High-value transitional care: translation of research into practice.

OBJECTIVE: To evaluate the impact of translating into a large US health plan, the Transitional Care Model (TCM), an evidence-based approach to address the needs of chronically ill older adults throughout acute episodes of illness. METHODS: A prospective, quasi-experimental study of 172 at-risk Aetna Medicare Advantage members in the mid-Atlantic region who received the TCM. A baseline and post-intervention (average of 2 months) comparison of enrolees' health status and quality of life was conducted. Member and physician satisfaction were assessed within 1 month post intervention. Health resource utilization and cost outcomes were compared to a matched control group of Aetna members at multiple intervals through 1 year. RESULTS: Improvements in all health status and quality of life measures were observed post- intervention compared to pre-intervention. Among 155 stringently matched pairs, a significant decrease in number of re-hospitalizations (45 vs. 60, P < 0.041) and total hospital days (252 vs. 351, P < 0.032) were observed at 3 months. Reductions in other utilization outcomes or time points were not statistically significant. The TCM was associated with a short-term decrease of $439 per member per month in total health care costs at 3 months and cumulative per member savings of $2170 at 1 year (P < 0.037). CONCLUSIONS: Findings demonstrate that a rigorously tested model of transitional care for chronically ill older adults can be successfully translated into a real-world organization and achieve higher value.

Telemonitoring with case management for seniors with heart failure.

OBJECTIVE: To assess the impact of supplementing nurse case management with Internet-connected telemonitoring on clinical outcomes in an elderly heart failure (HF) population. STUDY DESIGN: Randomized clinical trial allocating high-risk HF subjects to the telehealth system with case management (THCM) versus case management (CM) alone. METHODS: Medicare Advantage members with HF and recent hospitalization were randomized to THCM or CM. Consenting participants received THCM for 6 months or the health plan's usual Medicare specialized CM as long as deemed necessary. The primary outcome measure was a composite of all-cause hospitalization, ED visit, or death. Because only a subset of those who were randomized consented and participated, the strategies were evaluated as-treated rather than by intention-to-treat, with multivariate adjustment in logistic regression models for confounding introduced by postrandomization exclusions. RESULTS: The treated sample size was 164 subjects in THCM and 152 in CM. Treatment arms did not differ significantly for the primary composite outcome (45% for THCM vs 40% for CM, relative risk 1.18; P = .22). Telehealth alerts prompted frequent telephonic contact, increasing THCM case managers' workload. The participant population overall had 42% fewer inpatient days during the intervention period compared with the previous year. CONCLUSIONS: Despite effective implementation of an Internet-based telehealth intervention in an elderly HF population, there was no discernible impact on overall morbidity or mortality. Notably, limited postrandomization participation decreased power to detect a difference. The reduction in days hospitalized for trial participants overall underscores the benefit of CM for such HF patients.

A comprehensive case management program to improve palliative care.

OBJECTIVE: The objective of this study was to evaluate the impact of comprehensive case management (CM) and expanded insurance benefits on use of hospice and acute health care services among enrollees in a national health plan. STUDY DESIGN: Retrospective cohort design with three intervention groups, each matched to a historical control group. METHODS: Intervention groups were health plan enrollees who died after 2004: 3491 commercial enrollees with CM; 387 commercial enrollees with CM and expanded hospice benefits; and 447 Medicare enrollees with CM. Control groups consisted of enrollees who died in 2004 prior to the start of the palliative care CM program. The main outcomes measured were the proportion using hospice, mean number of hospice days, and number of inpatient days measured through medical claims. RESULTS: Hospice use increased for all groups receiving CM compared to the respective control groups: from 30.8% to 71.7% (p < 0.0001) for commercial members with CM and from 27.9% to 69.8% (p < 0.0001) for Commercial members with CM and enhanced hospice benefits. Mean hospice days increased from 15.9 to 28.6 days (p < .0001) and from 21.4 to 36.7 days (p < 0.0001) for these groups, respectively. Inpatient stays were lower for all groups receiving CM services compared to their respective control groups. CONCLUSIONS: Comprehensive health plan CM and more liberal hospice benefit design may help to break down barriers to hospice use; benefits might be liberalized within the context of such case management programs without adverse impact on total costs.

Translating research into practice: transitional care for older adults.

RATIONALE: Over the last decade, in order to close the safety and health care quality chasm, there has been a growing imperative to translate evidence-based research into practice. AIMS AND OBJECTIVES: This study examines the major facilitators and barriers of implementing in a large US insurance organization - Aetna Corporation - an evidence-based model of care, the Transitional Care Model, which has been rigorously tested over the past twenty years by a multidisciplinary team at the University of Pennsylvania. METHODS: Semi-structured interviews of 19 project leaders, case managers, and transitional care nurses were conducted during two phases of translation - start-up and roll out. Qualitative analysis was used to identify more than a dozen key barriers to and facilitators of translation in these two critical phases. Results Six facilitators and seven barriers that are consistent with the literature were identified during and categorized as either start-up or roll-out. CONCLUSION: The combined results have important practical implications for other, subsequent translational efforts and for assisting providers, policy makers, payers, and other change agents in integrating evidence-based practice with "real world" management.