Jun 212013

By Carol Castillon

By developing a feedback loop so that community-based organizations and hospitals can communicate more effectively about shared patients, San Diego’s Community-based Care Transitions Project  (CCTP) has opened a door for improving patient health improvement. Over the past few months I have witnessed first-hand the development of this crucial piece of the program. In the San Diego CCTP,  anchored by Aging & Independence Services, a community-based organization, we offer two CCTP-approved interventions: the Care Transitions Intervention (CTI) and Care Enhancement. Our partnership includes four health systems and 13 hospital campuses.

When I think of hospitals and medicine, I think of answers.  Individuals seek attention from hospitals and physicians for answers as to why they are ill or why their bodies are not reacting as they should. Clinicians and other professional caregivers witness health problems within the clinical environment, or only hear about them from a patient or caregiver.  For those individuals who are in a high-crisis mode, accuracy can become a problem.  And often,  as soon as a patient is admitted to the hospital, he or she  patient expresses the desire to go home—and, in order to get home, they will say or agree to just about anything clinicians recommend.  I know this from my own experience, as someone who believes quite sincerely, that “there’s no place like home.” At the same time, patients and their loved ones often are unprepared for the functional decline that is often associated with a hospital admission, often not fully appreciating how depleted they are until they actually get home.

To respond to this, CCTP has engineered a merging of the hospital and home perspectives. My organization, AIS, is a real partner in this process; we have had the opportunity to collaborate closely with each hospital. One of our approaches has been to participate in bi-weekly internal meetings or huddles. We use these meetings to debrief one another about patients; smooth work flow processes; review data to ensure that we are on target to meet performance targets; present success stories and conduct a root-cause analysis whenever a patient is readmitted.

These meetings are truly multidisciplinary and include all members of the partnership assigned to a particular hospital. As we go around the table and discuss our pre- and post-discharge interventions, we have found that our feedback circle is gaining a presence of its own.  The feedback circle enables us to bridge the clinical to home environment in ways we have not experienced before.  We are able to immediately feed information back to hospitals about successes, accomplishments and challenges.  In some cases, the feedback circle has even enabled hospitals to change internal processes.  The home assessments conducted by  our CTI Coaches and Care Enhancement Social Workers are beginning to be incorporated into the patient’s hospital medical records and even into primary care physician’s records!

We’ve had physicians contact our coaches to commend the CCTP team on a job well done.  One particular physician was amazed in how much a patient had changed, and even commented, “You guys have done more for this patient with your interventions than I could ever do.” Such feedback is almost music to our ears.


Carol Castillon works with AIS to manage the San Diego CCTP . 

key words:  CCTP, care transitions, evaluation, feedback loops, quality improvement, community partnerships, San Diego,

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