On the heels of a successful pilot program to reduce hospital readmissions, The Delaware County Office of Services for the Aging (COSA) in Pennsylvania, has been selected among the first 30 organizations around the nation to participate in the Community-based Care Transitions Program (CCTP) for its work in southeastern Pennsylvania. COSA, the project’s community-based organization, is anchoring a collaboration among five of the county’s six acute care hospitals, which serve an area of more than half-a-million residents.
The pilot program, funded by the Administration on Aging (AoA), included a partnership with the Crozer-Keystone Health System, and a demonstration program at Taylor Hospital and Springfield Hospital. That project initially aimed to enroll 235 patients but, to date has enrolled 395. It has achieved a readmission rate of 7.06 percent from 13.33 percent. The project used a modified version of the Transitional Care Model (TCM), originally developed by Dr. Mary Naylor. While TCM relies on advance practice nurses working with patients and caregivers, COSA’s new CCTP is a modified version, as it includes hospital-based registered nurses and social workers. The social workers, who are affiliated with COSA, work closely with the RNs to deliver patient education and arrange referrals for follow-up services.
In the AoA pilot program, an advanced practice nurse enrolled patients based on screening criteria that included patients over the age of 65 who were, because of their diagnosis, at risk for an avoidable readmission. The hospital had a COSA assessor, who offered patients a level of care assessment at bed-side for potential enrollment into COSA programs. Once assessed, patients were assigned to a COSA care manager who followed them in the community. The advance practice nurse followed patients for up to 60 days, while the COSA care manager could follow them for much longer.
In the modified Centers for Medicare and Medicaid Services (CMS) CCTP program, a registered nurse will screen hospital admissions for patients who are 60 years old and older with Medicare Fee-for-Service with both Parts A and B, all-cause hospital admissions, and meet any of several criteria, such as at risk for readmission, poly-pharmacy, lack of informal supports, living alone, lack of follow-up with a primary care physician (PCP) in a previous hospital discharge, or hospital readmissions within the previous 180 days. Once the nurse has identified an eligible patient, the nurse will meet with him or her at the bedside to discuss enrolling in the program.
Patients who agree to participate will receive a visit from the project’s social worker. Together, the nurse and social worker will provide the patient with user-friendly transfer and discharge forms, and teach the patient how to use AHRQ’s Taking Care of Myself. That booklet, which is customized to the patient’s needs, includes information about medications, diagnosis, nutrition and activity, follow-up appointments, and so on. Patients will be encouraged to take the booklet with them to follow-up appointments, and to have physicians update it as needed. The CCTP nurse is scheduled to make two home visits to the patient, as the first visit will be with-in 72 hours of the hospital discharge and another at week 4, before the completion of the program. The COSA CCTP social worker will meet with patients weekly and also follow-up by phone. The nurse and social worker will follow the patient for 30 days. The COSA social worker will work with the patient, according to his or her needs and preferences. If the patient would like, the social worker will accompany him or her to the first post-discharge PCP visit. If additional COSA services are needed, the patient can be assessed at bedside or in the community by a COSA Assessor, and then assigned to a COSA Care Manager who would follow the patient much longer if needed.
In addition, social workers have over-sized business cards that will feature their photographs and contact information. The cards give social workers a face—patients can share the cards with family members at home, so that they can see who will be visiting the patient. For patients who have people in and out of the home daily, the card is a visual reminder about the social worker.
The CCTP is an initiative of the Partnership for Patients, a nationwide public-private partnership launched in April 2011 that aims to cut preventable errors in hospitals by 40 percent and reduce preventable hospital readmissions by 20 percent over a three-year period. CCTP’s goals are to reduce hospital readmissions, test sustainable funding streams for care transitions services, maintain or improve quality of care, and document measurable savings to the Medicare program.
The CCTP project, which received funding late this spring, is ready to hit the ground running. Two hospitals will launch the work on August 6, and three others will join in by October. According to the COSA CCTP Project Director, Terry Levine, the project’s success hinges on the relationships among COSA and all the participating hospitals. In planning it, he said, it was important to communicate with the hospitals and to let them know that the CCTP work is not meant to replace their discharge planning, but to supplement it. Over the course of the next two years, the project aims to enroll 4,282 patients; with hopes that successful work will lead to subsequent years of funding.
For more information about the project, contact Mr. Terry Levine, the COSA CCTP Project Director at [email protected]
key words: CCTP, CMS, Naylor model, care transitions