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JCOM Abstract

J Clin Outcomes Manage 
2013 Sep;20(9):408-418
Development and preliminary evaluation of an innovative advanced chronic disease care model
Hoefer DR, Johnson SK, Bender M

Abstract Objective: To describe and evaluate Sharp’s Transitions program as a model of caring for the advanced heart failure (HF) population. Methods: Sharp HealthCare developed an innovative advanced chronic disease model of care that addresses patient, family, and caregiver needs throughout the progression of their illness. Advanced HF patients enrolled in Transitions between January 2008 and December 2010 were evaluated (n = 155). Patient demographic data, hospital and emergency department (ED) utilization, and total costs of care were obtained from electronic medical records to determine acute care utilization and total care costs for patients before and after enrollment. Results: Mean length of stay in Transitions was 165 days. 74% transferred into hospice care upon discharge. Within-group analysis showed a significant decrease in hospitalization rate after enrollment in Transitions, from 32% to 17%. There was also a significant decrease in ED visit rate after enrollment, from 57% to 31%. The average total cost of care decreased significantly during enrollment ($73,025 vs. $46,588). Conclusions: Aligned with the goals of comprehensive care management, Transitions provides an innovative model of health care delivery for the advanced chronic disease population that may be replicable across diverse chronic disease patient populations and health care organizations.

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