t get around anymore like she used to.Mrs. Harrison is having difficulty coping with her mobility changes.Mrs. Harrison has questions about her medical bill and doesn’t know what her insurance will cover.Mrs. Harrison can’t afford her medications anyway.Mrs. Harrison has no transportation to her follow-up medical appointments.Mrs. Harrison is feeling isolated now that she’s homebound.Mrs. Harrison’s Community Services are delayed
- 19. http://blog.reflexstock.com/2009/12/a-selection-of-stunning-images/The Bridge Model
- 20. The Bridge ModelOverview of ComponentsSocial-worker Based: Bridge Care CoordinatorInterdisciplinary TeamsHospital HomePatient Focused, Community-Specific The Aging Resource CenterUrban, Suburban, and Rural applicability
- 21. The Bridge ModelThe participant enters the hospital with more than an illness. Caregiver
- 22. Family
- 23. SES
- 24. Race
- 25. Gender
- 26. Ethnicity
- 27. Religion
- 28. Mental Health
- 29. Personal Values and Beliefs Referrals can originate from an electronic medical record, a discharge planner, the patient or a family member.Risk screen built in to the EMR
- 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.
- 31. The Bridge Model ProcessThe Bridge Care Coordinator builds relationships with the community service providers. Services get fast-tracked to aid in a seamless transition upon discharge The Bridge Care Coordinator conducts a comprehensive assessment and intervention to identify needs unrealized prior to discharge.Medication compliance
- 32. Transportation to doctor’s appointmentsCommunity resources neededScheduled doctor’s appointmentSafety at home At 30 days, the participant/caregiver gets contacted and the transitional process gets assessed.Warm handoff made to appropriate agenciesDoctor’s visit completed
- 33. Medication regimen understood Safety at home
- 34. Any additional unmet needs
- 35. Building off of Aging NetworkConducting Choices for Care Assessments and CCC AssessmentsSetting up CCP Interim Services and Interim Home Delivered MealsProviding and referring families for Caregiver Support Services and Respite Conducting Benefits Check-UpsProviding Information & Assistance to Patients and their families on site (i.e. Medicaid, Food Stamps, Circuit Breaker, Tax Freezes, Medicare Part D, Home Modification, FSS)
- 37. Bridge Care CoordinatorsWhy Social Workers?Systems TheoryBiopsychosocial framework Psychosocial determinants of healthhttp://early-childhood-resources.com/2010/05/reflection
- 39. Psychosocial IssuesSocial isolationDepressionDifficulty coping with changeFinancial stressorsLanguage barriersHealth literacy barriersOlder generations taught to be “good patients”40-50% of readmissions linked to psychosocial issues and lack of community resources
- 40. Calculating the CostWhat is the REAL cost?Staff allocationOverheadTrainingCase load efficiencyhttp://www.boston.com/ae/theater_arts/exhibitionist/2007/06/salaries_of_sym.html
- 41. SustainabilityCan’t do good without doing wellWho’s money are you saving? Who is your audience?Business case optionsReadmissionsHigher yield patientsPatient SatisfactionThe “3026 RFP”Grantshttp://www.thinkgeek.com/gadgets/tools/a396/
- 42. Building RelationshipsIlana Shure, Aging Care ConnectionsEsther Izaguirre, Solutions for Care
- 44. The Role of the ARCSymbol of hospital-community collaborationGreater ability to interface with the communityPromotes the notion of “systems” approach to discharge planning.Maximizes the opportunity for a servable moment.
- 47. Community-Hospital PartnershipsAging Care Connections (CCU - Suburban Chicago) Adventist LaGrange Memorial Hospital Shawnee Alliance for Seniors (CCU – Rural, downstate Illinois)Memorial Hospital of CarbondaleHerrin HospitalSolutions for Care (CCU – Suburban Chicago)Mac Neal HospitalCentral West (CMU – Chicago)Rush University Medical Center
- 48. Aging Network: National State
- 49. Illinois Aging Services Network
- 50. Establishing a Connection to the Aging NetworkMany older adults seen at the hospital by Bridge Care Coordinators have yet to get connected to resources available through their community54% of ARC clients had no previous interaction with their local Care Coordination Unit (N=399)Bridge Care Coordinators connect older adults to the aging network49% 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 ARCTime frames for developing the ARCOutreach to hospitalThrough existing programs or contracts already establishedBegin contacting individuals at the hospital who are supportive of the model.
- 52. Establishing a PartnershipEvaluate Potential PartnersMake the “ASK”Identify what you are asking the partner to contributeEstablish the basic structure of the partnership prior to launching the projectKeep parameters loose enough to allow for growth developmentAn 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 programResponsibilities of both partiesIndividual responsibilities of the partnersFinancial liabilitiesConfidentiality and data sharingTerminationAnnually review agreement!http://www.fortklock.com/signatures.htm
- 54. Lessons Learned Integrate at all levels of the hospital systemFront desk reception to Regional DirectorBe patient and persistentGuest versus Team MemberTroubleshoot challenges before they become barriersLearn both cultures and languagesNetwork, network, networkCultural Competency SFC services a Diverse Population40% Hispanic 37% Limited English Speaking or only speak SpanishBilingual and Bicultural Bridge Care Coordinators
- 55. Cultural Competency Continued Assess clients and caregivers in their language and coordinate and link them to servicesBCC 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 ContinuedSupport Groups for Spanish Speaking CaregiversChronic 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 HealthResearch & Evaluation
- 58. The Bridge Model Evidence BaseThe 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 sitesBridge is a hospital and community partnership
- 59. Rush University Medical Center Study Randomized controlled trial of 720 patientsAll patients older than 65 with multiple medical conditionsHalf received follow-up intervention, half were in the “usual care” groupQualitative 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-dischargeFor 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 RCTAlmost 1/3 of patients (29.3%) contacted the Bridge social worker for additional services or information after the case was closed49
- 65. Evaluation of the Bridge Model Important variables from our previous work and other evidence based care transitions interventionsPatient characteristicsHealth statusPatient stressCaregiver stressUnderstanding of responsibilities for managing healthMedical follow upHospital readmissionsMortalitySatisfaction
- 66. Evaluation data collection- ITCC BridgeIntake assessment2 day post discharge assessment30 day follow up assessment Satisfaction surveyBoth “patient” and “caregiver” versions of the assessment surveysTelephoneEmail /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 5/10-3/11Male 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 assessmentOlder 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 assessmentOlder 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 assessmentCaregiver stressSince 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 assessmentUnderstand medicationsI 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 assessmentUnderstand 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 assessmentProblems/“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/adherencePhysician communication- 95.1%Physician visit -95.3%
- 76. 30 day outcomes adverse eventsRehospitalized within 30 days of d/c- 8.9%Mortality - 2.0%
- 77. Satisfaction surveyDecision makingThe assistance or information you received from the Bridge Program helped you (or your loved one) make decisions about your careStrongly agree 40.1%Agree 59.1%Disagree 0%Strongly Disagree 0%
- 78. Satisfaction surveyLinks to community servicesThe 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 surveyPatient stressBridge 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 surveyCaregiver stressThe Bridge program helped to make the hospital discharge experience less stressful for family or other loved onesStrongly agree 31.8%Agree 59.1%Disagree 4.5%Strongly Disagree 4.5%
- 81. Satisfaction surveyBridge Care Coordinator - knowledgeThe Bridge social workers were knowledgeable.Strongly agree 47.8%Agree 47.8%Disagree 4.3%Strongly Disagree 0%
- 82. Satisfaction surveySatisfaction I would recommend this program to othersStrongly agree 41.0%Agree 59.0%Disagree 0%Strongly Disagree 0%
- 83. Satisfaction Survey - QuotesSatisfactionUnmet 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 ….”
- 85. Contact InformationSusan 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)
Editor's Notes
- #5: ITCC is a result of collective experience in the field of aging, and visionary leadership
- #7: Kristen – I’ve mentioning this a lot on presentations – when you get to the 40-50% make it clear that it does not imply that social workers can only prevent 40-50% of readmissions because social workers can intervene on numerous medical issues by connecting the right silos of care together. Things like medication regimen or discharge instruction confusion, etc.
- #16: ilana
- #18: Pre-discharge: referrals in one of a few ways (emr, walk-ins, d/c planners), assessment in one of a few ways (emr, interdisciplinary team, d/c-planner, family/patient)
- #19: Post-discharge: 48 hr. assessment and intervention (in-depth piece, follow up on important non-resource issues like pcp f/u, regimen understanding, caregiver burden, unmet needs, home health, etc. )
- #23: Key word: advocacy
- #24: Bring up own experience when possible (tell them a little story)“good patient” is a big reason why the situation changes post discharge. We’re all taught to respect doctors and we nod and say yes, but do we really understand? So even with good coaching, however (coleman, naylor), things will go wrong at d/c
- #35: Note that not all participants live in area…this is just a snapshot from one CCU
- #44: Building on what we have learned
- #46: Not a discharge planning issue but UNANTICIPATED SURPRISES!
- #52: Integrating intervention and data collection to minimize burden for pts and staff
- #53: Data on a much smaller sample --- designing data measures, irb approvals, hospital approvals, coordination
- #55: (point out on slide the name of the variable ---and then how the question was asked)
- #69: Marketing!
- #70: Walter and ilanaTell them that more details on BCCs and data is still coming