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Evaluation Results and Outcomes from a Hospital to Home Care Transitions Pilot Project

Evaluation Results and Outcomes from a Hospital to Home Care Transitions Pilot Project. Taj Bhaloo, PhD, MHA Director, CHRISTUS Health Adjunct Assistant Professor, University of Texas. Outline. Brief description of the H2H Pilot Results Kansas City Cardiomyopathy Questionnaire

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Evaluation Results and Outcomes from a Hospital to Home Care Transitions Pilot Project

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  1. Evaluation Results and Outcomes from a Hospital to Home Care Transitions Pilot Project Taj Bhaloo, PhD, MHA Director, CHRISTUS Health Adjunct Assistant Professor, University of Texas

  2. Outline • Brief description of the H2H Pilot • Results • Kansas City Cardiomyopathy Questionnaire • Client & System Outcomes

  3. Description of Pilot • Partnership: Care for Elders & Methodist Hospital • Pilot based on Coleman Care Transitions Intervention • Home Visits/Telephone Monitoring (education) • Medication Management • PHR • Follow-up Care

  4. H2H Unique Elements • Modifications: • Transitions Coach: SW, Case Management experience • 12-week duration • Depression Screening & Referral: Healthy IDEAS • Pilot included: comprehensive case management; depression screening; referrals to community-based services.

  5. Rationale for Change • Growing evidence that recognizes the influence of socio-economic & psycho-social factors in care transitions (Arbaje, Wolff, Yu, Powe, Anderson & Boult, 2008). • Transitions Coach developed good relationships with each client • Depression often goes hand in hand with heart disease

  6. Primary Objectives 1) To understand the impact of the program at the client level (changes to overall quality of life & self-management competency) 2) To understand the broader impact of the pilot program on 30-day readmissions.

  7. Pilot Description • Eligibility criteria: older adult, Harris County resident, diagnosis of CHF, speak English, be accessible by phone after hospital discharge. • Study timeframe: April 2009-December 2010 • 69 participants were invited, 32 accepted • Study group n=32, 28 completed the program

  8. Descriptive Statistics

  9. Descriptive Statistics

  10. Results • Each client received either a home visit or telephone call each week • 25% of clients received subsidized blood pressure cuffs and/or weighing scales; 13% needed financial assistance with other necessities

  11. Community Referrals

  12. Success Rates with Referrals • Direct Referrals: • Out of 41 made, 25 referrals were successful (61%) • Indirect Referrals: • Out of 17 indirect referrals, only 3 successful (17%) • More than 3x likely to have successful outcome when referral made by TC

  13. Medication Reconciliation & Follow up Medical Care • # of Meds: 12 meds/client • Range: 6 – 27 medications/client • No clinically significant concerns • Transitions Coach spent time on medication –related education • 36 out of 38 follow up visits kept (95%) • 113 follow up visits for specialty care (3.5/client)

  14. Client Level Outcomes KCCQ Summary Scores (n=27): • Group mean change of 8.95 points (pre & post): statistically significant (p=0.03) & clinically significant (moderate improvement). • Magnitude of Change: slight, moderate, large • 30% had a slight to moderate improvement • 37% had a moderate to large improvement.

  15. Quality of Life Assessment • Quality of Life (subset of KCCQ) • Group mean change =18.65, Statistically significant(p=0.009) • Clinically significant (d> 12 considered large improvement) • 67% had a small, moderate or large improvement in QoL score

  16. Self-Management Competency • Two questions: • How sure are you that you know what to do/ whom to call, if your HF symptoms get worse? • Statistically significant change (p=0.03) • How well do you understand what things you are able to do to keep your HF symptoms from getting worse? • Statistically significant change (p<0.001) • “mostly sure” to “completely sure”

  17. Depression and HF • Every client pre-screened with 2 questions. • GDS administered on 13 clients (46%) • Mean change in score (-1.38): Not Statistically significant (p=0.29) • 46% of clients saw a clinically significant reduction in depression (n=6) • No referrals to Healthy IDEAS

  18. Related Readmissions Study group only

  19. Conclusion • Tested a new model of care: using a SW as Transitions Coach • In spite of small sample size, results are promising • Outcomes at client level: improved overall health, improved QoL. • Some reported decreased levels of depression. • Model needs to be tested with larger cohort of clients.

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