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Transitional Care Programme Evaluation – The Singapore Experience12th April 2013

Dr Patsy Chow (Patsy.CHOW@aic.sg)

Dr Loong Mun Wong

Dr Jason Cheah

Agency for Integrated Care

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What is Transitional Care?

“Care transitions” refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.

In its position statement in 2003, the American Geriatrics Society defined transitional care as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location”.

Source: Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society. 2003;51(4):556-557.

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The Care Transitions Intervention® spearheaded by Dr Eric A. Coleman Aims to empower patients/care-givers to assume greater and active role in self

management as they transit across settings 4-week programme led by Transitions Coach® The Four Pillars®

Medication self management Dynamic patient-centric health record Timely primary care/specialist care follow-up Knowledge of ‘red flags’ and appropriate responses

The Transitional Care Model (TCM) by Dr Mary D. Naylor 8 -12 week programme directed by Advanced Practice Nurses

Patient assessment and development of care plan begin within 24 hours of hospital admission

Regular home visits with telephonic support (7 days a week) after discharge First post discharge visit with the physician accompanied by the

Transitional Care Nurse Interdisciplinary approach; close collaboration with physician

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Some Classical Models

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Transitional care initiatives are nascent in Singapore; most are in pilot phase.

Transitional care (TC) in our local context is defined as care and/or services to support patients’ transfer from the acute care to community setting.

Objectives To support post discharge patients to transit from hospital to community by

streamlining and coordinating care services. To optimise patients’ outcomes following an episode of illness. To minimise hospital utilisation by facilitating timely discharge and

reducing unnecessary hospital readmissions and/or ED visits.

Key features Time-limited Coordinates services according to individualised care plans Handover to community based partners for follow-up care

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Defining Transitional Care in Singapore

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Existing programmes can be broadly classified into two categories:

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Transitional Care Initiatives in Singapore

Predominantly Care Coordination Predominantly Skilled Care Interventions

Caters to patients with complex social care needs and those at risk of functional decline

Targets at patients with higher level of acuity in terms of physical care needs

Emphasis rests on care coordination and patient/caregiver empowerment

Focuses on direct intervention or care provision (e.g. medical, nursing, functional, pharmaceutical)

Minimal provision of direct skilled care Less emphasis on care coordination activities

FOC Fees for service

All are hospital-led at present (3 in total)

E.g. Aged Care Transition Team• The first transitional care pilot in

Singapore inspired by The Care Transitions Intervention®

• The most mature programme by far

• Demonstrates positive results

E.g. Post Acute Care at Home• Slightly more advanced in

development compared to the other hospital-led TC programmes

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ACTION is a government funded project started in 2008.

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Aged Care Transition (ACTION) Teams

Aim:To help patients make a safe and smooth transition from hospitals into their homes or community, by streamlining and coordinating care services to optimise patients’ outcomes throughout and after an episode of illness.

Scale: 81 care coordinators in 6

Restructured Hospitals (RHs), 1 Tertiary Centre & 5 Community Hospitals.

More than 28,731 patients recruited since 2008.

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Patient Screening Criteria of ACTION

Elderly above the age of 65 yrs Multiple co-morbidities Polypharmacy Impaired mobility or significant functional decline Impaired self care skills Poor cognitive status Lives alone or has poor social support Catastrophic/Chronic illness and injury with anticipated long

term health care needs Multiple admissions / ED visits over the last 6 months

Note: Provision of 80/20 rule for exceptions (e.g. young patients)

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Hospital Community

Admission Discharge About 1-3 months post discharge

• Screening high-risk patients• Assessment of needs• Referral to appropriate ILTC services

• Develop and implement care plan • Goal setting and evaluation of care plans

ACTION Team

Care Coordinators

•Nurses, Social workers, Allied health professionals

High-risk hospital inpatients

Residential Facility e.g. community hospital

Home with supporting services• Day rehabilitation services• Home Medical & Home nursing services• Social support services

Discharge

• Telephone follow up, home visit and assessment • Optimize a patient’s self-care capabilities at home• Caregiver education and support• Monitoring of high risk clients• Hand-off to other services

ACTION Process

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Comparison of hospital utilisationACTION vs. Controls

Validation of 15-item Care Transi-

tions Measure (CTM) in Singa-pore’s context

Care recipient/ caregiver survey

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Mixed-Method Evaluation Approach

Administrative data analysis

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ACTION Clients are Elderly and Frail

77% above 70 years old

38% are main carer of themselves

72% have 3 or more co-morbidities

Patient profile is heterogeneous

across sites

Based on 2009Q1 to 2011 Q2 administrative database (N=14,025)

Source: RHIME Administrative Data Analysis

27% with history of >1 fall

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Does ACTION Reduce Hospital Utilisation?

Retrospective case-control study to compare the number of readmissions and ED visits within 6 months after index hospitalisation

Cases from ACTION cohort (Feb 09 - Jul 10) Controls were selected from MOH Casemix and

Subvention Database Inclusion criteria – at least 1 of the following

≥3 diagnoses At least 1 of these diseases: diabetes, hypertension,

hyperlipidemia, dementia, COPD, stroke and schizophrenia ≥1 hospitalisation or ED visit in past 6 months prior to index

hospitalisation

Exclusion criteria Social over-stayer / absconder Age <65y Non-subsidised patients

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Baseline Characteristics of Clients (after weighting by propensity score)

Source: RHIME-MOH Comparison with Comparator Group

  ACTION (N=4132) Control (N=4132) P-valueAge (years)    Mean (SD)  79.2 (7.7) 79.2 (7.7) -Gender    Male 1795 (43.5%) 1797 (43.5%) -Female 2335 (56.5%) 2333 (56.5%) -Charlson Index    Mean (SD) 1.6 (1.8) 1.5 (1.8) 0.37Length of stay (days)    Mean (SD) 11.6 (13.0) 11.1 (15.4) 0.25Past Hospitalisation history    No. of admissions within 180 days before index hospitalisationMean (SD) 0.79 (1.4) 0.81 (1.4) 0.51Patients with ≥ 1 admission within 180 days before index hospitalisationn (%) 1731 (41.9%) 1847 (44.7%) 0.014No. of 180-day ED attendances within 180 days before index hospitalisationMean (SD) 1.9 (2.0) 1.9 (3.1) 0.89Patients with ≥ 1 attendance within 180 days before index hospitalisationn (%) 4004 (96.9%) 3781 (91.5%) <0.001

Propensity score used to adjust for Age, Gender, Charlson’s index, Length of Stay, Number of admissions in 180 days prior to index admission, Number of ED attendances in 180 days prior to index admission

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Comparison Results

Propensity score used to adjust for Age, Gender, Charlson’s index, Length of Stay, Number of admissions in 180 days prior to index admission, Number of ED attendances in 180 days prior to index admission

Odds ratios of hospital readmission and ED attendance - ACTION vs. Controls (after weighting by propensity score)

ACTION patients significantly less likely to be readmitted, and less likely to visit ED.

The odds of unplanned readmission within 15, 30 and 180 days for ACTION patients are lower than the odds for control patients.

The odds of ED attendance of ACTION clients within 30 days are lower than that of controls.

Source: RHIME-MOH Comparison with Comparator Group

Outcome Adjusted Odds Ratio (95% CI) P-valueReadmission        within 15 days 0.5 (0.4, 0.5) <0.001    within 30 days 0.5 (0.5, 0.6) <0.001    within 180 days 0.6 (0.6, 0.7) <0.001ED attendance       within 30 days 0.81 (0.72, 0.90) <0.001   within 180 days 0.90 (0.82, 0.99) 0.027

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0.9

00

.95

1.0

0

0 50 100 150 200

Days from Index Discharge

ACTION CONTROL

180-Days Readmission-free Survival by Groups

Hazard ratio (95% CI) = 1.3 (1.2 - 1.5),P<0.001

ACTION Clients are More Likely to be Readmission-Free

Source: RHIME-MOH Comparison with Comparator Group

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Estimated Cost Savings

Estimating cost savings from the difference in reduced hospital days and programme implementation costs

ACTION saved 6283 bed days of unplanned admissions over 6 months Estimated S$5.3m saved from these reduced bed days

Operational cost of ACTION programme over six months (Apr to Sep 2010) was S$1.94m (>95% the care coordinators’ salary)

Hence overall cost savings = S$3.4m over 6 months

Assumes no net additional healthcare cost used by ACTION care recipients compared to the control group**.

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ACTION clients/ caregivers were surveyed in Feb/ Mar 2011 after discharge from service

ExclusionThose who lodged a hospital complaint

Social overstayer

Cognitively impaired without a caregiver

Those transferred to community hospital/ inpatient in rehabilitation ward/ sub-acute ward/ sheltered home/ nursing home

1st interview: 1 week post-discharge Health-Related QoL (EQ-5D)

2nd interview: 4-6 weeks post-discharge Care Transitions Measure (CTM-15), Health-Related QoL (EQ-5D), satisfaction ratings

451 completed both surveys 70% of responses by caregiver proxy

More Evaluation of ACTION

Source: RHIME-IMH Survey

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Quality of Care Transition

CTM-15 measures four domains

Information transfer

Patient and caregiver preparation

Self-management support

Empowerment to assert preferences

Total score ranges from 0 to100

Higher scores indicate better transition

Overall mean CTM-15 score of surveyed clients/ caregivers was 63.8.

Source: RHIME-IMH Survey

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Perception in Health-Related QoL (EQ-5D)

Analysed for surveys completed by same person (n=296) Higher proportion reported having ‘no problems’ at 4-6 weeks for all

5 dimensions (P<0.05)

Interview 1 Interview 2

‘Self’-rated health(0=worst health, 100=best health)

60.4 64.1P<0.05

Mob

ility*

Self-C

are*

Usual

Activi

ty*

Pain/ D

iscom

fort*

Anxiet

y/ D

epre

ssion

*0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

29.7%

40.2% 39.2%42.2%

57.4%

40.9%

49.7% 48.6%

57.8%

65.2%

Interview 1 Interview 2

Source: RHIME-IMH Survey

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Majority were Satisfied with ACTION

70% rated ACTION service overall as good or excellent.

68% rated care and concern shown by ACTION care coordinators as good or excellent.

63% rated knowledge of care coordinators as good or excellent

Knowledge of CCs Care and concern shown by CCs Overall satisfaction0%

10%

20%

30%

40%

50%

19%

24% 24%

44% 44%46%

27%

24%22%

2% 2% 3%

0.0% 0.4% 0.4%

Excellent Good Satisfactory Poor Very Poor

(N=451)

Source: RHIME-IMH Survey

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The ACTION, a hospital-based transitional care program, significantly reduced acute care utilization for up to 6 months post discharge.

Improved care recipient well-being, and positive responses to quality of care transition and service satisfaction ratings

Findings confirmed the effectiveness of the Care Transition Intervention in Singapore’s public health system.

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Conclusion of ACTION Analysis

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A tertiary hospital pilot programme that delivers transitional care to patients that requires multi disciplinary team interventions post discharge

Key objective include: Reducing unnecessary ED attendance and readmissions and

hence burden on hospital resources

Services provided are time limited with an average duration of

3 months

Encourages handover of patient management to the community whenever possible

The hospital had conducted the first phase of its evaluation to assess the effectiveness of the programme

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Post Acute Care at Home (PACH)

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Based on the analysis of administrative database of PACH client cohort (Apr 11 – Dec 11),

2.9 bed-days can potentially be saved per patient, from

ED visits and readmission averted through timely response by team to urgent calls made by clients

Management of certain conditions at home (which in the absence of PACH would have led to hospital admissions), e.g.

Behavioural problems from persons with dementia staying at home

Facilitation of timely discharge from acute hospital through the provision of post discharge support

AIC and Ministry of Health will work with the hospital on the second phase of the evaluation in acquiring mortality and health service utilisation data to facilitate further analysis.

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Initial Results: Bed Days Saved

Source: PACH Administrative Data Analysis

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There are currently 3 hospital-led transitional care programmes that provide multidisciplinary interventions to help patients transit from hospitals to community.

Common challenges faced by this category of TC programmes

Patients were not keen to be enrolled into such community programmes due to high out-of-pocket charges

Difficulties in recovering cost from patients and hence services were highly subsidised by hospitals

Problems in discharging patients to community partners who are not well-equipped

Limitations in performing robust evaluation by hospitals due to lack of access to comprehensive data

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Challenges of Current TC Programmes

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Expansion of ACTION service in other segments such as specialist outpatient clinics and ED

ACTION teams will collaborate and align more closely with other local projects within respective hospitals

Revision of funding model for hospital-led TC programmes to ensure affordability and sustainability

A unified evaluation will be conducted under the oversight of AIC and Ministry of Health to assess programme outcomes in-depth.

Emergence of new hybrid models taking reference from, for instance Project BOOST and UK Virtual Ward

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Moving Forward

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ACTION Managers, ACTION Care Coordinators, ACTION Clinical Champions and ACTION Heads of AH, CGH, NUH, KTPH, TTSH, SGH, NHC, RCCH, SLH, AMKCH, SACH and BVH

Colleagues from Health Services Research and Health Information Department, Ministry of Health

Colleagues from Research Division, Institute of Mental Health Dr Ian Leong, PACH Programme Director, TTSH Dr Wong LM, Chief, CID, AIC Ms Polly Cheung, Deputy Chief, CID, AIC Dr Wee Shiou Liang, Head (RHIME), AIC Colleagues from Regional Integration Office, AIC MOH and AIC Management

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Acknowledgement

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Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):556-557.

The Australian Government. National Evaluation of the Transition Care Program. Final Evaluation Report. 2008.

The Care Transitions Program [Internet]. [Cited 2013 Feb 18]. Available from: http://www.caretransitions.org/index.asp

Health Workforce Solutions LLC and Robert Wood Johnson Foundation. Transitional Care Model [Internet]. 2008 [cited 2013 Feb 18]. Available from: http://www.innovativecaremodels.com/care_models/21/overview

Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomised controlled trial. Arch of Int Med. 2006;166:1822-8.

Coleman EA. The care transitions intervention [Internet]. [Cited 2013 Feb 20]. Available at: http://www.cfmc.org/integratingcare/files/Care%20Transitions%20Intervention%20for%20CFMC.pdf

Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalised with heart failure: a randomised, controlled trial. JAGS. 2004;65:675-684.

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References

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Thank you