Hospital Transition Program: Expanding Services to Seniors

7/29/2019 Hospital Transition Program: Expanding Services to Seniors

1/12

HOSPITAL TRANSITION

PROGRAMChicago Southland Coalition for Transition of Care

(CSCTC)


2/12

Community-based Care

Transition Program

Created by Section 3026 of the Affordable Care Act

Administered through the Center for Medicare andMedicaid Services (CMS)

Tests models for improving care transitions fromhospital to other settings

Reduces readmissions for high-risk Medicarebeneficiaries

Community-based organizations (CBOs) must haveformal relationships with acute care hospitals andother community providers


3/12

Hospital Readmissions

20 to 25% of all Medicare and Medicaid patientsreturn to the hospital within 30 days of

discharge, costing $15 billion annually.

Hospitals within the upper quadrant with theseoccurrences will be penalized 1% of their

entire Medicare reimbursements if they do not

reduce their readmissions by at least 20% by

2013If the reductions do not occur by 2015, the

penalty increases to 3%


4/12

Program Requirements

1. Identify community-specific root causes of readmissions

2. Define target population and strategies for identifying high-

risk patients

3. Specify care transition intervention that will impact rootcauses identified

4. Describe how care transition strategies will incorporate

culturally appropriate and effective approaches

5. Provide implementation plan with milestones6. Provide clear budget

7. Demonstrate prior experience


5/12

Our Collaboration

Catholic Charities of the Archdiocese of Chicago (CBO)partnered with Metropolitan Family Services to provide

coaching services to four neighboring high readmission

hospitals:

- Ingalls Memorial Hospital- MetroSouth Medical Center

- Franciscan St. James Health

- Little Company of Mary Hospital and Health Care Center

Open Kitchens will provide post-discharge meals

Several out-patient/community pharmacies will provide

medication management services.

Independent Living Systems (ILS) will provide the PASS system

used for this model


6/12

Mission and Vision

The mission of CSCTC is to reduce preventable

hospital readmissions as an opportunity to

improve quality of care and reduce costs in the

healthcare system.

The coalition is committed to reducing 30-day

readmission rates by 20% over three years, and to

develop community partnerships to eliminate

barriers to successful care transitions


7/12

Community

The Chicago Southland Coalition for Transition of Care is

targeting 70 ZIP Codes in Southern Cook County, an area

that includes portions of Chicagos South side and its

surrounding suburban area.


8/12

Implementation Plan

1. Hospitals provide list of eligible participants

2. Coaches initiate hospital visit and introduce PASS program

to patient

3. Medication reconciliation occurs by pharmacy prior todischarge

4. Coach initiates home visit within 48-72 hours after

discharge

5. Referral for home delivered meals, if necessary6. Post-discharge follow-up calls occur on the 2nd, 7th, 14th,

and 30th day after discharge


9/12

Coaching

1. Conduct initial hospital visit and related

components

2. Conduct home (post-discharge) visit and related

components

3. Assist in care coordination follow-up calls

4. Provide client education during visits using care

transition components.

5. Maintain clients personal health record and

electronic client file.


10/12

Typical Failures FollowingDischarge from the Hospital

Medication errors

No follow-up appointment

Follow-up appointment left

up to patient Lack of emergency plan with

number the patient should

call first

Confusing discharge

instructions

Lack of social support

Follow-up appointment too

long after hospitalization

Lack of transportation tokeep follow-up appointments

Multiple care providers

Lack of patient adherence to

self-care due to poor

understanding or confusion


11/12

The Five PASS Pillars

1. Medication self-management

2. Nutrition management

3. Personal Health Record

4. Primary Care and Specialist Follow-Up

5. Red Flags/Signs & Symptoms


12/12

Example of Red Flags

Documents

Hospital Transition Program: Expanding Services to Seniors