1. CMS National Conference on Care Transitions December 3, 2010 1

2. Implementing the Care Transitions Intervention sm Alan B. Stevens, PhD Director, Program on Aging and Care Scott & White Healthcare Richard McGhee Director, Central Texas Aging and Disability Resource Center 2 2

3. Overview Establishing a trusted partnership to benefit the community The Central Texas Community Living Program Embedding the Care Transitions Intervention sm within a healthcare system 3

4. Trusted Partnership The Central Texas Aging and Disability Resource Center (ADRC) – Partnership of 11 health and service related organizations – Partners provide unique and valued contributions to a core mission – Partners embrace a unified public image supported by social marketing Scott & White Program on Aging and Care – Contributes to the ADRC’s objective of providing evidence-based interventions – Facilitates community and patient engagement 4

5. The Central Texas Community Living Program Co-designed by the Central Texas ADRC and Scott & White Healthcare Targets individuals at high risk of nursing home placement and spend down to Medicaid Provides a family centered plan of community based care that includes: – Transitional coaching using the Care Transitions Intervention sm – Support and skills training for family caregivers – Community-based formal support services Funded by a US Administration on Aging (AoA) grant awarded to the Texas Department on Aging and Disability Services. 5

6. The Care Transitions Intervention sm (CTI) A Transition Coach is the vehicle to build skills, develop confidence and provide tools to support self-management 4 Pillars of the Intervention – Medication reconciliation/self management – Identifying “red flag” symptoms – Follow with Primary Care Provider (PCP) – Personal health care record One home visit, three phone calls over 30 days http://www.caretransitions.org/

7. Delivery of the Care Transitions Intervention 189 Individuals were enrolled in the Community Living Program 65 of those individuals received CTI during the 10 month intervention phase 7

8. MonTueWedThuFriS/Sun 123456/7 8910111213/14 151617181920/21 222324252627/28 E-MAIL REFERRAL 65YO Female COPD, heart condition Hospital Visit Enroll, PHR Home Visit Review PHR, Med Rec, Red Flags Primary Care Follow-Up Discharged Home Home Visit Introduction of new coach Home visit Baseline for CLP A Case Report

9. 9 Strategies for Embedding CTI Objective CTI Coach access to case managers, patients and families Technique Convey joint ownership of project by making CTI Coaches S&W staff Contractual arrangement allows Scott & White to be the employer of record for CTI coaches, providing full access to electronic medical record.

10. 10 Strategies for Embedding CTI Objective Timely identification of target population Technique Engage hospital Case Managers Engage Hospitalists Multiple strategies to educate, accommodate and motivate case managers and hospitalists to refer patients and introduce service Feedback to build trust

11. 11 Strategies for Embedding CTI Objective Integration into hospital workflow and policies Technique Know the culture CTI were accepted by Post Acute Services, Quality & Patient Safety Council Physicians involvement has been encouraged via consults Leadership endorses efforts to reduce readmissions

12. Texas ADRC Evidence-Based Care Transition Program Recently funded project that will provide CTI to 750 individuals across multiple hospitals in the Scott & White system Funding provided by HHS’ Administration on Aging (AoA) and the Centers for Medicare & Medicaid Services (CMS) via “Implementing the Affordable Care Act: Making it Easier for Individuals to Navigate their Health and Long- Term Care through Person-Centered Systems of Information, Counseling and Access" initiative

13. Texas ADRC Evidence-Based Care Transition Program Three Goals: Embed additional CTI coaches within S&W Memorial Hospital and replicate model in a partner hospital Certify staff as CTI coaches within 6 additional Central Texas ADRC partner agencies (e.g., Independent Living Center, Children’s Special Needs Network) Support adoption of CTI across the statewide network of 8 Texas ADRCs

14. For more information, contact: Alan B. Stevens – astevens@swmail.sw.org Richard McGhee – richard.mcghee@ctcog.org 14