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

Solution

• Develop a local Care Transition Coalition to provide leadership and partner in providing quality care transition services for Medicare beneficiaries

Purpose/Goals

• 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

RCA Results

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-

discharge

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

Next steps

• 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

Data collection

• 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

Pilot Results

• Still in beginning phase