- Describe your topic.
- What is the issue or question? Following an index hospital admission, what is the effectiveness of care transition interventions to reduce 30- and 90-day mortality, 30- and 90-day hospital readmission, 30- and 90-day total health care utilization/cost? • What are the provider/staff roles for the transition model interventions, including the hand-off and first five days following the transition? Following an index hospital admission, what is the evidence to appropriately guide selection of specific types of post-acute care settings – including utilization of a skilled nursing facility (SNF), long-term acute care (LTAC), or receipt of supplemental home care – within 30- and 90-day intervals following index admission? • What is the evidence for risk-assessment tools prior to patient discharge? (Note: This assessment should take into account type of medical condition(s) and social determinants of health. Effectively identifying patients who would benefit from a more “hands-on” transition would help networks manage resources.) Note: Another related, but distinct topic is: “What is the evidence about the effectiveness of post-acute care – provided in SNFs and LTACs or via home health – as it relates 30- and 90-day mortality, 30- and 90-day hospital readmission, and 30- and 90-day total health care utilization/cost? (It is not always clear what type of care is being provided – and paid for – in post-acute care or its impact on quality and cost.) Identify the population of interest, including details such as age range, gender, coexisting diagnoses, and reasons for therapy. • Adult patients post major joint replacement, cardiac surgery and/or adult patients discharged with congestive heart failure (CHF) Note: These patients are typically Medicare patients and are considered high-volume/high-cost patients. One panel member specifically requested focusing on the Medicaid population. This may lend itself to evidence on the comparative effectiveness of models for Medicare v. Medicaid population. Identify the interventions (treatments, tests, or strategies) that you want to know more about, and what are the appropriate comparisons. • COMPARATORS - Comparative effectiveness of care transitions models (e.g., the transitional care model (Naylor) which utilizes nurse practitioners, the Coleman model, patient navigators, remote monitoring) - Comparison of care transition models to usual care • INTERVENTIONS E.g., - Transitional care model (Naylor) (which utilizes nurse practitioners) - The Coleman model - Patient navigators - Remote monitoring Identify the important outcomes (health related benefits and harms) in which you are interested, such as improvements in symptoms or problems with diagnosis. • Quality and Safety (Better Health): 30- and 90-day mortality, 30- and 90-day hospital readmission, medical errors/adverse events • Patient-Reported Outcomes Measures (PROMs) (Better Care) • Costs (Lower Costs): 30- and 90-day total health care utilization/costs; personnel resources expended by the hospital to facilitate appropriate care transitions (NOTE: The AHRQ LHS Panel Members suggested framing outcomes in terms of the Triple AIM – Better Health, Better Care, and Lower Costs.)
- Describe why this topic is important.
- Post-acute care for Medicare beneficiaries receiving joint replacement surgeries and cardiac surgeries is resource-intensive and costly – and there is tremendous geographic variation in terms of access: • “Major joint replacement surgeries and cardiac surgeries are among the most common hospital discharges – major joint replacement surgeries remained the most common inpatient discharge, costing Medicare more than $6.6 billion in 2013” (Herman, 2015, Medicare sheds new light on hospital, physician pay, https://www.modernhealthcare.com/article/20150601/NEWS/150609999) • “Post-acute care is a major component of total per-episode spending. For example, post-acute care and readmissions account for nearly 40 percent of Medicare spending for 30-day congestive heart failures episodes and 37 percent of spending for joint replacement episodes. These proportions increase for longer episodes. And, post-acute care spending varies greatly from provider to provider and across geographic markets. A recent Institute of Medicine study found that post-acute care was the single largest factor driving geographic variation in Medicare per-beneficiary spending” (AHA, 2016, Issue Brief: Medicare’s Bundled Payment Initiatives: Considerations for Providers, https://www.aha.org/system/files/content/16/issbrief-bundledpmt.pdf). Thus, evidence is needed to better understand what are the most effective care transitions models for these patients to meet the Triple AIM and help health systems prioritize resources.
- Tell us why you are suggesting this topic.
- Several factors underscore the need for this evidence: • Overall, the Medicare population is a high-risk population – and thus is at high-risk for hospital readmissions. Thus, hospitals that serve the Medicare population are exposed to financial risks (e.g., penalties). • Hospitals employ a variety of personnel (e.g., care coordinators, discharge planners, navigators) to help guide and facilitate care transitions. • Medicare (and Medicaid) reimbursement rates play a large role in influencing the post-acute care setting for a patient – and thus the care transitions process. • Access to post-acute care settings/services varies by geographic location. Taking these four factors into account, evidence on which care transitions models are most effective for adult patients post major joint replacement or cardiac surgery – in terms of better health, better care, and lower costs – would help hospitals prioritize resources and potentially reduce preventable hospitals readmissions and other negative health outcomes.
- Target Date.
- Describe what you are doing currently and what you are hoping will change because of a new evidence report.
- Some hospitals may be spending money in the “wrong places,” for example on care transitions interventions/models that are not effective for the Medicare populations and/or on personnel (e.g., care coordinators, discharge planners, navigators) who are more effective in other roles. With additional evidence on the most effective care transitions models for the Medicare population, particularly those with a major joint replacement or cardiac surgery, hospitals can adjust their models to be more cost-effective and reduce preventable readmissions.
- How will you or your group use the information from a new evidence report?
- LHS organizations would evaluate their process for care transitions within their organization based on the evidence. If there is strong evidence to support specific methods of hand-off communication, for example, they would evaluate their current practices and consider revising it as appropriate. More specifically, LHSs could use the evidence to: (1) refine their care transitions process to identify patient at risk prior to discharge and (2) more effectively develop or manage the resources (including personnel, such as nurses or navigators, and specific services, such as remote patient monitoring) to deliver the right services to the appropriately targeted patients.
- How would you or your group plan to disseminate information from the report? Who would you plan to disseminate it to?
- Many of the organizations represented on the LHS Panel are members of the High Value Healthcare Collaborative (HVHC) and could potentially distribute this report to other HVHC members. The HVHC is a provider learning network committed to improving healthcare value through data and collaboration. To accomplish this, the HVHC measures, innovates, tests, and continuously improves value-based care. Rapidly disseminate and facilitate adoption of proven high value care models across HVHC members and beyond. Within LHSs, the information from the report would be disseminated internally. Dissemination of findings would be contingent on results. For example, if there was strong evidence for a particular patient population (e.g., cardiac surgery) then they would share the information within this service line specifically. Additionally, several of the LHS panel members are members of the Health Care Systems Research Network (HCSRN), an innovative consortium of research centers based on community-based health delivery systems. Thus, the LHS panel members could potentially disseminate this report to other HCSRN members.
- Do you know of organizations that could use an evidence report to change clinical practice? Are you a part of, or have you been in contact with, any organizations that might implement the research findings of an evidence report?
- Information About You: (optional)
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- Provide a description of your role or perspective.
- Vice President, Chief Clinical Effectiveness Officer, Baylor Scott & White Health
- If you are you making a suggestion on behalf of an organization, please state the name of the organization.
- <names> AIR, <email, phone number>
- Please tell us how you heard about the Effective Health Care Program.
