Jul 032013

By Carol Castillon

Defining success in work that focuses on people who are very sick can be a challenge: The usual metrics just aren’t always applicable. With that in mind, how will we know success in our community-based care transitions work (CCTP)? Like everyone else involved in this endeavor, San Diego faces the challenge of reaching a 20% reduction in Medicare fee-for-service readmissions. We are avidly monitoring our progress. But is that really success?

To some extent, of course it is, and it would be fabulous to get there. If and when we do, though, I think there would still be a void.  Perhaps I’m naïve or perhaps I have what we lovingly call a “social worker’s heart,” but my definition of success is something a little different.  The only way to convey this is by telling the story of patient X.

A day after admitting patient X to a partnering hospital, our Inpatient Transition Coach assessed the patient for meeting our high-risk criteria.  That same day, the patient was assigned to the Care Transitions Intervention (CTI) coach. The coach saw the patient and enrolled him into CTI, as well as into our Care Enhancement program, which could address the need for social services.  Throughout the hospital stay the partnering hospital provided the patient with assistance in communicating his needs to his healthcare team.  From this interaction, the team learned that the patient could not afford his medication co-pays.  Based on hospital regulatory charity guidelines, we were able to have that fee waived.  After 3 days in the hospital, the patient was discharged and the CCTP clock began to tick.

When the patient opened his apartment door, our coach found herself in an all too familiar situation. She found that the apartment had been hit by what looked like a tornado involving the patient’s medications.  The patient, filled with nervousness and relief at seeing the coach (who is a nurse), blurted, “I need to call 911! I need to get to the ER!”

Every CTI coach fears hearing this. Staying calm, our coach assessed the patient, and found that he had been suffering from a headache since the day of discharge. The patient did not have any pain medications or transportation to obtain such medications. Using her charismatic charm, the coach was able to coach the patient to call his physician and discuss these symptoms. She then helped him to identify some key issues that were quite evident with his medications.  The visit lasted for about 2 hours, but even with that much time, the coach could not complete the four pillars of the CTI model. Instead, she worked with the patient to set follow-up medical appointment with his physician and connected him with some of our Care Enhancement services.

Through Care Enhancement, we were able to provide a taxi prescription to get the patient to his doctor’s office.  The Care Enhancement social worker then worked miracles.  The social worker connected the patient with a home health program, which the patient had declined at discharge.  She assisted the patient in obtaining transportation through our Metropolitan Transit System Access, which assists people with disabilities.  The long-term needs assessment found that the patient had shown symptoms of depression, and so the social worker addressed this problem with the patient and physician.  The patient was connected with in-home counseling, aide and attendance through the VA, and housing. In terms of housing, she helped the patient to move from his second-floor apartment floor and limited his ability to go out (the patient uses a scooter) to a living environment better suited to his needs.

Now that’s success! Because of our team’s work and focus, the patient doing better. This was a direct result of our collective interventions.  Patient x has ongoing support from a team that is committed to improving the lives of each and every patient we meet.  Right now, we are at 80 days post-discharge—and no readmission.

Carol Castillon works for Aging & Independence services, and manages the CCTP work in San Diego County. 

key words:  CTI, Coleman model, care transitions, San Diego County, CMS, readmissions, quality improvement, care enhancement

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