What if a high-risk, chronically ill elderly patient that was admitted to the hospital had an advanced practice nurse (APN) caring for him (or her) from the get-go? And that nurse enhanced health care team communication and prevented functional decline? And also helped to design the discharge plans–and stayed involved with that patient’s care after he or she left the hospital?

And what if that nurse then visited the patient at home? Stayed in regular touch by telephone–seven days a week if needed? Worked hand-in-hand with the family? Made sure the patient had follow-up care from a primary care physician in the community–and went to, at least, that first post-hospital appointment with the patient? Facilitated communications with various care providers so everyone knew what they needed to know and crucial information didn’t fall through the cracks? Stayed in the picture for around two months – but provided planning and tools to create longer-term positive outcomes.

As some readers may know, that’s the Transitional Care Model that Mary Naylor, Ph.D., R.N. and team has developed and refined at the University of Pennsylvania.
Naylor’s been written about and talked about for many years. But in a health care system where perverse incentives can carry the day over promising innovations, her model hasn’t spread, hasn’t caught fire elsewhere.

Maybe that’s about to change. The Affordable Care Act creates numerous new openings to refine and replicate programs aimed at improving care of high risk older adults, with significant attention being paid to the problems that arise (and errors that are made) as patients transition from one care setting to another.

In addition, Naylor’s research program at Penn has recently partnered with some private insurers and health plans, including Aetna, that are finding that the approach reduces hospital readmissions, saves money, and improves patient and family satisfaction – not just in a research setting but in the messy real world. And that paved the way for other health care systems to start adapting it.

A quick review: the Transitional Care Model has been around for a long time, addressing many of the problems that are now buzzwords in health reform – before there was much buzz about those words. It aims to address high rates of medical errors, low patient and family satisfaction, the high rate of preventable hospital readmissions – and dozens of things that can and do go wrong when patients, particularly very sick frail patients, move from one health care setting to another – such as from a hospital to a skilled nursing facility, and a skilled nursing facility to home.

The Penn model focuses on older adults who have at least two risk factors and multiple chronic conditions, and who have had recent hospitalizations. The transitional care nurse gets involved while the patient is in the hospital. In addition to the nurse’s role in inpatient care, the nurse is already planning the transition out of the hospital, and will remain involved once the patient has been discharged.

It’s not just warm and fuzzy handholding. The APN helps lead a team-model of care, following evidence-based practices, and coordinating with other team members – ranging from physicians and therapists to direct care workers (like home health aides) in the community.

“It’s holistic care, a family-centered approach,” said Naylor.

And now she can cite research showing that the Transitional Care Model has increased the time to the first readmission or death, decreased all-cause readmissions, improved physical function and quality of life, boosted patient satisfaction–and reduced total health care costs.

But sometimes evidence isn’t enough for other health providers to make changes. Not when the payment incentives and revenue streams are all topsy-turvy.

Under health care reform, a number of new models will promote more streamlined care, what Naylor calls “a single point person across an episode of care.” That person, the APN (a master’s prepared nurse) with training in geriatrics, creates relationships, which contributes to continuity, which contributes to better care.

The Penn model isn’t the only one getting attention, as Naylor and several colleagues wrote in the journal Health Affairs soon after the passage of health reform last year:

“’Transitional care is defined as a broad range of time-limited services designed to ensure health care continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another. Transitional care is complementary to, but not the same as, primary care, care coordination, discharge planning, disease management, or case management. The hallmarks of transitional care are the focus on highly vulnerable, chronically ill patients throughout critical transitions in health and health care, the time-limited nature of services, and the emphasis on educating patients and family caregivers to address root causes of poor outcomes and avoid preventable rehospitalizations.”

In other words, transitional care is what patients and families deserve, but are often bewildered and at a loss as to how to do it on their own, when they and their loved ones don’t get it.

Naylor has recently been testing the transitional care waters in a series of partnerships with Aetna’s Medicare Advantage plans, Kaiser Permanente, and other private insurers in the Philadelphia area. Both Aetna and Blue Cross are now reimbursing the University of Pennsylvania Health System. Paying for the services of the APN is preventing other big ticket expenses. One study found cost savings of $2,170 per member annually. Another found that it nearly halved costs for these high-risk patients at the 6-month mark ($3,600 versus $6,600), and brought them from about $12,400 down to $7,600 at the 12-month mark.

Readmission rates, in one study, were cut in half at 6 months, and were still down from about 62 percent to 48 percent a year out in another.

Naylor believes the health care system may be on the cusp of finding ways to adapt her approach, as well as other programs designed for the high-risk, high-needs elderly. The Affordable Care Act, she said, could “get us to higher value.”

Think about it. Right now, under fee-for-service Medicare and most private health plans, there is no payment mechanism for an APN to put this kind of intensive time and effort into care coordination across settings. To the contrary, it may well cost the hospital money.

Health reform tries to change the incentives in multiple ways. For instance, transition services were a big component of the Partnership for Patients initiative that the Centers for Medicare & Medicaid Services (CMS) announced this spring. It included $500 million for community-based organizations partnering with eligible hospitals for care transition services.

Other reform initiatives aimed at improving care for this population involve the CMS Innovation, the shared savings programs that are part of the effort to create accountable care organizations in Medicare (which admittedly seem to be getting off to a bumpy start with lots of industry skepticism, at least at this early stage); new efforts at streamlining care of dual eligibles; patient-centered medical homes for both Medicaid and Medicare, bundled payments; and other programs that could make providers rethink how they share responsibility for care in and out of the hospital.

For Naylor, all this spells a potential new day, not just to build and help spread models like the one she has developed at Penn, but for other approaches with similar goals. It’s not just about saving money. It’s not even just about better health care, she said. It’s also about another, less tangible benefit.

“We’re rebuilding trust in older Americans,” she said,” who no longer believe we are on top of their care needs.”

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Contributing Writer Joanne Kenen writes monthly news features for the Health Policy Forum discussing health policy innovation and “what works” in our health care system, as well as the politics of health policy and reform. As a leading nonprofit health care research and consulting institute dedicated to improving human health, Altarum encourages open discussion and debate about the many challenges in health care today. All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Altarum is a nonprofit, nonpartisan organization. No posting should be considered an endorsement by Altarum of individual candidates, political parties, opinions, or policy positions.