1. Community-Based Care Transitions Program
Care Connection for Aging Services
Primaris

2. 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

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

4. 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

5. 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

6. 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 .

7. 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.

8. 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).

9. 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

10. Key Components of the RCA
Completion 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

11. RCA Results
Target population identified by the RCAs included the following most frequently identifed diagnoses:
AMI
Heart Failure
COPD
Pneumonia

12. 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

13. 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

14. 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

15. 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)

16. 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

17. 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.

18. 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

19. Role of Care Connection Transition Coordinator
Accept referrals of qualified patients
Establish contact with patient/caregiver within 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

20. 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.

21. Care Connection for Aging Services Role
Provide Care Transitions Coordinator
Accept referrals of qualified patients
Compile data on pilot project

22. 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?

23. 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?

24. Tools Used in Program Communication Tool Referral form
Personal Health Record
Care Transitions: Information Counselor Protocols
Discharge Preparation Checklist

25. Pilot Results
Still in beginning phase