HCLF keynote: Methods to improve care transitions

CHICAGO—“It’s really devastating for people to be coming in and out of hospitals,” said Mary D. Naylor, PhD, RN, delivering the keynote address at the Healthcare Leadership Forum on Sept. 29. Naylor is the Marian S. Ware Professor in gerontology and director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing and the national program director for the Robert Wood Johnson Foundation program—Interdisciplinary Nursing Quality Research Initiative

There are elements effective transitions have in common, such as consistent, standardized assessments and care planning.

If we bucket the evidence, said Naylor, there are two fundamentally different approaches. One is a that a vast majority of efforts are still focused on trying to smooth processes from one site to another or from one clinician to another and addressing gaps in care. “Our team started out that way. We learned quickly that we can reduce 30-day readmissions easily. It was getting to longer term value that was the problem. What were the root causes of poor outcomes? That’s when we have a chance of getting to long-term outcomes.”

According to the Naylor model, it’s important to figure out who is at risk for poor outcomes. “It’s not an algorithmic approach but a real understanding of looking at years of data from clinical trials to distinguish the factors that do well and don’t do well.”

Engaging older adults and their family caregivers directly in their care is crucial to improving outcomes, she said. For example, many people would fill prescriptions and then providers wondered why they weren’t adhering. It turns out that when patients have numerous prescriptions from different clinicians, all those medications make people feel terrible and they just stop taking them.

“We had to work with all the clinicians involved to better manage symptoms,” said Naylor. If you take the best care plan for four chronic conditions and try to combine them, she said, you will likely end up with a plan of care that includes negative drug interactions and other problems. “It’s only when we realize what’s happening to patients as a result of several conditions that we’ll get to better outcomes.”

When healthcare focuses on symptoms rather than conditions then providers are in a position to promote better care management, she said.

But all the research won’t lead to better outcomes unless they are translated into practice. About 10 years ago Naylor and her team realized that nobody was using the information they had gathered through their research. “No systems were changing. We could just continue to publish our findings but we were in it to influence care and outcomes in the real world. It can happen if you have really engaged leaders in your systems, in communities, in payers working with you.”

She admitted they were quite naïve, not realizing how important were the tools of translation. “We had to develop those tools for patient screening and recruitment. We built webinars. We had to build a clinical documentation system, quality monitoring and improvement systems so we could engage everyone in the culture of learning.”

A comparative effectiveness research study with a payer offered the chance to get their foot in the door. “Despite many barriers, we were able to demonstrate improvements and cost savings that lasted a year. That enabled us to get in the doors of health systems.”

Naylor created a service line for this as well as set rigorous performance expectations. “We review everything we’re learning and make adjustments in the model of care as we go.”

She cited the importance of considering the most complex of people in our society—people who, in addition to living with complex chronic conditions, also have functional deficits. Those who can’t walk or who have cognitive impairment, use healthcare resources at a rate two to three times higher than their peers who only have chronic conditions. While this is “an extraordinarily important group, there is very little understanding of what success would look like. It wouldn’t be an improvement of their chronic conditions.”

They enrolled 500 people from 50 organizations in New York and Pennsylvania who have just begun to receive long-term services and support to understand how they are using resources. “It’s extraordinary what we’re learning. There are multiple opportunities for improvements in health and healthcare for this population.

“Overall findings indicate that we need to reenvision care for the chronically ill. We need to think about care systems in the community that target at risk people and are designed to index hospitalizations not rehospitalizations and the use of costly services that are unnecessary.”

Healthcare also needs to think about better follow up, she said. “When we get to better outcomes, we still need to think about this as a population that needs more than we currently provide.” Her team keeps thinking about how best to do this. “This is a population whose transitions in healthcare are so frequent that we’ve got to be able to be nimble in responding by engaging caregivers, improving symptom status and preventing acute resource use.”