Hospital Transitions: Manual to Engage Georgia Aging Network | HCBS-5300-MANUAL

The seven evidence-based, hospital transition (EBHT) programs articles include many common implementation elements. Four programs rely on trained individuals to coordinate and implement the EBHT components (Boult et al., 2011; Coleman, Mahoney, & Parry, 2005; ITCC, 2013; Naylor, Kurtzman, & Pauly, 2009), and the other three have a team approach to providing structured support to patients identified as being at risk for readmission (Allendorf, 2012; Counsell et al., 2006; Jack & Bickmore, 2010). All seven programs identified medications management and encouraging self-management, caregiver engagement, enhanced healthcare team communication, and a post-discharge follow-up of some sort.

Each of the programs have unique components, are offered for varying durations, occur within different settings, and have differing training requirements for staff conducting the program. The two most well-known EBHT programs are the Care Transition Intervention (CTI) and the Transitional Care Model (TCM) (Meier & Beresford, 2008; Lim, Foust, & Van Cleave, 2012). Four additional programs promoted by the U.S. Administration on Community Living (Padilla, Ryan, & Markwood, 2011) are Project BOOST (Better Outcomes by Optimizing Safe Transitions), The GRACE (Geriatric Resources for Assessment and Care of Elders) Model, The Bridge Program, and Guided Care. The Georgia Hospital Engagement Network selected Project Re-Engineer Discharge (RED) to promote, which is also included in this literature review (Cameron, 2013).

The Care Transitions Intervention (CTI) relies on training a registered nurse as a Transitions Coach (TC) to implement the four week intervention. The TC coordinates the care of the identified patient and ensures, through encouraging and modeling self-management (Lim, Foust, & Van Cleave, 2012) that the individual is able to adhere to a discharge plan revolving around the following four pillars: proper medications management, use of a Patient Health Record, ability to schedule and get to recommended follow-up appointments, and that the patient and caregivers are aware of possible "red flags" that a condition is worsening and then know what to do in such a case.

The TC meets with the patient pre-discharge, schedules and conducts a home visit within 72 hours, and then makes three or four follow-up phone calls over the remaining duration of the 28-day program to ensure the patient and any caregivers have full mastery of the four pillar concepts.

Dr. Eric Coleman and colleagues at the University of Colorado developed the CTI well over a decade ago and have conducted extensive research on its effectiveness in reducing acute care readmissions (Meier & Beresford, 2008). In their 2006 study, Coleman, Parry, Chalmers, & Min found CTI to reduce readmissions with statistical significance at 90 and 180 days post-discharge. In the articles reviewed, however, there was not a great deal of information regarding study subjects in terms of socioeconomic status or diversity in terms of race and ethnicity. Based on a 2009 study with Medicare fee-for-service clients (many lower-income individuals), CTI was found to be an effective intervention though demographics of participants were not discussed (Parry et al., 2009).

As for cost savings, Coleman, Parry, Chalmers, & Min (2006) found the return on investment for using the CTI on their study sample was a conservatively estimated annual savings of approximately $295,500 per Transition Coach’s caseload (24-28 participants at any given time).

Dr. Mary Naylor and colleagues at the University of Pennsylvania developed the Transitional Care Model (TCM). Similar to the CTI, one person is responsible for the TCM’s implementation. However, for this model it is a trained Advanced Practice Nurse, or Transitional Care Nurse (TCN), who provides continuity of care for the individual patient, beginning no more than 24 hours after being admitted to the hospital. The duration of the TCM intervention is as short as one month and up to three months, depending on the client’s needs.

Over this time, the TCN implements the TCM’s "nine core elements": pre-discharge assessment and established care plan; continuity of care facilitated by TCN; scheduled and regular home-visits and 24 hour access to support via telephone; patient-centered care; engagement of patient and informal and formal caregivers in care plan ownership; setting long-term goals with patient and caregivers and providing education and support for ways to meet those goals to ensure successful outcomes; using a multi-disciplinary, team building approach; communicating directly to physicians and Primary Care Providers (PCP) on the patient’s behalf with knowledge of healthcare goals; and acting as the liaison and providing effective and clear communication between patient, family, caregivers, and healthcare providers (Meier & Beresford, 2008).

The TCN accomplishes this by meeting daily with the patient while admitted to establish a rapport with the patient and to ascertain the patient’s long-term health goals. Post-discharge, the TCN schedules and visits the home within 24 hours, and once a week for the rest of a month’s time. The TCN, during one of the first month’s visits, accompanies the patient to their first PCP appointment to provide healthcare-speak "translation."

Through their 1999 randomized clinical trial, Naylor et al. had an excellent representation of African Americans, persons of low-income, those with limited education, and persons self-reporting only fair or poor health. The researchers found, with statistical significance, that the intervention group experienced fewer acute events resulting in fewer hospitalizations after 24 weeks. The reimbursement requests for the control group were more than double that of the intervention participants.

Though the TCM is more costly to implement (use of a master’s level nurse and up to a three month intervention), Lim, Foust, & Van Cleave (2012), gleaned from former publications of the TCM developers that intervention participants had a reduction in hospitalizations as compared to the control group resulting in an average $5,000 annual healthcare saving per individual. The authors also stated that patients reported an increased quality of life, enhanced physical functioning, and higher satisfaction with care received.

Developed by the Society of Hospitalists, Project BOOST uses a healthcare team approach to ensure five key program elements: I) to assist hospitals develop a comprehensive intervention; 2) to construct a comprehensive implementation guide; 3) to provide hospitals with longitudinal technical assistance with face-to-face visits for the year-long patient intervention; 4) to establish a BOOST collaboration for those implementing the model to share tools and resources; and 4) the BOOST data center provides online communication, tools and resources for members (Enderlin et al., 2013).

According to Allendorf (2012) and the "Society of Hospital Medicine…​" (2012), studies have found that early adopters of Project BOOST reduced 30 day readmission rates by more than 3%, and produced "a 21% reduction in 30 day all-cause readmission rates." From the literature, BOOST is geared towards helping hospitals change their culture and processes to improve communication and teamwork across the many healthcare staff and functions, ultimately resulting in more efficient and quality service provision to patients.

As with CTI and TCM, the Bridge Model relies on trained individuals to coordinate the three phases of intervention. However, instead of RNs or APNs, trained social workers (MSW), called Bridge Care Coordinators (BCC), implement the pieces of the Bridge Model. Members of the Illinois Transitional Care Consortium identified the following three phases for transition: pre-discharge, post-discharge, and follow-up (ITCC, 2013).

During the pre-discharge phase, the BCC is made aware of an at-risk patient and meets with the individual and caregiver(s) in the patient’s room or in the on-site Aging Resource Center (ARC) to conduct a needs-based assessment and to make referrals to or set up services for the older adult to access prior to phase two (Altfeld, Pavle, Rosenberg & Shure, 2013). At this time the BCC also connects to additional interdisciplinary healthcare staff (physicians, nurses, pharmacists, etc.) to enhance the coordination of discharge planning.

Post-discharge the BCC follows-up with a phone call to see if additional necessary supports and services were identified after the first two days at home, and will coordinate acquisition of those resources. Finally, at 30 days, the BCC places one last follow-up phone call to check on the patient and address any additional concerns or service needs.

The unique aspect of the Bridge Model is that its social work-based design can be implemented by a hospital or by a community-based organization. The BCC work to provide care coordination between healthcare professionals and community-based service providers (e.g. Area Agencies on Aging and Aging and Disability Resource Centers), while at the same time providing psychosocial support to the patient and caregivers.

From early evaluation of 315 intervention participants, Altfeld et al. (2013) reported a 14% readmission rate compared to the 19.6% national average. The authors also stated the participant satisfaction rates were in the upper 90%. No details were given about participant demographics, nor was any financial return on investment mentioned for the Bridge Model.

GRACE is a model designed to be implemented within the primary care setting for low-income patients at high risk for hospital utilization. The main goal of GRACE is to improve the quality of primary geriatric care services in order to promote aging in place or to prolong long-term care facility placement. Unlike CTI, TCM, and the Bridge Model, GRACE implementation centers around the GRACE support team. A trained nurse and social worker are the main components of the support team, and they coordinate the larger interdisciplinary team that may be comprised of the PCP, pharmacist, physical therapist, occupational therapist, and a community liaison.

This model requires the use of electronic medical records and a long-term ongoing tracking mechanism to gauge the participant’s progress as long as he/she is a patient. The small GRACE support team conducts a home visit with the patient and available caregiver(s) and administers a formal geriatric assessment and a home safety assessment. The nurse and social worker then convene a meeting with the full team to create a care plan, obtain the PCP’s input and approval, and then work with the patient to implement their plan. The support team provides ongoing support throughout the year and reassesses the client annually.

Counsell, Callahan, Buttar, Clark, & Frank (2006) conducted a longitudinal study utilizing the GRACE Model within a primary care setting. They offered the intervention to 254 patients and found that the diverse, low-income, mostly frail participants responded quite well to the supports offered by their GRACE support team. Though time consuming and labor intensive for PC staff, when surveyed they reported being very satisfied with the GRACE process and was found to be somewhat to very helpful in providing healthcare to elderly patients.

According to their 2009 article, Counsell et al. found the GRACE Model to be cost neutral, but that more cost-effective evaluation would need to be conducted.

Similar to the GRACE Model, Guided Care is also designed for implementation within a primary care setting. A trained Guided Care Nurse (GCN) engages the PCP throughout the intervention and coordinates the eight services provided under this model: 1) a comprehensive patient assessment, 2) development of a patient-centered care plan, 3) monthly monitoring, 4) encouragement of self-management behaviors, 5) provision of coordinated care transitions, 6) liaison between members of the healthcare team, 7) caregiver and family support, and 8) referrals to community-based services.

Boult et al. (2011) conducted a yearlong study to see if the Guided Care intervention would have any effect on healthcare utilization and found that Guided Care may improve the quality of care administered to older patients with multiple chronic conditions. Kaiser insured participants in the intervention group reported a decreased use of some health care services but not with statistical significance. However, the researchers did find statistically significant differences between the control and intervention group in terms of being admitted to and spending time in a skilled-nursing facility, with the intervention group admissions considerably fewer. The Guided Care participants also reported a 29.7% decrease in negative at-home healthcare events.

Though the overall healthcare utilization numbers did not all reflect significant change as a result of the intervention, Guided Care patients reported increased quality of life and satisfaction with the healthcare services provided. Boult et al. (2011) were not able to determine if there were any significant cost savings of Guided Care patients involved in this particular study and more research needs to be conducted.

Project RED, designed by the Boston University Medical Center, is a team-based, interdisciplinary approach to implement all eleven components of the intervention to enhance the quality of the patient’s discharge experience. The eleven components of the intervention include: 1) patient education of condition, 2) scheduling follow-up PCP appointments for the patient before discharge, 3) explaining the purpose of any additional medical tests if they are required post-discharge, 4) coordinating post-discharge supports, 5)reviewing and confirming appropriateness of the medication regime, 6) comparing the After Hospital Care Plan (AHCP) with the national guidelines, 7) ensuring the patient understands what to do if symptoms worsen, 8) communicating with and transferring the patients AHCP to the patient’s primary healthcare provider, 9) assessing the patient’s comprehension of the AHCP, 10) making sure the patient and caregiver(s) have a written copy of the AHCP, and 11) follow-up via telephone within two to three days post-discharge to make certain the patient is able to adhere to the plan.

The intervention is unique in its use of a "virtual patient advocate" (Enderlin et al., 2013). To support the various components of this model, participants have access to computer-generated information about the individual’s AHCP. The computer-based modules are tailored to the patient’s personal diagnosis and provide the patient with education on the condition(s), medications, and AHCP instructions. The "virtual patient advocate" enhances the interactions with the participant’s healthcare team by allowing the patient time, before discharge, to learn about the condition(s) and to then ask questions of healthcare professionals if needed (Enderlin et al., 2013).

Jack & Bickmore’s (2011) article discusses, briefly, the results of a randomized control trial (RCT) to gauge the effectiveness of Project RED on reducing readmissions. Half of the 749 participants received the Project RED intervention with the use of the AHCP and the other half received usual care. Intervention participants reported 30% fewer re-hospitalizations within 30-days after discharge as compared to the control group. Jack & Brickmore (2011) further reported an average healthcare utilization cost savings of $412 per intervention participant, which was a 33.9% cost difference between the two groups.

This article did not describe the participant selection process or any demographic composition of the participants.

Some of these EBHT programs, interventions, and models were established more than twenty years ago (Naylor et al., 1999) allowing for the accumulation of RCT studies and collected data to create, further study, and implement a variety EBHTs for use by a number of organizations interested in improving transitions of care. The common elements of assuring proper medications management, having a person responsible for ensuring continuity of care, encouraging patient self-management, and providing patient-centered care over the course of a transition from hospital to home have proved effective in reducing acute care occurrences, but more importantly improving the overall experience during a difficult event and increasing the patient’s quality of life.

The literature reviewed rarely offered information as to the demographics of the participants engaged in the various interventions. This is a weakness as many of the articles claimed great generalizability and that the interventions would be successful with the population at large. As these programs tend to be geared towards supporting the frailer, lower income, lesser insured populations, perhaps those are the participants we are to assume are being studied.

The issue of health literacy and enhanced medication management support was not clearly addressed by any of the models. Non-adherence to medications after an acute episode accounts for many readmissions. Beyond the cost of access to prescriptions, which is a common barrier, understanding the importance of and then actually taking medications when and how they are prescribed may be something that needs to be addressed further through these interventions.

The most obvious gap in the hospital transition literature is that the majority of the interventions target hospital culture change, with an emphasis on improved discharge planning and suggested staffing changes and training - all internal hospital processes. However, there are very few interventions, with the Bridge Model the only example, that mention linking at-risk patients to existing resources in their communities. In fact, the Bridge Model literature was the only EBHT program to acknowledge the Aging Services Network as a viable partner to enhance quality transitions of care.

The Transitions Theory looks at transitions of any kind as a continuous process. Im (2011) identified that the Transitions Theory of Meleis et al. (2000), is comprised of four main concepts: the nature of transitions; transition conditions; patterns of response; and nursing therapeutics. The "transition condition" involves the individual, the community, and society (Im, 2011). Established hospital transition interventions focus mainly on the nursing therapeutics component of Transitions Theory: on changes to the hospital setting and operations and not on referring participants to resources available within the community to which the patients are returning. Not only are unsuccessful transitions resulting in costly avoidable readmissions, but older adults are not successfully managing health conditions, resulting in lost quality of life, isolation, premature entry into long-term care facilities, and early death.

Ever since its passage in 1965, programs offered under the Older American’s Act have been available to provide social, nutrition, and community services to older adults and their caregivers (Administration on Aging [AoA], 2010). This would suggest additional research should focus on hospital transition programs involving community-based organizations that can provide services to older adults after discharge and even after an intervention’s end.

As Transitions Theory implies, to have successful and healthy transitions from one setting to another, adequate and appropriate community and social support should be in place. Area Agencies on Aging (AAA), Community Based Organizations (CBO), and Home and Community Based Service (HCBS) providers can play that pivotal role for individuals transitioning back into their homes from the hospital. Existing services include: in-home care, transportation, home delivered meals, case management, home repair, social engagement (senior centers), chronic disease self-management programs, adult day care, respite, caregiver support, help navigating the health care system, Adult Protective Services, Aging and Disability Resource Center - information and referral, and much more.

To strengthen this argument, Altfeld, Pavle, Rosenberg, & Shure (2013) stated "40 - 50% of hospital re-admissions are linked to psychosocial problems and lack of community resources." As such, more hospital transition programs need to engage providers that are serving the social, nutritional, and community-based needs of older adults.

Federal funding continues to dwindle for community-based, social and nutrition services for older adults, the aging population continues to grow, and Medicare spending maintains its cost escalation. As such, Federal level funders (e.g. U.S. Centers for Medicare and Medicaid Services [CMS] and the U.S. Administration on Community Living) should require and facilitate the partnering of State and Local level recipients of such funding (e.g. Medicare and Older Americans Act) to ensure partnership, communication, referral systems when serving similar populations.

Grant opportunities like the CMS sponsored Community-based Care Transitions Program engaged the Aging Network and forced community level partnership with hospitals (Centers for Medicare& Medicaid Services, 2012). This provides an opportunity for at-risk older patients to be introduced to services provided by Aging Network organizations.

Cumbler, Carter, and Kutner (2008), stated that "ultimately, it is the duty of the hospitalist to take responsibility for the safety and well-being of the patient…​ " While that may be true within the hospital there is a safety net of Aging Services partners ready to support, embrace, and welcome patients back into the community setting.