May 082013

Today, we introduce a new series of posts that will describe the experiences of San Diego County as it rolls out its Community-based Care Transitions Project (CCTP) funded by the Centers for Medicare and Medicaid Services (CMS). Carol Castillon, who manages the project, will share stories about the work–its successes and challenges, and what the team learns along the way. The project is one of the largest in the program. We hope this series encourages and inspires others, and that you will share your stories, too. Look for the posts on the 1st and 3rd Wednesday of each month. Thank you, Carol, for sharing your insights!

By Carol Castillon

The County of San Diego’s Health and Human Services Agency, Aging & Independence Services (AIS), in partnership with Palomar Health, Scripps Health, Sharp HealthCare and the University of California San Diego Health System has received CCTP funding from the Centers for Medicare and Medicaid Services (CMS). The project, which launched in January, will use those funds to provide innovative care transitions services countywide to up to 21,000 high-risk Medicare patients in 13 hospitals.

All partners will test an intervention called Care Enhancement. To appreciate the scope of this endeavor, keep in mind that each Care Enhancement worker is assigned to a specific hospital but must also provide coverage to various other hospitals across the different systems.  As the project’s common intervention ,we’ve learned to adapt our approach to each hospital culture to ensure consistency across the services provided.

The Care Enhancement intervention offers  patients and their caregivers critical social support services, either by referral or direct provision of support services, that can reduce the risk of an avoidable readmission.  A Care Transitions coach—a nurse—completes a risk assessment, which can trigger the referral to the Care Enhancement team. The Care Enhancement worker is then required to make a hospital visit prior to discharge as well as a home visit within 72 hours of discharge.

The Care Enhancement position is brand-new.  Even so, all of the Care Enhancement workers had had years of experience in various programs throughout AIS prior to this role.  The manner in which they had provided services was engrained in handbooks—and shifting to new roles and procedures required a huge shift in what they were doing.

Yes, shift does happen! But never did we realize that it would take so much work to shift. As we further engulfed ourselves in developing the CCTP, we realized that this was going to be a process, not something that would happen overnight.

The new world of CCTP totally changed our work. A world that was once filled with 23 -page assessments, and all the makings of what is typically long term case management by community-based organizations (CBOs) was brought to a sudden halt. That model shifted into an intense short –term patient centered care coordination.  Clients became patients, partners became nurses and our assignments became tasks.

Shift is difficult and, for many of us, it has been laborious.  Along the way, we  have created a CCTP training module for Care Enhancement to assist staff in adjusting to their new roles.  We lovingly called the module CCTP 101, and even included a section about this “shift”.  We have found it essential to foster an environment in which over communication and input is maintained as a vital piece to our developing system. However, our old ways sneak up on us like those catchy songs that play in your head over and over again.  Nevertheless we are confident that we will adapt to this shift and soon enough we will be asking what was that song we kept singing?

Want to know more?

Community-based Care Transitions Program Overview

key words: San Diego County, CCTP, care transitions, readmissions, frail elders

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  2 Responses to “A Shift Happens: Care Transitions Lessons from San Diego County”

  1. Can we see a copy of CCTP 101 or a link to the manual. That would be a good resource. Thanks – Ken

  2. Can we see a copy of CCTP 101 or a link to the manual. That would be a good resource. Thanks

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