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Community-Based Care Transitions Program. Care Connection for Aging Services Primaris. The Problem. 17% of Medicare beneficiaries are readmitted within 30 days of discharge 64% receive no post-acute care between discharge and readmit 76% of these readmits may be preventable - PowerPoint PPT Presentation
Community-Based Care Transitions Program
Care Connection for Aging ServicesPrimaris
The Problem• 17% of Medicare beneficiaries are readmitted
within 30 days of discharge• 64% receive no post-acute care between
discharge and readmit• 76% of these readmits may be preventable• Avoidable hospital readmissions cost Medicare
an estimated $12 billion annually• Coming steps with the CMS “Value Based
Purchasing” initiative will include penalties for these preventive hospital readmissions
• Develop a local Care Transition Coalition to provide leadership and partner in providing quality care transition services for Medicare beneficiaries
• To build and sustain a community coalition with a focus on improving transitions of care for Medicare beneficiaries
• To encourage person-centered and person directed models of care
• To collaborate and encourage efforts of organizations with shared vision
The CMS Community Care Transitions Program
• Hospitals within a geographic region partner with a Community-Based Organization (CBO), in a collaborative initiative to reduce preventable 30 day hospital readmissions.
• The focus is on Medicare “Fee for Service” patients.• The CBO and hospitals, along with area “downstream
providers”, form a working “coalition”, to reduce readmissions and improve care continuity
• The “coalition’s” partner hospitals identify their “high-risk” patients for unscheduled readmission, from among the Medicare FFS population
The CMS Community Care Transitions Program
• The community calculates the anticipated volume of their eligible patients.
• The “coalition” identifies a best intervention for reducing readmissions, from evidence-based models.
• The CBO submits a application for program funding to CMS, on behalf of the community coalition.
• If accepted, the CBO provides staff to deliver the agreed upon / CMS -accepted post-discharge intervention
• CMS monitors the community’s performance in reducing readmissions .
First steps• Care Connection for Aging Services and
Primaris met with all acute care hospitals in 13 county area.
• The West Central Care Transition Coalition was formed.
• The partner hospitals conducted a Root Cause Analysis of their 30 day readmissions to determine their individual “high-risk” Medicare population.
Root Cause Analysis • The five participating hospitals were instructed in
conducting a Root Cause Analysis, to help in identifying a “target population” to receive the Care Transitions intervention.
• Four of the five Coalition hospitals successfully completed an RCA.
• RCAs were to evaluate readmission trends for Medicare Fee for Service patients, only (as defined in the CMS – CCTP Program guidelines).
RCA Focus• Identify patterns of readmissions specific to the
community and hospital provider• Used to guide targeting criteria and intervention
selection• Assist the Community Based Organization and
participant hospitals in identifying their “high-risk” population and anticipated program volume
• Assist the CBO and participant hospitals in defining a “screening methodology for these “high-risk” discharges
Key Components of the RCACompletion of an RCA could include any or all of
the following components:• Medical Record review (including use of
specific audit tools)• Analysis of admission and discharge data• Process assessment including patient/family
interviews and direct observation• Focus groups with patients and providers
Target population identified by the RCAs included the following most frequently identifed diagnoses:AMIHeart FailureCOPDPneumonia
Other RCA Findings• Hospitals identified opportunities for improvement
in their pre-discharge process, including (examples); Identification of pre-discharge risk factors Patient/family pre-discharge education process effectiveness
and lack of standardization Specific medication –reconciliation issues Inadequate understanding of need for timely primary care
physician follow-up visits Nutrition / dietary needs clarified and addressed
Other RCA Findings (continued) Inadequate patient instruction on “red flag” signs / symptoms Lack of, or inadequate, patient support system (i.e. available
family, other possible care-givers) Financial resources for recommended follow-up care Delays / inconsistency in discharge instructions/
communication to home health, long term care providers Lack of any (or inadequate) follow-up contact with patient
post-discharge Identification of potential transportation barriers, post-
Evidence-based Transition Interventions
• Coalition reviewed the Evidence-based Transition interventions
• The Care Transition Intervention (CTI): (the Dr. Eric Coleman/Care Coach Model) was selected.
• Staff will be trained in the model the summer of 2013
• The group did not apply for the CCTP funding in the last round.
• It was decided to do a pilot project• Hospitals in pilot: Fitzgibbon Hospital
(Marshall) and Golden Valley Memorial Hospital (Clinton)
Pilot – Qualified Patients• 60 years of age or older• Diagnosis of CHF, COPD, or PNEU• Discharged from hospital to home• Without adequate support• Reasonable expectation that after services
stop that person will either be able to manage on their own or have other supports in place to remain living at home
Pilot – Care Transition Program• Care Transition Coordinator – will support
patient’s recovery efforts during the 30 days immediately following discharge.
• Additional Support Services Options:– Home delivered meals– Transportation– In-home services – a homemaker aide providing
household assistance; including housekeeping, meal preparation, grocery shopping, prescription pickup, and/or personal care up to 2 hours a week for 30 days.
Role of Hospital
• Identify qualified patients• Explain the Care Transitions Program and role
of the care transition coordinator• Secure written consent to share information• Provide appropriate referral information• Notify Care Connection Transition Coordinator
if patient readmitted to the hospital within 30 days
Role of Care Connection Transition Coordinator
• Accept referrals of qualified patients• Establish contact with patient/caregiver
within 24-26 hours• Review information with patient/caregiver• Set up documentation and tracking system• Follow up to verify services are being
delivered as ordered and at discharge from program, close out services and make referrals for any unmet needs
Care Transition Coordinator Reviews
• Personal Health Care Record• Verify the follow-up appointments have been
scheduled• Medication reconciliation• Identify Red Flags to watch for• Verify if additional support services are required• Arrange for support services• Conduct future care planning, including making
referrals such as care management or other services.
Care Connection for Aging Services Role
• Provide Care Transitions Coordinator• Accept referrals of qualified patients• Compile data on pilot project
• Client name, address, etc.• Diagnosis, reason for hospitalization• Where did referral come from?• Tracking of all care transition coordinator
contacts, services received and for how long• Were there any hospital readmissions or ER
visits within 30 days – if so what for?
Data collection (cont.)
• What happened after the care transition services stopped? What additional supports and services were needed?
• Client satisfaction with care transition service package or other feedback
• Any issues of non-compliance?
Tools Used in Program
• Communication Tool• Referral form• Personal Health Record• Care Transitions: Information Counselor
Protocols• Discharge Preparation Checklist
• Still in beginning phase