Transitional care model improves care, decreases costs

The data are in. After 20 years of testing and refining the transitional care model first implemented by registered nurse Mary Naylor it has been proved that transitional care interventions improve health outcomes, prevent avoidable readmissions, enhance patient and family caregiver satisfaction and decrease healthcare costs. However, in the program's current structure, the question remains: Is the transitional-care model financially sustainable for hospitals? Although the TCM has been shown to have high efficacy in a controlled setting, the effectiveness of similar programs in real-world healthcare systems has been less extensively researched.

HealthTexas Provider Network in conjunction with Baylor Health Care System has embarked on their own study to test the effects of an advanced practice nurse-led transitional-care program for patients with heart failure and its sustainability within a hospital system. The first objective was to perform a prospective study with concurrent controls to test an advanced practice nurse-led transitional-care program for patients with heart failure who were 65 years or older and were discharged from Baylor Medical Center at Garland from August 24, 2009, through April 30, 2010. HTPN and BHCS compared the effect of the program on 30-day (from discharge) all-cause readmission rate, length of stay, and 60-day (from admission) direct cost for BMCG with that of other hospitals within the Baylor Health Care System. The second objective was to carry out a budget impact analysis using costs and reimbursement experience from the intervention to see if this model would be sustainable within Baylor Health Care System.

Preliminary results of the study suggest that transitional-care programs do work to reduce 30-day readmission rates for patients with heart failure underscoring the potential of the transitional care intervention to be effective in a real-world setting. However, the result of the budget impact analysis was not as promising. From a positive perspective, total direct costs for patients receiving the intervention were less than those receiving usual care. Conversely, costs associated with the intervention were not recovered through reductions in index admission direct inpatient costs. From the hospital viewpoint, the intervention did not save money. Also, under the current reimbursement system, the hospital lost revenue by preventing readmissions and had a reduction in the contribution margin for an episode of care. For BHCS, the intervention reduced the contribution margin by an average of $227 for each Medicare patient with heart failure.

The million-dollar question now is "What next?" We know that chronically ill patients and their families benefit greatly from transitional-care interventions. How can the TCM be refined to be financially sustainable by hospitals? One solution may be a bundled payment system, based on a 30-day post-discharge episode of care in which no additional payments would be made for readmission. This makes the intervention financially more attractive than usual care. However, the modified reimbursement system would result in a significant reduction in contribution margin if payment rates are set at the current level for HF index admissions under Medicare's prospective payment policy, without additional consideration for the cost of interventions such as TCMs.

Another solution would be to fine tune the model to reduce the cost barrier. HTPN and BHCS are investigating a risk stratification method to determine patient and family transitional-care needs based on patient severity. Using risk stratification, patients will be categorized into three risk levels: low risk, intermediate risk and high risk, as determined by undergoing a variety of assessments. A customized intervention package will then be offered based on patient risk factors. Patients considered to be low risk would receive reduced interventions as compared to high-risk patients who would receive "full-service" interventions. For example, patients 65 years or older admitted to Baylor University Medical Center with heart failure will receive the following basic interventions:

• Dedicated advanced-practice nurse (APN) assigned to patient while in hospital
• Social worker assigned to assess resources and social needs
• Dedicated clinical pharmacist to review medications prior to discharge (high-risk medication, medication simplification) and to serve as consultant for RN and nurse practitioner
• Risk assessment performed at discharge where patient is classified as low, intermediate or high risk

Low- and intermediate-risk patients would receive modified transitional-care interventions that include the basic package plus

• Post-discharge phone calls by RN
• A designated clinical pharmacist to assess for high-risk medications; provide medication simplification; and serve as consultant for RN and APN
• Telemonitoring services managed by an RN to oversee certain protocols that would include advancing medications

High-risk patients and families would use the original Transitional Care Model and receive increased interventions that include

• Daily visits by APN while in hospital
• Home visits 24-72 hours after discharge
• Weekly home visits up to 12 weeks
• Acute visits and 24/7 access to care via phone (follow-up as needed)
• Team approach to care that would include the patient, their family, physicians, nurse practitioners, home healthcare providers, social workers, and other providers as deemed necessary

HTPN and BHCS believe in the Transitional Care Model and its proven ability to positively affect the health of chronically ill patients and the rising rate of healthcare costs. Our desire to always be improving, along with our history of serving our patients with quality care, is what motivates us to refine the Transitional Care Model so it can be financially sustainable within BHCS as well as other hospital systems around the nation. Making the TCM easily adoptable by hospital systems gives chronically ill patients and their families the opportunity to receive transitional care interventions and reap the rewards of a healthier lifestyle and improved quality of life.

Dr. Cliff Fullerton

Vice president, chronic diseaseBaylor Health Care SystemDallasChief quality officerHealthTexas Provider NetworkDallas