Transitional Care Programme Evaluation – The Singapore Experience

1. Transitional Care Programme Evaluation – The Singapore Experience 12th April 2013 Dr Patsy Chow (Patsy.CHOW@aic.sg) Dr Loong Mun Wong Dr Jason Cheah Agency for Integrated Care

2. 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.

3. Some Classical Models 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 visitswith 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

4. Defining Transitional Care in Singapore • 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 utilisationby 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

5. Transitional Care Initiatives in Singapore • Existing programmes can be broadly classified into two categories:

6. Aged Care Transition (ACTION) Teams • ACTION is a government funded project started in 2008. 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 & 5Community Hospitals. • More than 28,731 patients recruited since 2008.

7. 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)

8. ACTION Process Residential Facility e.g. community hospital High-risk hospital inpatients • Home with supporting services • Day rehabilitation services • Home Medical & Home nursing services • Social support services Discharge Admission Discharge About 1-3 months post discharge Hospital Community ACTION Team • Screening high-risk patients • Assessment of needs • Referral to appropriate ILTC services • Care Coordinators • Nurses, Social workers, Allied health professionals • Develop and implement care plan • Goal setting and evaluation of care plans • 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

9. Mixed-Method Evaluation Approach Administrative data analysis

10. ACTION Clients are Elderly and Frail Based on 2009Q1 to 2011 Q2 administrative database (N=14,025) • 27% with history of >1 fall Source: RHIME Administrative Data Analysis

11. 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-subsidisedpatients

12. Baseline Characteristics of Clients (after weighting by propensity score) 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 Source: RHIME-MOH Comparison with Comparator Group

13. Comparison Results • 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. Odds ratios of hospital readmission and ED attendance - ACTION vs.Controls (after weighting by propensity score) 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 Source: RHIME-MOH Comparison with Comparator Group

14. ACTION Clients are More Likely to be Readmission-Free Hazard ratio (95% CI) = 1.3 (1.2 - 1.5), P<0.001 Source: RHIME-MOH Comparison with Comparator Group

15. 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$5.3msaved 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**.

16. More Evaluation of ACTION ACTION clients/ caregivers were surveyed in Feb/ Mar 2011 after discharge from service • Exclusion • Those 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) 2ndinterview: 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 Source: RHIME-IMH Survey

17. 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

18. 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) P<0.05 Source: RHIME-IMH Survey

19. Majority were Satisfied with ACTION (N=451) • 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 Source: RHIME-IMH Survey

20. Conclusion of ACTION Analysis • 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.

21. Post Acute Care at Home (PACH) • 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

22. Initial Results: Bed Days Saved 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. • Behaviouralproblems 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 utilisationdata to facilitate further analysis. Source: PACH Administrative Data Analysis

23. Challenges of Current TC Programmes 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 communitypartners who are not well-equipped • Limitations in performing robust evaluation by hospitals due to lack of access to comprehensive data

24. Moving Forward • 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 programmeoutcomes in-depth. • Emergence of new hybrid models taking reference from, for instance Project BOOST and UK Virtual Ward

25. Acknowledgement • 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 • MsPolly Cheung, Deputy Chief, CID, AIC • Dr Wee Shiou Liang, Head (RHIME), AIC • Colleagues from Regional Integration Office, AIC • MOH and AIC Management

26. References • 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.

27. Thank you