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Service Delivery Innovation Profile

Transitional Care Program With Advance Care Planning for Frail Elders Reduces Emergency Department Visits and Readmissions

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The High Risk Touch Team provides transitional care to frail elderly patients (including those with cognitive impairment) at high risk for complications, relapses, or accidents after they return home from a hospital stay. Adding advance care planning to an established transitional care model, the program provides in-home education and assistance in five areas: medication self-management, use of a personal health record, followup with primary care physicians and specialists, warning signs of potential problems and how to respond to them, and advance care planning. To address the numerous self-care issues that arise, the program includes licensed social workers on its transitions team, as well as advanced practice nurses, clinical pharmacists, and social work interns. The program has significantly reduced hospital readmissions and emergency department visits.

Evidence Rating (What is this?)

Moderate: The evidence consists of a pilot test comparing hospital admissions and ED visits among 46 at-risk elderly patients in the 12 months before and after program participation.
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Developing Organizations

Monarch HealthCare
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Date First Implemented

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Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years)end pp

Problem Addressed

Frail elderly patients often find it difficult to manage their health care needs, especially when moving from one setting to another (e.g., from the hospital back home). This difficulty often leads to serious health problems and frequently results in medication errors, emergency department (ED) visits, and hospital readmissions. In addition to creating a strong transitional care program, recording patient end-of-life preferences in an advance care plan can help frail, elderly patients to better manage their health care; but, few elderly patients have such plans in place.
  • Difficulty transitioning between settings: An insufficient understanding of their condition, combined with the complexities of today’s health care system, can make it very difficult for frail seniors to manage their health and self-care needs, especially when transitioning from the hospital to home. Effective transitions typically require coordination between providers in different settings based on an assessment of the patient’s needs, development and implementation of a care plan, and ongoing evaluation and refinement of that plan as necessary.1 The fragmented nature of today's health care system often prevents such coordination from taking place.
  • Serious consequences from poor transitions: Breakdowns in communication and miscommunications can have serious consequences for frail elderly patients transitioning from the hospital to home, including patient or caregiver confusion about the patient’s condition and what constitutes appropriate care, the failure to secure needed followup care, and errors in using medications.1 These problems frequently lead to relapses that require ED care and/or readmission to the hospital.
  • Improved care with advance care planning: Patients who talk with their families or physicians about their preferences for end-of-life care had less fear and anxiety, felt they had more ability to influence and direct their medical care, and believed that their physicians had a better understanding of their wishes.2,3 However, in studies of severely or terminally ill patients, fewer than 50 percent had an advance directive in their medical record.4,5

What They Did

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Description of the Innovative Activity

The High Risk Touch Team (formerly known as the Senior Touch program) provides transitional care to frail elderly patients at high risk for complications, relapses, or accidents after they return home from a hospital stay. The program provides in-home education and assistance in five areas: medication self-management, use of a personal health record, followup with primary care physicians and specialists, warning signs of potential problems and how to respond to them, and advance care planning. Key program components include the following:
  • Inhospital identification of at-risk seniors: The identification of high-risk seniors occurs in three ways:
    • Daily telephonic rounds: The High Risk Touch Team conducts a daily telephonic meeting with the inpatient case managers to review patient status and enhance the discharge planning process. Ambulatory case managers and members of the High Risk Touch Team participate in these telephonic rounds, which efficiently identify and engage patients who would benefit from a home visit upon discharge.
    • Review of electronic list: An electronic list of "high risk" patients is electronically generated by inpatient case managers. The report is populated with patients being discharged and is distributed to the hospital's ambulatory care team. They in turn may triage appropriate patients to the High Risk Touch Team or enroll them into case management.
    • Involvement of Care Navigator: Lastly, as a Pioneer Accountable Care Organization for Medicare fee-for-service beneficiaries, Monarch created a new position called a Care Navigator. This individual acts as an extension of a physician office to assist specific patients as they navigate through the fragmented healthcare delivery system. The Care Navigator has become a new and active source of referrals for the High Risk Touch Team.
  • Inhospital consent and preparation: For those identified, an inpatient/home transitions care team comprising an advanced practice nurse (APN), case manager, social worker, social work intern, and health educator work with hospital discharge planning staff to coordinate the transition from hospital to home.
    • Consultation and consent: Before discharge, the case manager explains the program to the patient and/or caregiver, and obtains consent for the initial home visit and subsequent followup care.
    • Preparation of transitions care packet: The team creates a transition packet containing the patient’s personal medical record and a "POLST" (Physician Orders for Life-Sustaining Treatment) form or advance care directive (if completed). The packet includes blank POLST and advance care directive forms for the APN and licensed social worker to discuss with the patient if necessary. Information provided in May 2012 indicates that additional information has been added to the transitions care packet, including a list of clinical warning signs and symptoms for patients to be aware of in order to avoid a preventable admission or ER visit. Also included in the packet is a reference tool for local urgent care centers, with each centers' hours of operation and location.
  • Initial and followup home visits and telephone support: Once patients return home, the case manager or social worker calls to remind them about participation in the program and confirm the time of the home visit, which occurs within 72 hours of discharge. At this visit, the transitions team reviews all information in the transition packet and assists patients in completing the personal health record and POLST, and learning to self-manage their condition(s). The team identifies factors that may affect patients' ability to manage health care needs and perform activities of daily living, and then develops transition plans based on these needs. During the visit, program services emphasize the "pillars" of ongoing self-management and self-advocacy (four of which have been drawn from an existing transitions care model), as outlined below:
    • Medication self-management: Clinical pharmacist team members make sure patients have a list of all medications and understand the purpose of each and how to take them (e.g., dosage, frequency, etc.). This review includes all prescription and over-the-counter medications. As part of this process, the pharmacist makes sure that patients have the cognitive and physical ability to manage their medication needs. In some instances, the pharmacist contacts pharmaceutical companies to get free/reduced-cost medicine or identify alternative medications.
    • Use of personal health record: The personal health record contains essential medical information regarding patients' recent hospital stay and discharge orders. The team explains its contents and the importance of making sure patients shares it with their primary care physician and other specialists.
    • Followup with the primary care physician and/or specialists: The team discusses the scheduling of needed followup care with patients' primary care physician and specialists. If necessary, the team will contact physicians to make sure they have copies of discharge orders and all other relevant information, and assist patients in securing transportation to and from appointments.
    • Knowledge of warning signs and symptoms and how to respond: The team educates patients and caregivers about the warning signs and symptoms associated with the patient’s condition, and uses role playing to help the patient and/or caregiver practice the skills and actions needed to respond properly and expeditiously to such signs and symptoms.
    • Advance care planning: As an addition to an established transitions model, the team carefully introduces options for advance care planning, which includes an advance health care directive that allows the patient to delineate treatment wishes and designate a person to make their health care decisions. For patients facing diseases likely to result in death within 1 year, they also suggest the use of a POLST form. This form lists patient medical treatment preferences as physician orders for cardiopulmonary resuscitation, comfort measures (limited intervention or full treatment), use of antibiotics, and tube feeding. The patient’s doctor, as well as the patient must sign the POLST form, which is then included in the personal health record.
    • Full clinical evaluation: Clinical components have been added to the visit to address the overall needs of the patient. An APN now conducts a "head to toe" clinical evaluation to identify quality gaps in needed preventative/wellness services; this evaluation has also improved the capture of appropriate risk adjusted codes for Medicare Advantage patients. The APN uses data driven tools at the point of care in order to identify gaps in care and risk adjustment opportunities. Social work interns also participate in this assessment, and the results of the evaluation are shared with the patient's primary care physician. As a result of the added clinical components, visits are longer than before (about 2 hours each). However, it is now a single visit after discharge (in contrast to the initial program design, which included a shorter visit with followup phone calls and/or home visits for 30 to 60 days). After this one home visit, the patient receives a phone call from a member of an ambulatory care team to ensure that followup physician visits have been made. If the patient would benefit from longer term management or treatment, the patient is referred to a homebound program (physician or APN) or ambulatory case management.
  • Weekly rounds and ongoing oversight: As necessary, the nurse practitioner and social worker participate in weekly rounds with other team members and medical staff to discuss difficult cases. The medical group medical director provides ongoing oversight to the transitions care team.
  • Care coordination using patient profile: The program has created a patient profile that summarizes the patient's treatment. This is a 12-month patient-centric document that allows the High Risk Touch Team to see the treatment the patient has received. Components of the patient profile include patient demographics, hospitalizations, skilled nursing facility admissions, ER visits, laboratory data, and filled prescriptions.
  • Services for patients with dementia: The High Risk Touch Team previously focused primarily on a subset of the patient population for which the system assumed global financial risk. However, the team has grown in order to offer home visits for other types of patients, including those with Special Needs Plans. Due to the frequency of cognitive impairment found in this population, visits now include patients with dementia (previously such patients were excluded due to the emphasis on patient education for self management). The interaction with the caregiver and family has been successful in achieving educational goals for patients with dementia and arranging social work assistance and community resource referrals.

Context of the Innovation

Monarch HealthCare is an association of private practice physicians affiliated with a coordinated network of hospitals, laboratories, and urgent care centers. The company originally developed the Senior Touch program (now the High Risk Touch Team) for high-risk elderly patients being cared for under a global risk contract, with the goal of addressing the self-care and health management difficulties that elderly patients often face when they return home from a hospital stay.

Before creating the program, Monarch had attempted to provide transitional care through high-risk clinics located near network hospitals. However, elderly patients preferred seeing their own primary care physicians, perceived the clinics as an additional layer of unnecessary care, and often found it difficult to get transportation to the clinic sites. As a result, Monarch leaders decided to revamp the program to focus on in-home support, and began looking for existing models to do so.

Did It Work?

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The program significantly reduced hospital readmissions and ED visits.
  • Fewer readmissions: Participating patients experienced a 60 percent decrease in hospital admissions during the 12 months after completing the program (as compared with the 12 months before participating).
  • Fewer ED visits: Over the same time period, participating patients experienced 40 percent fewer ED visits.
  • Results maintained over time: A followup review of 110 patients conducted for the January-July 2011 time period demonstrated that, although the frequency of the home visits has been decreased to a single interaction, the decrease in readmissions and ER visits previously documented for this program has been maintained. The decrease in readmissions was 61 percent and the ER visits decreased by 31 percent.
  • Potential for greater access: Even though the visit time per patient is longer, the team is able to impact a larger number of patients because there is only one visit per patient. With the expanded staffing and revised model, the team plans to increase in the number of home visits in 2012 by 40 percent.
  • Improvements in medication management: The addition of clinical pharmacists has improved the medication reconciliation process and has increased the utilization of generic medication.

Evidence Rating (What is this?)

Moderate: The evidence consists of a pilot test comparing hospital admissions and ED visits among 46 at-risk elderly patients in the 12 months before and after program participation.

How They Did It

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Planning and Development Process

Key elements included the following:
  • Establishing task force to research, develop care model: Monarch leaders formed an internal task force, led by senior nursing, medical directors, and case management staff and charged them with developing a new model of transitional care. To that end, the task force researched various models and reviewed current patients' needs along with lessons from the aforementioned inhospital high-risk clinics. This research uncovered Dr. Eric Coleman’s 4 Pillars of Transitions of Care, which the task force felt offered a good model on which to base the new program. In designing it, task force members decided to add a fifth pillar (advance care planning) and to include a social worker on the team to address the myriad self-care issues faced by frail elderly individuals.
  • Developing standard operating procedures: Once management approved the new care model, task force members developed a set of standard operating procedures to guide program implementation and ongoing operations. These procedures address staff roles and responsibilities, appropriate scheduling of interventions, use of program-related tools and products, and program evaluation.
  • Refining care team: Based on these standard operating procedures, Monarch refined the roles and responsibilities of transitional care staff and, as noted, expanded the team to include licensed social workers.
  • Hiring staff: Monarch initially hired one APN and one licensed social worker to provide home support to frail elderly patients. Based on the positive results, this has been expanded to three APNs and two licensed social workers.
  • Identifying pilot test participants: Using claims data on hospitalizations and ED visits, Monarch identified 46 frail elderly patients to participate in a pilot test of the program.
  • Expanding the program: The program infrastructure was expanded in order to meet the needs of more patients across various lines of business. The name of the program has been changed to the High Risk Touch Team in order to reflect the expanded patient base.
  • Enhancing patient identification: Monarch plans to implement a predictive modeling tool, which will add another layer of sophistication to the patient identification process.
  • Providing electronic medical record (EMR) training: In order to capture the information from the visit and share it with others caring for the patient, all members of the home visit team have received training on using the EMR and will soon begin using it to document their visits.
  • Palliative medicine home visit pilot: In 2011, Monarch started a Palliative Medicine home visit pilot, which was successful in that many chronically ill patients were able to define and memorialize their end of life wishes, or goals of care. The High Risk Touch Team has been instrumental in identifying and referring patients who would benefit from an ambulatory palliative medicine visit at home.

Resources Used and Skills Needed

  • Staffing: The program includes APNs, licensed social workers, clinical pharmacists, social work interns, and an administrative coordinator who coordinates home visits and assists with primary care physician notification of the visits. The APNs each perform two to three home visits per day, and make 5-7 phone calls per day; the phone calls are no longer patient followup calls, but are used to actively coordinate care with physician offices and referrals for other patient services. The program currently serves between 1,000 and 1,100 patients.
  • Costs: Data on program costs are unavailable. The major expense relates to salaries and benefits for the APNs and social workers, along with program-related expenses (e.g., travel to and from patients' homes).
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Funding Sources

Monarch HealthCare
Funding for the program comes from Monarch's internal operating budget.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Determine need for transitional care: Review data on hospital readmissions and ED visits among elderly patients to determine the need for this type of program.
  • Carefully consider potential financial impact: The financial impact of this program depends in part on how an organization gets paid for services. Not all organizations—particularly those paid on a fee-for-service (FFS) basis—have a financial incentive to reduce readmissions and ED visits. However, capacity-constrained hospitals paid on an FFS basis might benefit from the ability to free up needed ED and inpatient capacity.
  • Review existing care models: Models for transitional care vary, so choose a model that reflects organizational needs and objectives. For example, Monarch leaders wanted all patients to have advance care directives, and hence made that one of the five program pillars.
  • Establish goals and relevant metrics: Adopters of this program should create specific goals and accompanying outcome measures specific to organizational needs. For example, Monarch created goals related to reducing readmissions and ED visits.
  • Develop standard operating procedures: Organizations need to consider how to integrate transitional care into current patient discharge programs. Standard operating procedures that delineate roles and responsibilities for all staff involved in the discharge process can aid in this process and serve to guide program implementation and operations.
  • Identify staffing needs: Staffing will depend on the care model chosen and the number of current and future patients who might benefit from program services. As noted, Monarch found adding social workers to the team to be extremely helpful for elderly patients.

Sustaining This Innovation

  • Monitor and report on program effectiveness: Ongoing monitoring and reporting helps to maintain support for the program, especially when program-related costs come directly from operating funds. Monarch uses claims records to document and report on the program's impact on readmissions and ED visits.
  • Develop database of community resources: Numerous public and private sector organizations provide services to senior citizens. A database of available community resources and other sources of support can aid all team members, especially as the program expands and new needs arise.
  • Develop data sets: The ongoing development and enhancement of this model has been successful in part due to the development of actionable data sets that allow for better care coordination. The proper use of patient-specific data is a key component in identifying which patients to visit, and allows the team to intervene in a purposeful manner at the point of care.

More Information

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Contact the Innovator

Nancy Boerner, MD
Chief Medical Officer
Monarch HealthCare
11 Technology Drive
Irvine, CA 92618
Phone: (949) 923-3486
Fax: (949) 923-3564

Julie Anne Keen, RN, MSN, ANP-C
Board Certified Adult Nurse Practitioner
Supervisor - High Risk Touch Team & Palliative Care Team
Monarch HealthCare
11 Technology Drive
Irvine, CA 92618
Phone: (949) 453-4140
Fax: (949) 923-3523

Innovator Disclosures

Dr. Boerner and Ms. Keen have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

The following Web sites provide additional information on transitions care:
  • This site includes information on the Care Transitions Program, developed by Dr. Eric Coleman; see the Planning and Development Process section for more information.
  • This site provides information on the National Transitions of Care Coalition organized by the Case Management Society of America.
  • This site provides information on use of POLST.


1 Improving Transitions of Care: The Vision of the National Transitions of Care Coalition, May 2008. Available at: (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
2 Ditto PH, Danks JH, Smucker WD, et al. Advance directives as acts of communication. Arch Intern Med. 2001;161:421-30. [PubMed]
3 Smucker WD, Ditto PH, Moore KA, et al. Elderly outpatients respond favorably to a physician-initiated advance directive discussion. J Am Board Fam Pract. 1993;6(5):473-82. [PubMed]
4 Teno JM, Licks S, Lynn J, et al. Do advance directives provide instructions that direct care? J Am Geriatr Soc. 1997;45:508-12. [PubMed]
5 Bradley EH, Rizzo JA. Public information and private search: evaluating the Patient Self-Determination Act. J Health Polit Policy Law. 1999;24(2):239-73. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 02, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 02, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 24, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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