Navigating Care Transitions in California: C A L I FOR N I A H EALTH C ARE Two Models for Change F OU NDATION Introduction California, CHCF selected two consultants Care transitions refer to the movement of patients with expertise in California health care policy, from one health care practitioner or setting to operations and financing, to explore opportunities another as their condition and care needs change. to spread effective care transitions models. The These may include transitions from hospitals Issue Brief consultants, Bonnie Darwin and Monique Parrish, to nursing homes or home care after an acute interviewed representatives from health care illness, or transitions from nursing homes to home organizations with a history of incubating best care or home without care. Medication lists that practices for patient populations with complex don’t match, undeveloped and underdeveloped health care needs and facilitated a forum to connections to care after a hospital stay, and provide a broader discussion of the strengths and complex discharge instructions are just a few of the weaknesses of two evidence-based care transitions most common care transition challenges. models piloted in California, which are discussed below. The process yielded a distinctive outline Health Care Organizations Respond of the advantages and disadvantages with the two Too often patients with complex acute or chronic models — from an in-the-trenches perspective, conditions are ill-prepared for the transitions that as well as a thoughtful analysis of the barriers to occur during the course of their care, resulting in effective implementation. increased risk for readmission and the compromise of patient health. Because poor care transitions A Look at Two Care Transition Models affect patients, clinicians, and the health care During 2007 to 2008, the California HealthCare delivery system, a growing number of health Foundation sponsored implementation of two care organizations and professional organizations evidence-based care transitions models: The have identified improved patient care, safe Coleman Care Transitions Intervention, developed discharges, and medication reconciliation as core by Eric Coleman, M.D., M.P.H., University care transition issues requiring new performance of Colorado Health Sciences Center; and The measures and public reporting requirements. Naylor Transitional Care Model, developed by Mary Naylor, Ph.D., R.N., F.A.A.N., University The California HealthCare Foundation sees of Pennsylvania. Although using different improvements in care transitions as central to approaches, both models provide patients with its overall efforts to improve chronic disease the tools and support they need to understand care in California. With support from CHCF, and take a more active role in managing their two projects promoting proven care transitions care. Additionally, both provide a framework for models are being tested in California on a small larger systems transformations, including practice scale; one with Kaiser Hospitals and one with and cost-savings changes. Several advantages and ten community/hospital partnerships. To identify disadvantages associated with implementation of S eptember options to spread effective care transitions in the two models surfaced. Examining these findings 2008 provided important insights and contributed to the larger From an individual perspective, the primary goal of CTI discussion regarding how best to spread and sustain is to empower patients with chronic illnesses to manage effective care transition models in California. their health and care needs; from a population and system perspective, the primary goals of the intervention Each model has been tested to prove its effectiveness. are to improve patient transitions from one care setting Study findings from the randomized clinical trial of the to another and to stimulate change within health care Coleman Care Transitions Intervention revealed that delivery systems. intervention patients had lower re-hospitalization rates at 30 days and at 90 days compared to controls.” 1 Four Elements of the Coleman Care Transitions Intervention For the Transitional Care Model developed by Naylor, the most recently reported multi-site RCT tested a care transitions model addressing health problems 1  Medication Self Management Focus: Reinforcing the importance of knowing each medication — when, why, and how to take what throughout an acute episode of heart failure. is prescribed, and developing an effective medication When compared to the control group, members of management system. the intervention group showed better physical function, quality of life, and satisfaction with care and fewer total re-hospitalizations resulting in a mean savings of 2  Patient-Centered Health Record (PHR) Focus: Providing a health care management guide for patients; the PHR is introduced during the hospital $5,000 per elder.2 visit and used throughout the program. The Coleman Model. The Coleman Care Transitions Intervention (CTI) is a four-week process designed to 3  Primary Care Provider/Specialist Follow-Up Focus: Enlisting patient’s involvement in scheduling appointment(s) with the primary care provider or empower and support patients to take a more active specialist as soon as possible after discharge.  role in their health care. Through one hospital and one home visit and a series of follow-up phone calls with a designated transition coach (typically a nurse, social 4  Knowledge of Red Flags Focus: Ensuring patient’s knowledge about indicators that suggest that his or her condition is worker, or community worker), whose primary role is “to worsening and how to respond. coach not do;” patients with chronic or serious health conditions develop improved capacity in the areas of medication management, personal health record keeping, The Naylor Model. The Naylor Transitional Care Model, knowledge of “Red Flags” (health indicators that suggest a model of care coordination with an interdisciplinary that a condition is worsening and how to respond), and approach, is delivered to elderly patients at high risk for follow-up care with primary care providers and specialists. poor post-discharge outcomes. The care is overseen by by master’s degree-prepared advanced practice nurses CHCF sponsored a 12-month pilot of the CTI model (APNs), identified as transition nurse managers (TNMs), with ten project site teams, each hosting a sender who work in conjunction with physicians. Transition (hospital) and receiver (community organization) support lasts approximately eight weeks and includes partnership, from around the state. Five of the teams were comprehensive discharge planning and home follow-up hospital-led and five were county-led. Patients targeted to high-risk, high-cost, high-volume patient groups to for the intervention represented California’s diverse racial, improve post-discharge outcomes among this vulnerable ethnic, cultural, geographic, and economic communities. population.3 2  |  California HealthCare Foundation CHCF sponsored an extended implementation pilot learning and change, the Naylor model provided a of the Naylor model in three Kaiser sites in California more protracted time for patients to develop the skills using several variations of the model originally delivered and abilities to manage their health needs. Both pilots by advance practice nurses . One of the three sites used promoted improved care transitions through a process of bachelor’s-level nurses, one used advanced practice patient empowerment (more pronounced in the Coleman nurses, and one used a combination of both. Despite model), education, and support, beginning in the hospital the different professional compositions, all three models setting. followed the same intervention outline. The transition nurse met daily with the patient during hospitalization. Advantages and Disadvantages of the Models Following discharge, a home visit was scheduled within The central focus of the Coleman Intervention is helping 24 to 48 hours. Thereafter, home visits were conducted patients assume greater responsibility and control over weekly for the first month with follow-up calls during the their health care through a coaching process in which second month. Transition nurses were available seven days the transition coach abandons the traditional role of a week throughout the intervention. Specific tasks of the “doing” in favor of “modeling” how patients can care for intervention were: (1) to monitor and manage symptoms themselves more effectively. Because transition coaches and prepare the patient for discharge; (2) to provide do not have to be nurses (a scarce resource), there is the patient with health care information, education, greater flexibility in implementation. Moreover, the and training regarding his or her specific health clearly defined four pillars the model offered a simple condition; and, (3) to assist the patient with medication architecture for intervention. Regarding key disadvantages management and reconciliation. of the Coleman model, a number of the pilot sites felt the intervention lacked a built in way to identify and stratify Table 1 highlights the differences and similarities between patients for more intensive interventions for those patients the two models as they were implemented in their with complex psychosocial and medical conditions, CHCF-sponsored pilots in California. As depicted, the and moving them into case management programs. organizational structures differed. The Coleman pilot Other significant disadvantages included the cost of the used various hospital-community organization team transition coach, which, to be effective, required at least combinations to facilitate the intervention, while Kaiser a dedicated half- to full-time employee, and long-term implemented the Naylor model at three of its sites. commitment to fund the care transition role. Without While the Coleman model was designed specifically as funds or regulatory requirement, most of the pilots’ health a brief intervention to capture and address immediate care delivery systems lacked the incentive to sustain the needs and maximize post-discharge opportunities for care transitions program. Table 1. Comparison of Coleman and Naylor Care Transitions Pilots in California I nter v ention F oc u s Pat i e n t Follow P e rs o n a l O r g ani z ational L en g th of Educa t i o n M e d i ca t i o n up w i t h H e a lt h mo d el S tr u ct u re T ransitions L ea d I nter v ention Tra i n i n g Management D o c t o rs R e c o rd Coleman Hospital-community Transition coaches 4 weeks 4 4 4 4 organization teams (nurses, social workers, community workers, student nurses, etc.) Naylor Hospital Advanced practice and 8 weeks 4 4 4 bachelor’s nurses Navigating Care Transitions in California: Two Models for Change  |  3 The Naylor model exhibited a similar array of strengths The Elements of a Viable Care Transitions and weaknesses. A well-tested intervention over the Program past twenty years, the Naylor model proved flexible Building on the Coleman and Naylor models, interviewed in accommodating various nursing configurations for stakeholders identified a list of core care transitions the role of transition nurse. Additionally, the intensive elements (see sidebar) and care transition processes. The education, monitoring, and interdisciplinary team latter include: pre-hospital care transitions work — that approach was well received by patients with chronic is, health plans identifying high-risk patients before illness, and gave them increased confidence in their acute care admissions based on diagnoses and utilization ability to manage their health conditions. Challenging patterns; stratification of care transitions, that is, to Kaiser’s implementation of the intervention, however, establishing different interventions for patients based on were difficulties with staff continuity and recruitment, individual need (information, intensive case management, and experience and comfort level of nurses acting in new etc); variable lengths of care transitions interventions roles. The latter referenced the identification of transition governed by need and including a more comprehensive nurses who could fulfill clinical nurse functions and care overview of available home and community-based management functions, while simultaneously promoting services; and, finally, a process for engaging a wider group patient empowerment. Finally, as a health maintenance of natural partners — hospitals, community organizations, organization assuming financial risk for the costs of care, home health agencies, primary physicians, patients, and Kaiser has more incentives to test and implement care family members. transitions models. Other organizations without those incentives struggle to pay for the costs of the model, The process recommendations were informed by examples especially if they do not reap the benefits of reduced of other care transition models currently in place in hospitalizations. California. Contra Costa Health Plan employs a three- Implementation of the Coleman and Naylor models represented an important step forward in deconstructing Expanded Care Transitions Core Elements how to improve care transitions in multiple health • Medication reconciliation (to include accurate lists of care delivery systems using different approaches. Both medications transferred from one setting to another). care transition models initiated change in the care • Red flags (health indicators that suggest that a transitions process, engaged multiple stakeholders, and condition is worsening and how to respond). promoted consumer-centered care. Feedback from both • Personal health record (maintained by the patient models however, underscored that each intervention has and containing current medications, health status, and questions for providers). advantages and disadvantages. Feedback from the larger • Interdisciplinary team approach (recommend that statewide care transitions discussion with stakeholders nurses, social workers, and physicians provide the broadened the discussion, distilling the core elements and core interdisciplinary approach to promoting and processes for a viable care transitions effort. sustaining effective care transitions). • Engaged primary provider (focus is on engaging community physicians in the care transitions process before and after acute care stays). • Information dissemination (accurate and timely sharing of appropriate patient information among providers). 4  |  California HealthCare Foundation tiered patient support program that stratifies members adoption of improved care transitions, as well as public into the following services: member services for general policy options that could encourage all payers to embrace resource information; a modified care transitions service, implementation. Widespread adoption of new practices facilitated by nurses; or, intensive case management. across health care settings necessitates change in: Patricia Tanquary, Executive Director of Contra Costa K Payment mechanisms; Health Plan noted, “our [stratified] care transitions approach allows us to respect the diversity of our patient K Standards and regulations; and population and move away from a one-size-fits-all model K Medical culture and operations. of health care.” Hospital Readmission: How Payment Moving Toward Widespread Dissemination Mechanisms Encourage or Discourage of Improved Care Transitions Improved Care Transitions Twenty five years have elapsed since the Diagnostic Although hospital readmissions are just one symptom of Related Group (DRG) payment mechanism for hospitals the many clinical and social problems related to poorly ushered in widespread public concern over the “quicker, coordinated hospital care transitions, issues associated sicker” discharge of patients; however, little attention with readmission offer both an explanation for the early has been paid to the clinical and logistical challenges adoption of improved care transitions practices and the many patients face following discharge. Although seeming disinterest on the part of other providers. Medicare patients report greater dissatisfaction related to discharges than any other aspect of care that the MedPAC, an independent Congressional agency Centers for Medicare and Medicaid (CMS) measures, established to advise the U.S. Congress on issues and anecdotes abound about the difficulties elders and affecting the Medicare program, reports that 18 percent persons with chronic illness often face, little has been of Medicare hospital admissions result in readmissions done to address the problem until recently. However, it within 30 days of discharge, accounting for $15 billion in appears that in interest in improving care across settings spending. The Commission found that Medicare spends is now growing. Organizations and agencies ranging from about $12 billion on potentially preventable readmissions. the Medicare Payment Advisory Commission (MedPAC), And the most costly beneficiaries, those the top CMS, the Quality Improvement Organizations, the Joint 20 percent, have an average of 1.7 admissions per year. Commission, the World Health Organization, National Transition of Care Coalition, and the American Board of Managed care organizations. For organizations that Internal Medicine have all recommended strategies for manage risk, reducing costs associated with readmission improving care transitions. and improving member satisfaction provides a strong incentive for investing in improved care transitions. Not Although the two models described provide more than surprisingly, organizations in California that bear risk adequate evidence of reduced hospital admissions, are already in the process of implementing improved improved clinical outcomes, and increased patient care transitions practices, although not by any means satisfaction, these outcomes alone are not sufficient to universally. A number of organizations have tested induce health care providers to embrace implementation. either the Naylor or Coleman models and others have Significant barriers — operational, regulatory, and modified and embellished these models to suit the patient fiscal — abound. The second half of this paper examines populations they serve. both the incentives for and impediments to widespread Navigating Care Transitions in California: Two Models for Change  |  5 Such diverse organizations as SCAN Health Plan, Kaiser, improving certain aspects of care: reconciling medications Health Care Partners, On Lok, Contra Costa Health at the time of discharge; improving communication Plan and CalOptima have adopted variations of either with patients so they understand post-discharge the Coleman or Naylor models. These providers have a instructions and have adequate information about history of innovation with the populations traditionally self-care; communication with other providers; and thought of as needing additional support in transitioning timely summaries at the time of discharge. These between settings. In some of the implementation efforts, recommendations are consistent with the improved care care transitions coaching is extended to include care transitions practices in both the Naylor and Coleman coordination when necessary. America’s Health Insurance models. Plans (AHIP), representing 1,300 member companies, convened the HMO Workgroup on Care Management, Based on MedPAC recommendations, CMS is seeking which met quarterly for seven years to discuss ways in comment on three proposals to take the financial which the delivery of care to Medicare beneficiaries can reward out of readmissions: (1) direct adjustments to be improved. In its report One Patient, Many Places, the DRG payments for preventable readmissions; (2) make Workgroup reflected that Medicare Advantage plans have adjustments to DRG payments through a performance- the flexibility and incentives necessary to coordinate care based payment methodology; and (3) publicly report seamlessly across integrated settings. These organizations readmission rates. move beyond traditional utilization management aimed at monitoring service use in individual settings to a Recognizing disincentives for coordinating care broader focus that includes improving the efficiency and across settings, in June 2008, MedPAC additionally effectiveness of transfers to different venues. recommended creating a voluntary program to test the feasibility of “bundling” payment policies that would pay Fee-for-service. Traditional fee-for-service, on the other for care that spans across provider types and would hold hand, rewards readmission. Throughout the fee-for- providers accountable for quality over the course of the service delivery system, paying for each individual service episode of care. Under bundled payment, Medicare would and staying within current payment system “silos” inhibits pay a single provider entity (composed of a hospital and changes that might result in better coordination across its affiliated physicians) an amount intended to cover the services that could lead to efficiencies or enhanced quality costs of providing the full range of care needed. across settings. Currently, Medicare pays for all admissions based on the patient’s diagnosis, regardless of whether it Standards and Regulations Related to Care is an initial stay or readmission for the same or a related Transitions condition. As such, it does not reward hospital-based Standards set by CMS and other organizations serve initiatives that could successfully avert many readmissions. to impede or promote the adoption of improved care In addition, hospital discharge planning is a cost center transitions strategies. The Joint Commission and the rather than a revenue generator. World Health Organization have identified medication accuracy during transitions in care as one of nine patient In June 2007, MedPAC examined payment policies that safety issues that need to be addressed and for which rewarded hospitals that reduced readmissions, as well as solutions need to be developed. policies that penalized hospitals for readmissions that could have been prevented. From its findings, MedPAC In its Ninth Scope of Work contract with quality reported that many readmissions could be avoided by improvement organizations (QIOs), CMS will work with 6  |  California HealthCare Foundation selected state QIOs to implement initiatives throughout are not met, the result can be as problematic as errors in their local communities concerning quality care for medication reconciliation. Medicare beneficiaries at or after hospital discharge. Three measures of care coordination are specified: (1) reductions In general, medical providers and social service agencies in global re-hospitalization rates; (2) inclusion of patient have little understanding of each other’s cultures. It is assessment of hospital discharge performance in the not uncommon for social service agency personnel to Hospital Consumer Assessment of Healthcare Providers & disparage the inadequate job that hospital discharge Systems (H-CAHPS) survey, developed by CMS to collect planners do, not recognizing that hospitals are not paid information on hospital patients’ perspectives of the to follow patients after discharge. And, it is also not care they received while in the hospital; and (3) insuring uncommon for medical personnel to feel frustrated with timely physician visits post discharge. the constraints of social service agencies. In a hospital, a quick turnaround is often an hour, while for social service An alternative to hiring separate staff to coordinate care agencies with limited personnel a quick turnaround can transitions would be for the hospital to contract with be several days. Moreover, social service agencies may a home health agency to provide transitions coaching. not be able to accept all the referrals that medical care Albeit a seemingly natural partner, two regulatory hurdles providers send them. An additional challenge for hospitals were identified by leaders in the CHCF forum that is simply keeping an updated list of the myriad number of would limit use of this option. First, the requirement that community agencies and the services they provide. home health agencies administer the lengthy Outcome and Assessment Information Set (OASIS) patient Neither care transitions model specifically addresses assessment required by the federal government would whether social service agencies that are already connecting be operationally unfeasible within the care transitions people with services could be trained to “take the process. Second, there is concern expressed over the baton” and provide care transitions coaching. However, recent prohibition of home health and hospice agencies in some parts of the state, well-organized home and visiting patients in the hospital prior to discharge. The community-based service networks have stepped up particular application of this “restraint of trade” provision to respond to their client’s need for additional support is outside the scope of this paper; however, while home following a discharge. The advantage of reaching out to health agencies could be a natural partner in managing non-traditional partners is embodied in the work of the care transitions, the perception exists that current federal San Francisco Homecoming Services Program. Led by requirements would prohibit their involvement. the San Francisco Senior Center, this unique collaborative addresses care transitions for frail older adults returning Medical Culture and Operations home after hospitalization. Director Kathleen Mayeda Neither the Coleman model nor the Naylor model pinpointed the reason for the program’s success, “All the explicitly addresses connecting recently discharged partners are at the table. We have hospitals, senior centers, patients with social supports in the community. However, In-Home Supportive Services, Meals on Wheels, etc. It is any number of non-medical issues can threaten a safe a true partnership.” discharge to home, including shopping for food after discharge, driving to medical appointments, and the CMS has taken a small step toward creating new models need for personal care services. The coordination of these for collaboration between hospitals and social service services is generally thought to be the domain of social agency through their Real Choice Systems Change service agencies in the community. Yet, if these needs and Aging and Disability Resource Center (ADRC) Navigating Care Transitions in California: Two Models for Change  |  7 grants. The purpose of the grants is to establish “person- and health care systems, community organizations, centered” discharge planning and long-term community professionals from all backgrounds and disciplines, support models through partnerships involving hospitals, patients and families, and government and public community organizations, patients, and caregivers. The officials. ADRCs are dedicated to providing consumers with a one-stop entry for information and support — a benefit On the face of it, Medicare Advantage plans have an for hospitals trying to keep updated lists of community inducement to adopt improved care transitions practices. agencies. The ADRCs are also committed to improving The data suggests implementing either of the two models the critical pathways between hospital and home for will result in the reduction of member complaints patients discharged to home or other community settings. and lowered readmission rates. Once the case is made, it is likely that implementation will naturally result. Legislatively, California has also recognized the need for However, the prevalence of the delegation of risk in improved care transitions and safe discharges. California California muddies the incentive to put care transitions Senate Bill 633 (Alquist, 2007) attempts to bridge the into operation. Whether the plan or the networks they gap between hospitals and social service agencies by contract with has the incentive to enhance care transitions requiring hospitals to “provide every patient anticipated will depend on the risk arrangements. One of our to be in need of long term care at the time of discharge participants remarked “if you want a universal solution, with contact information for at least one public or you have to go to scale.” This suggests that on a case nonprofit agency or organization dedicated to providing by case basis, managed care organizations or provider information or referral services relating to community- networks will invest in improved care transitions practices based, long term care options in the patient’s county of if they believe there will be a net savings. residence and appropriate to the needs and characteristics of the patient.” Aligning incentives for Medi-Cal managed care is also tricky, either because the plans don’t manage the It is always a challenge to make changes in an entrenched long term care benefit or they serve as the payment culture. Based on their experience, health care providers administrator of the state rate. Consequently, there who were interviewed recommended that care transitions is an incentive for plans to institutionalize the very needs to be “someone’s job,” rather than an adjunct members who would most benefit from improved care duty for someone employed within the hospital. If care transitions protocols. However, there is considerable transitions functions are an “add on,” it is all too easy for interest on the part of County Organized Health Systems home visits to be skipped when duties within the hospital and some Local Initiatives to manage the long term are pressing. And, successful implementers stressed the care benefit — which could, as one plan has stated, “be need to engage physicians and administrative leaders early accomplished by the stroke of a pen.” Based on their and often. experience as one of the participating organizations in the CHCF-sponsored pilot, San Mateo County has Next Steps for California proposed the state add care transitions as a component of Seemingly, the success of widespread dissemination of their Long Term Support Services Program (LTSSP). The improved care transitions practices is dependent on plan’s intent is to keep members in the community and to having cost and payment for services all in the same place. ensure that the savings achieved by not institutionalizing Fortunately, diverse partners are starting to come to the a member could be used to enhance services provided to table to explore how best to work together — hospitals safely keep people at home — including enhanced care 8  |  California HealthCare Foundation transitions processes. Improving care transitions goes a Conclusion long way to ensuring that older individuals and persons Today’s health care system is burdened with rising with chronic conditions can continue to be safe at home. health care costs; limited resources; an aging population with a growing list of chronic conditions requiring Despite the fact that hospitals continue to be paid for months, years, and occasionally decades, of detailed readmissions, there is interest in care transitions from the care management; and a lack of coordination with perspective of patient safety. Many hospital readmissions the community from which it receives and returns its are preventable. Reducing in-hospital medication patients. With so many challenges, hoping that patients errors has also been of interest to hospitals seeking get the continuity of care they need won’t make it so. to improve patient care and reduce their associated Patients suffer when they don’t have well thought out liability. Medication reconciliation is a key component of coordination of their care after discharge. And it has a improved care transitions. negative impact on those beyond the patients — family members, hospitals and health systems, community The California Hospital Assessment and Reporting providers, and government agencies, to name a few. In Taskforce (CHART) was established in 2004 to develop fact, the impact of inadequate discharge planning trickles a statewide hospital performance reporting system. More down to society’s fundamental infrastructure, adding to than 220 of California’s 359 acute care hospitals have the health care crisis and the potential for a more serious chosen to participate in the voluntary effort that creates degradation of our nation’s health care system. For all the data displayed on a consumer-friendly Web site. these reasons addressing care transitions needs to be a In addition, the California Hospital Association has priority. established a patient safety organization that could permit the examination of care transitions on a statewide or regional level with the same peer review protections that Endnotes an individual hospital currently receives. This suggests 1.Coleman, EA, The Care Transitions Intervention, Archives that on a regional basis, networks — which could include of Internal Medicine, 2006;166:1822 – 1828 non-traditional providers of home and community based 2.Naylor, MD, “Transitional Care for Older Adults services — could implement improved care transitions Hospitalized with Heart Failure: A Randomized, protocols across settings and study the results. Controlled Trial,” Journal of the American Geriatrics Society, 2004; 52:675 – 684 Although none of the regulatory, operational, or fiscal 3.Hartford Center of Geriatric Nursing. Transitional issues are insurmountable; changing the payment policies Care. 2005. www.nursing.upenn.edu/centers/hcgne/ for hospital readmissions is the key to widespread TransitionalCare.htm. Accessed August 17, 2008. dissemination of improved care transitions practices. Navigating Care Transitions in California: Two Models for Change  |  9