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Translational and Implementation

The clinical and economic outcomes of TCM have been replicated in diverse health systems and communities. The success of these efforts requires both rigorously tested translation tools, and active partnership and commitment of local health systems and community leaders and staff as well as payers.

Adaptations

To extend the reach and improve the benefits derived from the TCM approach, we are examining adaptations of the TCM by local health systems and communities throughout the United States.

While some health care settings and communities choose to adopt the TCM core components as tested, multiple factors may affect how other sites implement this evidence-based care management approach. Some TCM users have chosen to adapt one or more core components to reflect local customs and practices. Others may not have resources (e.g., EHRs) to apply the TCM components. An ongoing study, Local Adaptations of the Transitional Care Model funded by the Robert Wood Johnson Foundation, is helping our team to identify how health systems and communities are adapting common core components. The team members hypothesize that some adaptations may further advance the model’s benefits, extending its reach and further improving outcomes. The team also hypothesizes that the nature and extent of some adaptations may substantially reduce or eliminate the TCM’s demonstrated benefits.

Our team completed a national scan to identify how health care organizations are using evidence-based transitional care to redesign their care systems. Findings from this initial phase of our work reveal that about 60 percent of 582 respondents report using the TCM alone or in combination with other approaches. Currently, we are conducting a deep dive to understand exactly how these sites are implementing the model, what adaptations have been made and what they are learning from this work.

University of Pennsylvania Health System

To determine if clinical and economic effects achieved in multi-site research projects could be replicated in “real world” health care systems, we partnered with the University of Pennsylvania Health System (UPHS) and a major health care insurer (Aetna). Findings demonstrated significant improvements in all assessed measures of health and quality of life among Medicare managed care members who received the TCM, plus telephonic case management, when compared to a similar patient group who received telephonic case management only. Among stringently matched pairs in this study, significant decreases in the total number of rehospitalizations and total hospital days were observed at 90 days. A significant reduction in total health care costs per member per month at 90 days and a cumulative per member savings of $2,170 at one year post-enrollment also were observed in the TCM intervention group, relative to the comparison group.

 

Based on this work, the UPHS launched the Transitional Care Program service line with support funding from major local health care insurers. To date (2009 through 2014), more than 800 high risk patients admitted to the UPHS have enrolled in this service line. The rehospitalization rate at 30 days is substantially below the national average for all cause rehospitalizations among Medicare beneficiaries (MedPAC, 2015) and is half that of the 30-day rehospitalization rate for Medicare beneficiaries with four or more chronic conditions (Lochner et al., 2013). Additionally, findings revealed that the positive impact on rehospitalizations has been sustained for patients through 90-days post index hospital discharge. Since February 2014, our team has been assessing the effects of ongoing monitoring and follow-up of this patient group through nine months post-index hospitalization.

Over time, our initial results indicate that TCM patients report fewer symptoms, less pain, and lower ratings of depressive symptoms and anxiety than similar, non-TCM patients, and improved quality of life, physical function, instrumental ADLs, and cognitive status.