Improving Transitions in
Care
From Hospitals to Community
Care Transitions
Poorly executed care transitions lead to
poor clinical outcomes, dissatisfaction
among patients, and inappropriate use of
hospital, emergency, and post acute
services.
Care Transitions
Nursing home
Hospital
Rehab Facility
Home
Readmissions
Reflect a breakdown in the process, a
failure in our ability to effectively transition
clients between care settings and
providers.
The Problem
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Hospital Readmissions are costly and can be
avoided
90% of patients nationally who were
readmitted to the hospital have experienced
a breakdown of post- discharge care
Costs to Medicare for hospital readmissions
is estimated at $15 billion a year, $12 billion
of which is for cases considered preventable
Root Causes?
1.
2.
3.
4.
5.
6.
Medication discrepancies
Lack of patient follow up with PCP
Poor communication and handoffs
Lack of ownership – personal responsibility
over their own care
Variety of complex family, psychosocial
problems
Lack of alignment with payment incentives
and provider risk
Southwest Ohio Community
Care Transitions Collaborative
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Includes:
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Council on Aging of Southwestern Ohio
Greater Cincinnati Health Council
Hospitals:
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University Hospital
The Christ Hospital
Jewish Hospital
Mercy Fairfield
Clinton Memorial Hospital
Health Collaborative
Healthbridge
Health Care Access Now
Mental Health and Recovery Services Board
Affordable Care Act
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Beginning in October 2012, Medicare
can withhold a portion of payments to
hospitals that have high readmission
rates for patients with certain
conditions such as heart failure and
pneumonia
Section 3026 created a Communitybased Care Transitions Program
(CCTP)
CMS Community-based Care
Transitions Program
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The Community Based Care Transitions
Program (CCTP) goals are:
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to reduce hospital readmissions
test sustainable funding streams for care transition
services
maintain or improve quality of care
document measureable savings to the Medicare
program
Eligibility
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65+
Medicare FFS
Admitted to one of five participating
hospitals
CHF, AMI, Pneumonia, and/or multiple
chronic conditions
Patient agreement and activation
assessment
By the numbers…
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We are one of the first seven funded
Will serve 5,400 patients each year
Scheduled to begin March 19th
Annual net savings to Medicare of $1
Million
Two year project with extension of
another three
Not a grant … bundled payment
Council on Aging Care Transitions
Program Background
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Developed a Care Transitions Pilot:
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December 2010 University Hospital
June 2011 The Christ Hospital
November 2011 Jewish Hospital
COA Care Transition Program
Two Outcomes:
#1 Reduce avoidable re-hospitalizations.
#2 Reduce unnecessary long-term
nursing facility placements.
Admitting Diagnoses for Participants
(n=311)
Admitting Diagnosis
23% of the
total were
admitted with
a diagnosis
considered to
be high risk
for
readmission
by CMS.
14
Source: Council on Aging of Southwestern Ohio, 10/27/11 n= 170
Note: Respiratory includes shortness of breath, pulmonary edema, bronchitis and related issues. In addition to items considered to be
‘other’, other also includes AFIB (2%), CVA (1%), and HTN (2%).
Our Initial Results:
65% were discharged directly to a community setting
Of those who were
discharged to a short
term nursing facility or inpatient rehab, 37 (41%)
were discharged back to
the community for a total
of 239 (77%) of CTI
participants successfully
transitioning back to their
homes and communities.
Source: Council on Aging of Southwestern Ohio, 3/5/12: n=311
Note: N/A: includes individuals discharged from CTI and individuals who are still in the hospital. Not equal15to
100% due to rounding.
Care Transitions Intervention
Designed to encourage older
patients and their caregivers to
assert a more active role during
care transitions.
(c) Eric A. Coleman, MD, MPH
Transition Coach
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Role is NOT to be a service broker,
Assessor, or Care Manager
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Client empowerment and skill transfer
is key for continued success after the
intervention
Transition Coach
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Do not fix
problems
Do not
provide
skilled
services
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Do model and
facilitate new
behaviors and
communication
skills for clients
and caregivers
The Care Transition
Intervention
Hospital/NF Visit
 Home Visit
 Follow up Phone Calls
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The Four Pillars
1.
2.
3.
4.
Medication self-management
Use of a dynamic patient-centered
record: The Personal Health Record
Timely primary care/specialty care
follow up
Knowledge of red flags that indicate a
worsening in their condition and how
to respond.
Client personal goal
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“What is one personal goal that is
important for you to achieve in the next
30 days?”
#1: Medication Review
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Client collects all medications (prescription and nonprescription) for review during the home visit.
Client describes medications they are taking and how
Compares what the client is actually taking with the pre
and post-hospitalization lists and identifies discrepancies.
Shows client how to update the medication list in the
Personal Health Record.
Discusses with client how he or she will follow up with
practitioners and PCP
#2 Patient-centered record
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Teach the client how to complete the Personal
Health Record
Discuss the importance and how to update the
PHR on a continual basis
Discuss the value of taking the PHR to all health
care encounters and sharing its contents with
health care professionals
The consumer/caregiver assumes ownership of the
PHR to facilitate cross-site communication and
ensures continuity of core information across
different practitioners and settings.
#3 Timely primary care and
specialty care follow up
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Have client contact PCP.
Schedule appointment
Prepare questions
Identify barriers like transportation
#4 Knowledge of Red Flags
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The client identifies signs and
symptoms that his or her condition
may be worsening
Determines how she/he would respond
to those “red flags”
Use the PHR for the client to list red
flags and plan of action.
Use educational materials about
condition given at the hospital
COA’s Fifth Pillar
5.
Community Resources such as…
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Ongoing care coordination
Home delivered meals
Medical transportation
Home Care Assistance
Coming soon…
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Improved targeting of care transition
intervention
Integration with patient centered medical
home
Assistance with finding physicians and
access to behavioral health care
Shared medical information across care
providers and settings
Care Transitions in Action
“It’s been really wonderful to help me stay at home.”
DONNA, CARE TRANSITIONS CLIENT WITH HER COACH, BETH