Improving Care for Older Adults: A Model to Segment the Senior Population

Zhou, Yi; Wong, Warren F.; Li, Hui

doi:10.7812/tpp/14-005

Cited by 28 publications

(20 citation statements)

References 9 publications

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“…26,27 Similarly, an internally developed algorithm automatically segments the population of older adults into 4 care groups with similar needs, trajectories, and utilization patterns. 28 A BPA prompting the discharging physician to implement the transition bundle is triggered for patients identified as being at high risk by the LACE index or belonging to the highest need care group. A recent readmission, any diagnosis of CHF, and identification of highrisk status by care coordinators, who are accountable for identifying high-risk patients, also trigger the BPA.…”

Section: Discussionmentioning

confidence: 99%

Tackling 30-Day, All-Cause Readmissions with a Patient-Centered Transitional Care Bundle

Rice

Barnes

Rastogi

et al. 2016

Population Health Management

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In 2008, Kaiser Permanente Northwest identified the transition from hospital to home as a pivotal quality improvement opportunity and used multiple patient-centered data collection methods to identify unmet needs contributing to preventable readmissions. A transitional care bundle that crosses care settings and organizational functions was developed to meet needs expressed by patients. It comprises 5 elements: risk stratification, a specialized phone number for discharged patients, timely postdischarge follow-up, standardized patient discharge instructions and same-day discharge summaries, and pharmacist-supported medication reconciliation. The transitional care bundle has been in place for 6 years. Readmission rates decreased from 12.1% to 10.6%, Hospital Consumer Assessment of Healthcare Providers and Systems scores for the discharge instruction composite moved from below the 50(th) to above the 90(th) national percentile, average time to the first postdischarge appointment decreased from 9.7 days to 5.3 days, and error rates on the discharge medication list decreased from 57% to 21% (P<.0001 for all). The program, which continues to evolve to address sustainability challenges and organizational initiatives, suggests the potential of a multicomponent, patient-centered care bundle to address the complex, interrelated drivers of preventable readmissions.

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Section: Discussionmentioning

confidence: 99%

Tackling 30-Day, All-Cause Readmissions with a Patient-Centered Transitional Care Bundle

Rice

Barnes

Rastogi

et al. 2016

Population Health Management

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“…In the context of increasing complexity of patient diagnoses (e.g., multi-morbidity), patient populations could be grouped, not by specific diseases but by health status, functional ability and/or healthcare needs (Lynn et al 2007). This has been proposed as an approach to support planning and organizing health service delivery (Lynn et al 2007) and specifically, primary care service delivery (BC Ministry of Health 2014; Dow et al 2013; Hewner et al 2014; Porter et al 2013; Zhou et al 2014) but with little discussion about the potential implications for performance measurement.…”

Section: Resultsmentioning

confidence: 99%

“…We considered principles used in examples of population segmentation with a focus on the work of Lynn et al (2007), Porter et al (2013) and others (BC Ministry of Health 2014; Dow et al 2013; Hewner et al 2014; Zhou et al 2014) to provide some guidance on optimal features of population segments. We have established the following criteria:…”

Section: Resultsmentioning

confidence: 99%

Primary Care Performance Measurement and Reporting at a Regional Level: Could a Matrix Approach Provide Actionable Information for Policy Makers and Clinicians?

Langton¹,

Wong²,

Johnston³

et al. 2016

hcpol

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Objective: Primary care services form the foundation of modern healthcare systems, yet the breadth and complexity of services and diversity of patient populations may present challenges for creating comprehensive primary care information systems. Our objective is to develop regional-level information on the performance of primary care in Canada. Methods: A scoping review was conducted to identify existing initiatives in primary care performance measurement and reporting across 11 countries. The results of this review were used by our international team of primary care researchers and clinicians to propose an approach for regional-level primary care reporting. Results: We found a gap between conceptual primary care performance measurement frameworks in the peer-reviewed literature and real-world primary care performance measurement Primary Care Performance Measurement and Reporting at a Regional Level and reporting activities. We did not find a conceptual framework or analytic approach that could readily form the foundation of a regional-level primary care information system. Therefore, we propose an approach to reporting comprehensive and actionable performance information according to widely accepted core domains of primary care as well as different patient population groups. Conclusions: An approach that bridges the gap between conceptual frameworks and realworld performance measurement and reporting initiatives could address some of the potential pitfalls of existing ways of presenting performance information (i.e., by single diseases or by age). This approach could produce meaningful and actionable information on the quality of primary care services. RésuméObjectif : Les services de soins primaires sont la base des systèmes de soins de santé modernes, mais l'étendue et la complexité des services ainsi que la diversité des patients peuvent présenter des défis quant à l'implantation de systèmes d'information efficaces sur les soins primaires. L' objectif est d' offrir de l'information au niveau régional sur le rendement des soins primaires au Canada. Méthodes : Une étude approfondie a été menée afin de recenser les initiatives existantes en ce qui concerne la mesure du rendement et la production de rapports sur le rendement des soins de santé de 11 pays. Les résultats de cette étude ont été utilisés par notre équipe internationale de chercheurs et de cliniciens en soins de santé primaires afin de proposer une approche pour la production de rapports sur le rendement des soins primaires au niveau régional. Résultats : Nous avons observé un écart entre, d'une part, les cadres théoriques pour la mesure du rendement présentés dans la littérature scientifique et, d'autre part, la mesure du rendement et la production de rapports que l'on trouve dans la réalité concrète des soins primaires. Les auteurs n'ont pas trouvé un cadre conceptuel ou une approche analytique qui pourrait servir de base pour un système d'information régional sur les soins de santé primaires. Par conséquent, nous proposons une approche en...

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“…Clinical programs that are expanding to proactive outreach may additionally identify eligible patients from an existing health system risk stratification model that uses EMR data to flag frail patients with an expected prognosis of one to two years. 24 Patients and caregivers are considered enrolled in the trial once they provide consent, complete the baseline surveys, and the patient is admitted to HBPC. Figure 2 summarizes the overall participant flow and Figures 3 and 4 are the CONSORT diagrams for patients and caregivers, respectively.…”

Section: S-24mentioning

confidence: 99%

Protocol for a Noninferiority Comparative Effectiveness Trial of Home-Based Palliative Care (HomePal)

Nguyen

Mularski

Edwards

et al. 2019

Journal of Palliative Medicine

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Introduction: As health care systems strive to meet the growing needs of seriously ill patients with high symptom burden and functional limitations, they need evidence about how best to deliver home-based palliative care (HBPC). We compare a standard HBPC model that includes routine home visits by nurses and prescribing clinicians with a tech-supported model that aims to promote timely interprofessional team coordination using video consultation with the prescribing clinician while the nurse is in the patient's home. We hypothesize that tech-supported HBPC will be no worse compared with standard HBPC. Methods: This study is a pragmatic, cluster randomized noninferiority trial conducted across 14 Kaiser Permanente sites in Southern California and the Pacific Northwest. Registered nurses (n = 102) were randomized to the two models so that approximately half of the participating patient-caregiver dyads will be in each study arm. Adult English or Spanish-speaking patients (estimate 10,000) with any serious illness and a survival prognosis of 1-2 years and their caregivers (estimate 4800) are being recruited to the HomePal study over *2.5 years. The primary patient outcomes are symptom improvement at one month and days spent at home. The primary caregiver outcome is perception of preparedness for caregiving. Study Implementation-Challenges and Contributions: During implementation we had to balance the rigors of conducting a clinical trial with pragmatic realities to ensure responsiveness to culture, structures, workforce, workflows of existing programs across multiple sites, and emerging policy and regulatory changes. We built close partnerships with stakeholders across multiple representative groups to define the comparators, prioritize and refine measures and study conduct, and optimize rigor in our analytical approaches. We have also incorporated extensive fidelity monitoring, mixed-method implementation evaluations, and early planning for dissemination to anticipate and address challenges longitudinally. Trial Registration: ClinicalTrials.gov: NCT#03694431.

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Improving Care for Older Adults: A Model to Segment the Senior Population

Cited by 28 publications

References 9 publications

Tackling 30-Day, All-Cause Readmissions with a Patient-Centered Transitional Care Bundle

Tackling 30-Day, All-Cause Readmissions with a Patient-Centered Transitional Care Bundle

Primary Care Performance Measurement and Reporting at a Regional Level: Could a Matrix Approach Provide Actionable Information for Policy Makers and Clinicians?

Protocol for a Noninferiority Comparative Effectiveness Trial of Home-Based Palliative Care (HomePal)

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