CMS National Conference on Care Transitions

1. CMS National Conference on Care Transitions December 3, 2010

2. Support from Hospital to Home for EldersThe SHHE project at San Francisco General Hospital Jeff Critchfield, MD Associate Professor Department of Medicine University of California, San Francisco

3. Objectives • Communicate challenges faced in the Safety Net Hospitals • Share Specific efforts by SHHE to address challenges • Adaptation of prior interventions for low-income, multi-ethnic setting

4. SHHE • Gordon and Betty Moore Foundation awarded grant to implement and evaluate a readmission initiative • Collaborate with Boston University to adapt Project RED for patients at San Francisco General Hospital • Large, academic, urban public hospital • 66-75% patients have limited health literacy

5. SHHEPrimary Questions • Can we reduce re-admissions among low-income elders using key components of prior clinical trials? • Is telephone follow-up feasible? • Why is this population re-admitted?

6. Study Design and Population • English, Spanish, Mandarin or Cantonese - speaking patients, age 60 or older • Admitted to medicine, family medicine, cardiology, and neurology • Transitioning to home (Hotel, shelter) • 200-patient pilot (all received intervention)

7. Intervention Elements: In-Hospital • Dedicated SHHE nurse • Culture/ language concordance • Focus on coaching and patient goal-setting – (Motivational Interviewing) • Computer-assisted transition packet • Licensing – Engineered Care • Interface with our hospital’s IT system • Translation time/costs

12. Intervention Elements : Post-Hospital • Follow-up telephone calls • Prescribing ability- Nurse Practitioner or Physician Assistant • Days 1-3 and 7-9 post-hospitalization

13. Pilot ResultsCharacteristics of Patients • 81% are non-white • 46% have less than a HS education • 53% born outside the United States • 72% are single, divorced, widowed • 92% earn less than $20,000 per year

14. Successes in the pilot • Remarkably successful connecting with patients • 80% completed at least one post-hospitalization phone call (clinical) • 98% completed 30-day follow-up interviews (evaluation)

15. Pilot ResultsHigh access to care • 93% had PCP visit in prior 6 months • 41% ED visit in 6 months prior • 32% Hospitalization in 6 months prior

16. Pilot Outcomes • 23% of patients were re-hospitalized within 30 days • 26% of re-admissions/ ED visits were at outside hospitals • 5.5% 30-day mortality

17. Randomized Controlled TrialEnrolling Now Comparing usual care to usual care with SHHE 700 person RCT Primary endpoint – 30, 90, 180 day readmission Build database –psychosocial, functional (readmission factors) Current enrollment – 115 subjects

18. Key Lessons Core of intervention is relationships Coaching – patients feel heard Teach back methods Cultural concordance Morbidity is high among this patient population Case management?! Palliative Care

19. Discussion Points In populations with social and economic challenges what parameters must be considered to determine preventability of re-admission?

20. Discussion Points How do you balance an evidence based approach with local needs, expertise and resources?

21. SHHE Team • Clinical • Kara Duffy • Lizbeth Flores-Byrne • Diane Robbins • Richard Santana • Tip Tam • Barbara Walter • Catheryn Williams • Co-Principal investigators • Sue Currin • Jeff Critchfield • Operations • Barbara Walter • Michelle Schneidermann • Margarita Sotelo • Will Huen • Evaluation • Eric Kessell • Margot Kushel • Urmimala Sarkar • Liz Goldman • Edgar Pierluissi • Data collection • Eric Kessell • Aurora Hernandez • Alice Lam • Tiffany Sin • Collaborators • Michael Paasche-Orlow (Project Red) • Chris Corio (Engineered Care)

22. For more information, contact: Jeff Critchfield, MD jcritchfield@medsfgh.ucsf.edu