July 12, 2013 slide presentation for the Transitional Care Workgroup Meeting.

1. Transitional Care
Workgroup Meeting
July 12, 2013
1

2. Welcome and Introductions
Chad Boult, MD, MPH, MBA
Program Director, Improving Healthcare Systems
2

3. Housekeeping:
Providing Input
Today’s webinar participants can provide input via
e-mail (transitionalcare@pcori.org); via Twitter
(#PCORI); or the webinar “chat” feature.
Please submit questions today, as they occur to
you. We will collect and synthesize these for
discussion at 12:45 p.m. (ET).
We welcome additional input through July 19,
2013, at 5:00 p.m. (ET) via e-mail
transitionalcare@pcori.org.
3

4. What Research Questions Are Within
PCORI’s Mandate?
PCORI funds studies that compare the benefits and
harms of two or more approaches to care.
Cost effectiveness: PCORI will consider the
measurement of factors that may differentially affect
patients’ adherence to the alternatives, such as out-of-
pocket costs, but it cannot fund studies related to cost-
effectiveness or the costs of treatments or
interventions.
Disease processes and causes: PCORI cannot fund
studies that focus on risk factors, origins, or
mechanisms of disease.
4

5. How PCORI Manages the Potential for
Conflict of Interest
The researchers, patients, and stakeholders who have been invited to this
workgroup will be involved in the process of determining the specific subject
areas that we should address in a PCORI Funding Announcement (PFA).
The broader community of researchers, patients, and other stakeholders who
are participating by web, Twitter, and chat can be involved as well.
Participants in this workgroup are eligible to apply for funding if PCORI decides
to produce a funding announcement studying models of transitional care.
The Moderators of this workgroup will not be eligible to apply for funding
under this PFA.
Input received during the workgroup deliberations will be broadcast via
webinar, and the webinar will be archived and made available to other
researchers, patients, and stakeholders via the PCORI website.
5

6. Introductions:
Moderators
6
Trent Haywood, MD, JD
Chief Medical Officer, Blue Cross and Blue Shield
Doris Lotz, MD, MPH
Medicaid Medical Director, State of New Hampshire

7. Introductions:
Workgroup Members
Leah Binder, MA, MGA
– Purchasers
Tara A. Cortes RN, Ph.D.
– Home Healthcare
Jeffrey Delafuente, MS, FCCP, FASCP
– Pharmacists
Gretchen Dickson, MD, MBA
– Family Practitioners
Eric E. Howell, MD
– Hospitalists
Elizabeth (Libby) Hoy
– Patients
James E. Lett II, MD, CMD
– Patient Advocacy
Mary D. Naylor, PhD, FAAN, RN
– Researchers
Shelley Price, MS, FHIMSS
– Healthcare Information Technology
Erin Rand-Giovannetti, PhD, MPH
– Researchers
John Schall, MPP
– Caregivers
David Schulke
– Hospitals/Health Systems
Sara J. Singer, PhD, MBA
– Researchers
Nancy Skinner, RN-BC, CCM
– Case Managers7

8. Background on
Transitional Care Workgroup
Lynn Disney, PhD, JD, MPH
Senior Program Officer, Improving Healthcare Systems
8

9. 9
How We Select Targeted Research Topics

10. Evolution of the Topic
1,000+ research topics collected
841 accepted
308 assigned to Improving Healthcare Systems (IHS) program
 Program director screened, consolidated, and rated topics
89 resulted from program director screening and were scored
15 scored highest and selected for advisory panel consideration
 Topic briefs commissioned for all 15 topics
 Reviewed and ranked by IHS Advisory Panel—April 19-20, 2013
10Link to PCORI Website—Full Description

11. PCORI Advisory Panel on IHS
Prioritized Five Research Topics
11
TOP TWO
• Models of Transitional Care
• Models of Patient-Empowering Care Management
NEXT THREE
• Features of Health Insurance Coverage
• Co-location of Mental Health and Primary Health Care
• Models of Perinatal Care Management

12. Setting the Stage—
Current State of Evidence
Mary D. Naylor, PhD, FAAN, RN
Marian S. Ware Professor in Gerontology and Director of the NewCourtland
Center for Transitions and Health, University of Pennsylvania, School of Nursing
12

13. Transitional Care: Meaning of Concept
Transitional care – range of time limited
services and environments that are
designed to ensure health care continuity
and avoid preventable poor outcomes
among at risk populations as they move
from one level of care to another, among
multiple health care team members and
across settings such as hospitals to
homes.
13

14. The Case for Transitional Care
Patients’ poor ratings of experiences
with healthcare system
Serious unmet needs reported by
patients and family caregivers
High rates of preventable medical
errors and associated poor outcomes
Tremendous human burden
14

15. Transitional Care: Published Evidence
21 clinical trials of diverse innovations focused on chronically
ill older adults
9 of 21 studies reported positive impact on health outcomes
and reductions in preventable rehospitalizations
Effective interventions:
 Extended from hospital to home
 Offered multiple solutions
 Relied on teams (including patients) with nurses as
“coordinator”
Naylor MD, Aiken LH, Kurtzman ET, Olds DM, & Hirschman KB. (2011). THE CARE SPAN -- The Importance of
Transitional Care in Achieving Health Reform. Health Affairs, 30(4):746-754.
15

16. Core Components of Effective
Interventions
16
Citation
Comprehensive
assessment, care
planning
Interactions with post
acute, community
clinicians
Coordination/
referrals for
community services
Care Transitions Program
Coleman et al., 2006
Parry et al., 2009
—
—
+
+
—
—
Chronically Critically Ill
Daly et al., 2005
+ + +
Project RED
Jack et al., 2009
+ + —
Transitional Care Model
Naylor et al., 1994
Naylor et al., 1999
Naylor et al., 2004
+
+
+
+
+
+
+
+
+
Congestive Heart Failure
Rich et al., 1995
+ — +
Telehealth (with HF)
Wakefield et al., 2008
— — —

17. Core Components of Effective
Interventions
17
Citation
Self management
support
Comprehensive
medication
management
Use of
Information
Technology
Care Transitions Program
Coleman et al., 2006
Parry et al., 2009
+
+
+
+
—
—
Chronically Critically Ill
Daly et al., 2005
— + —
Project RED
Jack et al., 2009
+ +
Transitional Care Model
Naylor et al., 1994
Naylor et al., 1999
Naylor et al., 2004
+
+
+
+
+
+
+
+
+
Congestive Heart Failure
Rich et al., 1995
— + —
Telehealth (with Heart Failure)
Wakefield et al., 2008
+ — —

18. Effects on Health, Quality of Life and
Patients’ Care Experience
18
Citation Health
Quality
of life
Patients’ Care
Experiences
Care Transitions Program
Coleman et al., 2006
Parry et al., 2009
—
NS
—
—
—
—
Chronically Critically Ill
Daly et al., 2005
NS — —
Project RED
Jack et al., 2009
+ — —
Transitional Care Model
Naylor et al., 1994
Naylor et al., 1999
Naylor et al., 2004
NS
NS
NS
—
—
+
+
NS
+
Congestive Heart Failure
Rich et al., 1995 NS + —
Telehealth (with HF)
Wakefield et al., 2008 NS + —

19. Effects on Healthcare Resource Use
19
Citation
Total readmissions,
all cause
(no. of months)
Time to first
readmission
(no. of months)
Length of
readmission stay
(no. of months)
Other
resource
use
Care Transitions Program
Coleman et al., 2006
Parry et al., 2009
+ (3 mo)
+ (3 mo)
—
—
—
—
—
—
Chronically Critically Ill
Daly et al., 2005
NS NS + (2 mo) —
Project RED
Jack et al., 2009
+(1 mo) — — +
Transitional Care Model
Naylor et al., 1994
Naylor et al., 1999
Naylor et al., 2004
+ (1.5 mo)
+ (6 mo)
+ (12 mo)
NS
+ (6 mo)
+ (12 mo)
+ (1.5 mo)
+ (6 mo)
NS
NS
NS
+
Congestive Heart Failure
Rich et al., 1995 + (3 mo) — + (3 mo) —
Telehealth (with HF)
Wakefield et al., 2008 + (12 mo) + (12 mo) NS NS

20. Examples of Unanswered Questions
That Could Build Upon This Evidence
What are common triggers of major health
transitions? (e.g., decline in function, death of
spouse)
What transitional care outcomes matter most to
patients (e.g., trust, achieving their health goals,
functional status, quality of life)? To their family
caregivers? How do we consistently measure
them?
What risk stratification strategies are effective at
identifying who will benefit most from transitional
care approaches of different intensities?
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21. Unanswered Questions
How can behavioral health be more effectively incorporated
into transitional care?
How can transitions between hospitals and homes be better
aligned with primary care and community organizations?
What components of effective transitional care interventions
are most valuable? Which models are most effective?
Which tools/technologies are most helpful?
What is the impact potential on various patient or
community subgroups? (e.g., people with low health literacy
or advanced illness, communities with fewer resources)
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22. Unanswered Questions
How can transitional care approaches more
effectively engage patients and family caregivers
and promote shared decision making?
What are the unique transitional care needs of
family caregivers? How can their needs be best
addressed?
Can transitional care evidence be extended to
improve palliative care outcomes?
What are the facilitators and barriers to successful
implementation of effective transitional care?
22

23. Measuring Patient-Centered Outcomes
Sara J. Singer, PhD, MBA
Assistant Professor, Harvard University, School of Public Health
Erin Rand-Giovannetti, PhD, MPH
Research Scientist, National Committee for Quality Assurance
23

24. How a Question Becomes a Measure
Identify
what
matters
Develop a
framework
Draft
measures
Test the
measures
Use the
measures
24
Refine
Refine

25. What Matters?
Scan the literature  Talk to stakeholders 
Identify gaps
 Gap 1: Just because structures and services are
integrated doesn’t mean that patients receive integrated
care.
 Gap 2: Patients and loved ones deliver care too. Their
needs, preferences, and responsibilities are part of
needs to be integrated.
25

26. Develop a Framework That Describes
What Matters
Aim to be comprehensive and mutually exclusive
26
Things that matter
Coordination within your provider’s office
Coordination across your providers / with your hospital
Coordination by your provider of care at home
Familiarity over time
Help with care before, after, and outside of office visits
Patient-centered care
Support for patient’s role in caregiving
--Singer et al., Patient Perception of Integrated Care (PPIC) Survey

27. Develop Specific Questions to Measure
What Matters
Borrow or craft items that address your framework
 Check that questions are attributable and
actionable  Balance number and type
27
Things that matter
Coordination within your provider’s office
Coordination across your providers / with your hospital
Coordination by your provider of care at home
Familiarity over time
Help with care before, after, and outside of office visits
Patient-centered care
Support for patient’s shared-responsibility
Questions that measure them
After your most recent hospital stay,
did anyone from your provider’s
office contact you to ask about the
condition you were in the hospital
for?
--Singer et al., Patient Perception of Integrated Care (PPIC) Survey

28. Test, Refine and Use the Survey
28
In the last 6 months, how often did this provider discuss
whether the care you were receiving matched your
values and preferences?
In the last 6 months, how often did this provider discuss
whether you were getting the health care you wanted?

29. Test, Refine and Use the Survey
Before using a survey
 Do patients understand intended meaning of the questions?
 Is the survey too long?
  Refine
Pilot-test the survey with a small group of patients
 Do groups of questions represent coherent concepts?
 Are the concepts distinct from each other?
 Do measures differentiate providers?
 Is there room for improvement?
29

30. Test, Refine and Use the Survey
 Do measures relate to things that should be related?
  Refine
Retest  repeat
30
Clinical and
financial
outcomes
Patient
perceptions
of integrated
care
Integrated
organizations
and activities

31. Provide rapid feedback of results 
Teach/learn  Act/refine  Repeat
Test, Refine and Use the Survey
31
0%
20%
40%
60%
80%
100%
%Always
How often did you get a timely
answer to your medical question
after hours?

32. Importance and Evidence for Outcomes
Importance
 Importance to individual
 Importance to health of population
Evidence
 Evidence that outcome leads to well-being for individuals
 Logic for how the outcome can be influenced by the
intervention
Ex: Person-centered goal achievement – Percent of
individuals who make progress towards a self-defined
goal?
32

33. Scientific Soundness of Measure
Scientific Soundness
 Reliability: Measure results are repeatable
 Validity: Measure results are correct
 Meaningful difference
33

34. Feasibility and Usability - Reality Check
Feasibility
 How do we actually capture the information we are
measuring?
 How do we capture the information for populations with
communication or cognitive limitations?
Usability
 Will the information gathered from the measure be useable
and worth the cost of measurement?
Ex: Person-centered goal achievement – Percent of individuals who
make progress towards a self-defined goal?
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35. BREAK
35
• Visit us at www.pcori.org
• Follow @PCORI on Twitter
• Watch our YouTube channel PCORINews

36. Vignette
It is March 5, 2018, and Jane Smith is about to be
discharged from Center Hospital, where she was diagnosed
with several chronic conditions, which have left her unable
to fully take care of herself. She will be leaving with several
new medications and the hospitalist’s recommendation to
“change your diet and activity level.” A new transitional care
program has just been implemented at Center Hospital and
is available to patients and caregivers, at their request.
Question for Workgroup Participants:
From your current perspective (patient, caregiver, clinician,
payer, etc.), what are three or four questions that you would
want answered before deciding whether to participate in this
transitional care program?
36

37. Collaborative Workgroup Discussion
Focus: Provide targeted input without scientific
jargon
Honor Timelines: Provide brief and concise
presentations and comments
Participate: Encourage exchange of ideas among
diverse perspectives that are present today:
 Researchers
 Patients
 Other stakeholders
37

38. Workgroup Objectives:
Narrowing the Broad Topic
Transitional care is a very broad concept
The process today is to take this broad concept
and:
 Understand it
 Determine which questions/issues are the most
important to all stakeholders
 Create a concise list of these high-priority
questions
38

39. Questions from Patient and
Stakeholder Perspectives
39

40. LUNCH
40
• Visit us at www.pcori.org
• Follow @PCORI on Twitter
• Watch our YouTube channel PCORINews

41. Comments Submitted by Others
E-mail (transitionalcare@pcori.org)
Twitter (#PCORI)
The webinar “chat” feature
Lauren Holuj, MHA
Program Associate, Improving Healthcare Systems
41

42. Discussion of Proposed
Research Questions
42

43. BREAK
43
• Visit us at www.pcori.org
• Follow @PCORI on Twitter
• Watch our YouTube channel PCORINews

44. Refinement of Research
Questions to be Addressed
44

45. Recap and Next Steps
45

46. We Still Want to Hear from You
We welcome your input on today’s discussions
We are accepting comments and questions for
consideration on this topic through July 19, 5:00 p.m. (ET)
via e-mail (transitionalcare@pcori.org)
We will take all feedback into consideration
46

47. Thank You for Your
Participation
47