Download Rush Enhanced Discharge Planning Program: A Model for

Rush Enhanced Discharge Planning Program:
A Model for Interdisciplinary Care Coordination
Robyn L. Golden, LCSW
Director, Older Adult Programs
Rush University Medical Center
Care Coordination Defined
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Client-centered
Assessment-based
Interdisciplinary
Integrating health care and social support
services
• Care coordinator manages and monitors an
individual’s needs and preferences
• Based on a comprehensive care plan
Rush EDPP: A Model for Care Coordination
• Rush Enhanced Discharge Planning Program
(EDPP)
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Short-term telephonic care coordination
Provided by Master’s-prepared social workers
From a biopsychosocial perspective
For older adults at risk for adverse events after an
inpatient hospitalization
© Rush University Medical Center, 2009
Rush University Medical Center
Rush is located minutes from
downtown Chicago in the West
Side Medical District
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Urban
Academic Medical Center
676 staffed beds (72 rehab)
27 patient care units
30,012 admissions
5.3 ALOS
4
Primary Goals
EDPP operates with three guiding tasks to reach
the goal of preventing avoidable adverse events
post-discharge:
1. Ensuring patients receive appropriate services in their home
post-discharge
2. Connecting patients to their physician for follow-up
appointments
3. Supporting caregivers to reduce stress and burden
© Rush University Medical Center, 2009
The Team
• EDPP Social Worker serves as primary care
coordinator
– Manages care coordination tasks
– Facilitating inclusion of other team members
• Additional team members vary by client
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Inpatient case manager and attending physician
Primary care physician
Pharmacist, therapists, other medical providers
Home health care provider
Community service providers
© Rush University Medical Center, 2009
Target Population
Must meet all the following criteria:
Age > 65
Returning home after discharge
>7 medications prescribed
Must also meet one additional criterion:
Lives alone
Without a source of emotional support
Without a support system for care in place
Discharged with a service referral
High falls risk
Inpatient hospitalization in past 12 months
Identified in-depth psychosocial need
High risk medication prescribed
© Rush University Medical Center, 2009
Process
Referral
PreAssessment
Assessment
© Rush University Medical Center, 2009
Intervention
Step 1: Referral
• Eligible patients referred
through Rush’s electronic
medical record, Epic
• Eligibility criteria based
upon:
– Review of literature
– Trends observed during
program’s pilot
– Feedback from Rush case
managers
© Rush University Medical Center, 2009
Step 2: Pre-assessment
• Upon receiving an electronic referral, the EDPP Social
Worker:
– Reviews the patient record for relevant information
– Investigates previous hospitalizations
– Identifies potential problem areas requiring in-depth
assessment
– Generates a list of questions about potential problem
areas
– Seeks information and clarification from inpatient
providers
© Rush University Medical Center, 2009
Step 3: Assessment
• EDPP Social Worker contacts
the patient and/or caregiver
by telephone within 2
business days of discharge
– Basic assessment for all
patients
– Targeted assessment of specific
problem areas
© Rush University Medical Center, 2009
Step 4: Intervention
EDPP Social Worker Intervenes until identified
issues are resolved and situation is stable
EDPP Social Worker performs
telephonic assessment
EDPP SW provides support,
education, and information
EDPP SW reconnects
with patient
No: EDPP SW contacts parties
on the patient’s behalf
Yes: Patient and/or caregiver
reconnects with EDPP SW
Does patient
and/or
caregiver need
more info or
support?
Yes: Can patient
or caregiver
contact
necessary
parties?
Is follow-up
with providers,
caregivers, or
resources
necessary?
Yes: EDPP SW provides contact information
for parties to patient/caregiver
No: Provide local aging resource center’s
contact information for future consult
© Rush University Medical Center, 2009
Step 4: Intervention
• The Patient’s Role
– Patients and caregivers empowered to take an active role in
their care with the EDPP’s Social Worker’s support
– Education on health care systems and self-management
provided
– EDPP Social Worker performs coordination tasks on patient’s
behalf as necessary
• Recognizing patients may be unable to do everything due to health
literacy and functional limitations
• The Team’s Role
– Hospital and community team members engaged based upon
post-discharge issues
– EDPP Social Worker facilitates team involvement
© Rush University Medical Center, 2009
Impact
• EDPP’s impact measured in a
randomized controlled trial
– June 2009 to March 2010
– n=740
– Referrals generated through electronic
medical record at point of discharge
– Participants randomized to intervention
and usual care groups
© Rush University Medical Center, 2009
Level of Intensity
Mean
Std Dev
Range
Duration of Intervention (Days)
5.8
11.3
1
72
Total calls
5.4
6.3
0
44
• More than one call was needed for 254 of the
360 (70.6%) patients in this study
– These patients had issues that needed intervention and
could not be resolved in the initial contact
© Rush University Medical Center, 2009
Impact
• Post-discharge issues:
– 300 of 360 (83.3%) of patients
had issues identified by an
EDPP clinician upon discharge
– For 219 of 300 (73%) of these
individuals, problems did not
emerge until post-discharge
© Rush University Medical Center, 2009
Common Problems
© Rush University Medical Center, 2009
Common Interventions
© Rush University Medical Center, 2009
Outcomes
• Improvements in the Intervention Group from
baseline to follow-up (p<.05)
– Increased understanding of the purpose for taking their
prescribed medications
• Baseline: 89.0%, Follow-Up: 95.3%, p=.002
– Decreased patient stress managing their health care needs
• Baseline: 38.8%, Follow-up: 31.8%, p=.037
– Decreased caregiver stress managing patients’ health
needs
• Baseline: 43.9%, Follow-Up: 32.2%, p=.003
© Rush University Medical Center, 2009
Outcomes
• The Intervention Group showed better
outcomes at follow-up when compared to the
Usual Care Group
– Greater understanding of their responsibilities for
managing their health
• Intervention Group: 93.3%
• Usual Care Group: 87.9%
• p=.011
– Better utilization of physician
services post-discharge
© Rush University Medical Center, 2009
Utilization
Patients scheduling and attending follow-up appointments
Intervention
Usual Care
Yes
No
239 (74.9%)
80 (25.1%)
206 (57.4%)
153 (42.6%)
• Patients receiving the EDPP intervention were
significantly more likely to:
– Communicate with their PCP within 30 days of discharge
– Schedule and attend their post-discharge appointments
(χ²=9.88, p=.001)
© Rush University Medical Center, 2009
Post-Intervention Contact
• 29.3% of intervention patients contacted the
EDPP clinician for additional services or
information after the case was closed
– Suggests EDPP provides consistent point of access to
health care information
– EDPP seen as trusted source of information and support
© Rush University Medical Center, 2009
Utilization
Readmissions to Rush University Medical Center
Since Discharge
Intervention
Usual Care
13.6%
16.1%
30 days
20.8%
27.5%
60 days
26.4%
34.2%
90 days
120 days
30.8%
36.5%
180 days
36.1%
42.5%
p-value
.201
.031*
.018*
.078
.068
*significant at the p<.05 level
Mortality at 30 days, p=0.03
Alive
Overall (n=740)
712 (96.2)
Intervention (n=360)
352 (97.8)
Usual Care (n=380)
360 (94.7)
Dead
28 (3.8)
8 (2.2)
20 (5.3)
© Rush University Medical Center, 2009
Systemic Impact
• Since concluding the research, EDPP has been
integrated into pilots and projects that highlight
the need for an interdisciplinary team
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Interdisciplinary Care Model Pilot
Home Health Pilot
Illinois Transitional Care Consortium
Patient Centered Medical Home Pilot
© Rush University Medical Center, 2009
Implementation Issues
• Five key implementation questions must be
answered for the program to be successful
1. Who will perform the intervention?
2. Who will manage the model’s administrative and
implementation tasks?
3. How will patients be identified and referred to the
program?
4. How will data be obtained, managed, and reported?
5. How will hospital support be established for long-term
sustainability?
© Rush University Medical Center, 2009
EDPP, In Conclusion
• EDPP is an exciting and innovative model for
providing transitional care
– Addresses non-medical aspects of transition
– Well-suited for integration into other initiatives
– Further research in progress will strengthen evidence base,
understanding of model
© Rush University Medical Center, 2009
Thanks to…
• EDPP would not be possible without the
support of:
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Community Memorial Foundation
Sanofi Aventis
New York Academy of Medicine
Harry and Jeanette Weinberg Foundation
Michael Reese Health Trust
U.S. Administration on Aging
© Rush University Medical Center, 2009
Questions and Comments
For more information on this project, please contact:
Robyn Golden, LCSW
[email protected]
312-942-4436