In Care Transitions, a Chance to Make or Break Patients' Recovery

When Lynne van Zonneveld and her husband moved to Dillon, Montana—population 4,000—access to health care wasn’t at the top of their minds. They were healthy and active, drawn to Montana by its magnificent high-desert landscape and clean air.

That changed last year when a doctor discovered that van Zonneveld, a retired sales rep, had two faulty heart valves. She underwent open-heart surgery to repair them in Missoula, 180 miles away. Her operation was a success, but afterward, she received few instructions and no information on whom to contact with questions or difficulties. “It seemed like I was just cut loose,” she remembers.

Her experience is not unusual. Our healthcare system has difficulty with transitions—where a patient is passed between levels of health care or from one care setting to another. “Miscommunication about medications, failure to schedule follow-ups, or not ensuring that patients have the supplies they will need lead to unnecessary hospital visits and worse health outcomes,” says Steven Clauser, PhD, MPA, Director of PCORI’s Improving Healthcare Systems program.

“This is a very important issue for patients,” Clauser says. “Poorly executed transitions can really harm patients and burden family caregivers.” His program’s multi-stakeholder advisory panel identified transitional care as one of its top priorities.

In recent years, care transitions have become a major focus of hospitals and payers. Twenty percent of Medicare beneficiaries who are released from hospitals are readmitted within 30 days, and 90 percent of those readmissions are due to preventable factors, according to the Medicare Payment Advisory Commission. Under the Affordable Care Act, hospitals with excessive readmission rates receive reduced Medicare and Medicaid payments.

In recognition of the importance of care transitions, PCORI is funding comparative effectiveness research to study this topic. Several PCORI-supported projects are comparing innovations in transitional care against existing approaches to identify the best options for distinct patient populations. The goal is to provide evidence that enables patients, caregivers, and communities, as well as healthcare providers and administrators, to make informed decisions about which transitional care services are most effective and how to implement best practices in their communities.

Poor care transitions are a particularly difficult problem not only in rural areas, as van Zonneveld learned, but also among underserved groups in urban settings. In this feature, we highlight one rural and one urban PCORI-funded project, and present a list of related projects.

PCORI also recently funded a larger-scale trial that will visit healthcare facilities across the country, interview more than 10,000 patients, and examine clinical and claims data. The study is called Project ACHIEVE (Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence).

Led by Mark V. Williams, MD, of the University of Kentucky, Project ACHIEVE will identify which transitional care services and outcomes matter most to patients in a variety of vulnerable populations, including older adults, minorities, those with low health literacy, low-income groups, rural residents, and individuals with special needs.

Through massive efforts in qualitative and quantitative data analysis, Project ACHIEVE will compare hospitals and communities that have implemented different clusters of transitional-care services. Preliminary outcomes will include patient and caregiver experience, patient-reported health outcomes, adverse drug events, use of health services, such emergency room visits, and re-hospitalizations. “This study will be PCORI’s flagship effort on transitional care,” says Clauser.

PCORI plans to establish an Evidence to Action Network to connect all the PCORI-funded teams that are studying transitional care. The network will facilitate information exchange between projects and also put investigators in touch with potential end users of the research findings to promote their dissemination and implementation.

Health on the Range…

Rural America covers 85 percent of US land, and 56 million people—about 20 percent of the population—live there. People in rural areas have worse health outcomes than urban dwellers, says Tom Seekins, PhD, a University of Montana psychologist. Poor discharge planning, the process by which hospitals help patients to transition back home, he says, is one reason why.

Seekins is leading a PCORI-funded project to address the hospital discharge experience for rural dwellers. He works in Missoula, where the regional hospital, St. Patrick, draws patients from an extensive mountainous area—about 100,000 square miles. The size of the area poses a challenge. Discharge planners at regional hospitals are often unfamiliar with the home communities of their rural patients and unaware of the resources for rehabilitative care or home services available there. Those resources may be informal, like a high-school coach who provides basic physical therapy or a church that prepares meals.

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“There is an amazing lack of connectedness and information exchange between these settings,” says Seekins. As a result, rural patients may be kept in the hospital for longer than necessary or sent home without adequate provisions for their care.

With input from van Zonneveld and other rural patients, Seekins’ team is designing and testing an intervention to help hospitals connect patients with local resources.

To review the existing discharge process, the research team shadowed discharge planners at St. Patrick Hospital, where van Zonneveld was treated, and four smaller, critical-access hospitals. Then the team conducted in-depth interviews with 40 rural patients who had been discharged from St. Patrick.

Those interviews guided development of a survey that was completed by more than 500 former patients in four rural counties. Major issues they identified include getting rehabilitation services locally, providers working together as a team, and patients receiving follow-up after treatment.

After a series of community discussions on those issues, a team will design an intervention, called ROADMAP, which the five hospitals will begin implementing this year. The design team will include the researchers, at least four patients, and two discharge planners, as well as rural health consultants and representatives from the Montana Hospital Association. Incorporating patient and provider input increases the likelihood that findings will be used, Seekins says.

The team will compare the intervention and standard treatment, looking at patient satisfaction, health outcomes, and re-hospitalizations within 30 days. Currently, about 16 percent of patients discharged in this community are re-hospitalized.

Seekins expects the intervention to address communication between the regional hospital and smaller rural health centers. He envisions a dynamic database listing the healthcare resources available in each community—from formal medical practices to individuals available to help with transportation and homecare.

“Health is not just a product of medical services, but of the communities in which we live,” says Seekins. He argues that transportation, accessible housing, and social support, although not typically considered medical issues, can make the difference between recovery and relapse. He expects that conversations with patients and other stakeholders will reveal surprising gaps that better planning can address.

The final ROADMAP intervention, Seekins predicts, will reduce re-hospitalizations in the study area by about 30 percent and improve patients’ return to normal life. If widely adopted in rural areas, he estimates, it could save up to $2 billion each year.

…and in the City

The proportion of patients who end up back in the hospital within a month after discharge is high not only among rural dwellers but also among some urban groups, including racial and ethnic minorities and patients of low socioeconomic status. The discharge process could be one reason for the high readmission rate, says Jerry Krishnan, MD, PhD, Associate Vice President for Population Health Sciences and Professor of Medicine and Public Health at the University of Illinois Hospital and Health Sciences System.

Krishnan leads a PCORI-funded project that looks at transitional care at a hospital in downtown Chicago. Minority patients make up a high proportion of those served by the University of Illinois Hospital, and about 30 percent of patients who are hospitalized there for one of six serious conditions are re-admitted within a month of release.

“Our patients talked about feeling abandoned when they were going home,” says Krishnan. Many are unable to digest the after-care instructions they were given as they left the hospital. Others lack the financial resources or social support to put those instructions into action.

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In the past, says Krishnan, strategies for lowering hospital readmission rates have focused on providing better medical services and improving communication among medical providers. The current project, called PATient Navigator to rEduce Readmissions (PArTNER), takes a different tack. It focuses on supporting patients during their transitions home.

Krishnan and his team put together a focus group of patients who discussed their healthcare experiences with researchers. “They were asking the right questions,” says Earl Ross, a sickle cell disease sufferer who was in the group. Those conversations helped Krishnan and his colleagues identify two patient-centered goals for their intervention: to increase the social support available to discharged patients and to decrease their anxiety about the possibility of getting sick again.

The focus group, a patient advisory board, and partner organizations, including the Society for Hospital Medicine and the Chronic Obstructive Pulmonary Disease (COPD) Foundation, helped to design an intervention, called Navigator, to meet these goals.

Patients receiving the intervention will get help from a patient navigator, employed by the hospital, both during the hospitalization and after hospital discharge. The navigator will be a community health worker, that is, a nonmedical professional trained to connect patients and healthcare providers to resources in the community, such as meals-on-wheels and nearby pharmacies or clinics. Patients in the intervention group will also have access to a phone line staffed by peer coaches who can answer nonmedical questions and provide tips, such as suggestions on how to train caregivers.

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The point, says Krishnan, is to boost social support, soothing patients’ anxieties and helping them to understand and follow their homecare instructions. “It’s filling in the cracks,” he adds. The project will also provide much-needed data about the effects of community health workers and peer patient navigators in underserved populations.

The project is now in a pilot phase testing the Navigator intervention. With feedback from the stakeholders involved in this phase, the team with tailor the intervention and then test it in a randomized clinical trial with approximately 1,100 patient participants.

That trial will compare the effects of quality-improvement initiatives already in place at the hospital with a combination of those initiatives and the Navigator intervention. The trial will gauge changes in social support and anxiety, as well as 30- and 60-day hospital readmission rates.

Krishnan expects that improving the quality of the discharge process for patients will cause readmission rates to fall. He views his trial as taking aim at a racial and economic healthcare disparity by placing patients’ experience front and center. He says, “This project is very different from previous ones because the endpoints are so patient-centered.”

Posted: April 1, 2015