D ATA D R I V E N . P O L I C Y F O C U S E D LDI ResearchBRIEF Research to Improve the Nation’s Health System 2018 . No. 15 COST IMPACT OF THE TRANSITIONAL CARE MODEL FOR HOSPITALIZED COGNITIVELY IMPAIRED OLDER ADULTS Use of advanced practice nurses can lower postacute care use and costs Mark V. Pauly, Karen B. Hirschman, Alexandra L. Hanlon, Liming Huang, Kathryn H. Bowles, Christine Bradway, Kathleen McCauley, & Mary D. Naylor Journal of Comparative Effectiveness Research – published September 11, 2018 KEYFINDINGS Using advanced practice nurses to support high risk patients and their families to transition from hospital to home can reduce postacute care use and costs. A study comparing three evidence-based care management interventions for a population of hospitalized older adults with cognitive impairment found that the Transitional Care Model, which relies on advanced practice nurses to deliver services from hospital to home, was associated with lower postacute care costs when compared to two “hospital only” interventions. THE QUESTION older adults with cognitive impairment. in the hospital, meeting with the medical/ Three hospitals in one health system were surgical care team daily, and following the Hospitalized older adults with cognitive randomized to one of these interventions: patient to the next site of care, among impairment and multiple chronic conditions • n Augmented Standard Care (“ASC,” I other activities. are at higher risk for poor health outcomes, including high and costly use of postacute care lowest dose), trained research assistants services and hospital readmissions. In 2016, screened patients for dementia on hospital THE FINDINGS the average annual per-person payment for admission and communicated positive At 30 days after discharge, patients in the postacute care for Medicare beneficiaries with findings to the medical/surgical team. TCM site had significantly lower average Alzheimer’s and other dementias was 11.5-times • In Resource Nurse Care (“RNC,” medium postacute care (skilled nursing and home greater than older adults without dementia. dose), trained registered nurses who health) costs ($1,660, not including the While evidence-based care management demonstrated competency on web-based additional costs of TCM) than patients in interventions for this population exist, their modules on dementia and delirium were the RNC site ($2,810) and ASC site ($2,753). impact on postacute care use and costs, and designated as resource nurses for the The TCM intervention costs averaged $364, on overall costs in the six months after hospital hospital, and cared for participants or including the time spent on visits, calls, travel, discharge, remains unknown. trained other nurses to do so. and documentation. At 30 days, patients in the TCM site had lower total costs ($2,699) than To shed light on these cost impacts, Mary • In the Transitional Care Model (“TCM,” patients in the RNC site ($4,171) and the ASC Naylor, Mark Pauly, and colleagues compared highest dose), trained advanced practice site ($4,861), though these differences were three interventions of different intensity nurses delivered services from hospital to only marginally statistically significant. delivered to more than 200 hospitalized home, which included visiting the patient COLONIAL PENN CENTER | 3641 LOCUST WALK | PHILADELPHIA, PA 19104-6218 | LDI.UPENN.EDU | P: 215-898-5611 | F: 215-898-0229 | @PENNLDI ResearchBRIEF LDI Table 1. Adjusted costs at 30 days after discharge ABOUT THE AUTHORS ASC Site (n=65) RNC Site (n=71) TCM Site (n=66) Total Postacute Care $2,753 $2,810 $1,660 Mark V. Pauly, PhD Mark V. Pauly, PhD is Skilled nursing/Rehab $1,790 $1,874 $1,124 Bendheim Professor in the Home health $963 $935 $536 Department of Health Care Management, Professor of Intervention costs $0 $0 $364 Health Care Management, Rehospitalizations $1,973 $1,270 $675 and Business and Public Policy at The Wharton School and Professor of Economics in the Other health care (hospice) $135 $92 $0 School of Arts and Sciences at the University Total Costs $4,861 $4,171 $2,699 of Pennsylvania. He is one of the nation’s leading health economists. Most recently, he has examined the topics of national Table 2. Adjusted costs at 180 days after discharge health care reform, the individual insurance ASC Site RNC Site TCM Site market, the effects of poor health on worker Total Postacute Care $3,630 $4,606 $2,260 productivity, and the market for voluntary health insurance in developing countries. He Skilled nursing/Rehab $2,316 $3,212 $1,328 is currently studying how insurance affects Home health $1,314 $1,394 $932 the rate of growth of medical spending. Intervention costs $0 $0 $804 Mary D. Naylor, Rehospitalizations $8,096 $5,317 $4,769 PhD, RN, FAAN Mary D. Naylor, PhD, RN, Other health care (hospice) $135 $127 $0 FAAN is Marian S. Ware Total Costs $11,861 $10,050 $7,833 Professor and Director, NewCourtland Center for Transitions and Health, at the University The findings were similar when average costs Additionally, reduced rehospitalization costs of Pennsylvania School of Nursing. Over were calculated at 180 days after discharge, among individuals in the TCM group more two decades she has designed, tested, where the TCM group had lower postacute than covered additional expenses associated implemented, and translated a model of care costs ($2,260) than the RNC group with TCM implementation. transitional care to improve outcomes for ($4,606) and the ASC group ($3,630). TCM TCM can lower patients’ use of postacute care older adults and their family caregivers. services, which extended for an average of More than a decade of rigorous research services and reduce the burden on caregivers. two months beyond hospital discharge, cost has demonstrated the effectiveness of Dr. Future studies should examine the specific Naylor’s Transitional Care Model (TCM) an average of $804 at 180 days. The TCM processes that bring about these lower costs group’s total average costs at this endpoint in using advanced practice nurse-led, team- in TCM or similar models, or ways to reduce based care management innovation. She has the study were $7,833, compared to $10,050 in TCM implementation costs without affecting led the translation of her findings into wide the RNC group and $11,861 in the ASC group. the standard of care. adoption and has been a leader in building the The breakdown of costs at 30 and 180 days, by evidence linking nursing to quality of care. type of service, appears in Tables 1 and 2 above. THE STUDY This study compared postacute care and THE IMPLICATIONS rehospitalization costs for hospitalized older ABOUT LDI Use of specially trained nurses who can provide adults with cognitive impairment who received continuity of care between hospital and home one of three care management interventions. Since 1967, the Leonard Davis Institute of can significantly reduce postacute care use It occurred across three sites within the same Health Economics (LDI) has been the leading and costs for high risk patients with cognitive urban academic medical system. Each site university institute dedicated to data-driven, impairment. TCM not only reduced the was randomly assigned to one of the three policy-focused research that improves our amount of postacute care services needed, interventions (ASC, RNC, or TCM) and nation’s health and health care. Originally such as home health visits or skilled nursing participants received the intervention at the founded to bridge the gap between scholars facility (SNF) stays, but also affected total costs site at which they received care. Statistical in business (Wharton) and medicine at the University of Pennsylvania, LDI now connects of care after hospital discharge. The impact methods were used to adjust for potential all of Penn’s schools and the Children’s Hospital on SNF use – the single largest contributor selection bias since randomization of patients of Philadelphia through its more than 280 to postacute care costs – was particularly was not possible. The authors then compared Senior Fellows. significant: costs among the TCM group were postacute care and rehospitalization costs for about $1,000-$2,000 lower than the RNC participants in each intervention group at 30 LDI Research Briefs are produced by LDI’s policy and ASC groups 180 days after discharge. days and 180 days after hospital discharge. team. For more information please contact Janet Weiner at weinerja@pennmedicine.upenn.edu