Jun 202016
The six components of MediCaring Communities

MediCaring Communities: Getting What We Want and Need in Frail Old Age at an Affordable Cost
Published June, 2016
194 pages, 6″ x 9″ (15.24 x 22.86 cm)

ISBN-10: 1481266918

List Price $9.95 at Amazon.com

Americans want a long life and most of us will get to live into our 80’s and beyond, but we have not squarely faced the challenges of living well in the last years of long lives. This book lays out a thoroughly pragmatic way to organize service delivery and financing so that Americans could count on living comfortably and meaningfully through the period of disability and illness that most will experience in the last years of life – all at a cost that families and taxpayers can sustain. MediCaring Communities offers to customize care around the priorities of elders and their families and to manage the local care system so it is reliable and efficient.

MediCaring Communities book cover

MediCaring Communities book (click cover to view on Amazon.com)

Three out of four of us will need long-term care. The period of needing someone’s help every day now lasts more than two years, on average. Most of us will not have saved enough to get through this part of life without financial help from family or government – indeed, we’ll spend almost half of our total lifetime healthcare expenditures in this last part of life, mostly on personal care that is not covered by Medicare. We have not yet required housing to be modified for living with disabilities or secured a ready supply of home-delivered food, and we certainly have not required medical care to focus on the patient and family priorities in order to enable the last years to be meaningful and comfortable. Family caregiving will be a crisis as families become smaller, more dispersed, older, and facing inadequate retirement income for the younger generation.

MediCaring Communities improve care by building care plans around the health needs and living situation of the elderly person and family, and especially from respecting their choices about priorities. The improvements in service delivery arise from integrating supportive services at home with customized medical care and installing local monitoring and management. The improvements in finance arise from harvesting savings from the current overuse of medical tests and treatments in this part of life. These come together in MediCaring Communities.

Strong evidence supports each component, but the real strength is in the combination, where savings support critical community-based services, communities build the necessary environment, and elders and their families craft their course with the help of interdisciplinary teams. This book lays it out, using expansion of PACE (The Program of All-Inclusive Care of the Elderly) as the test case. The book provides a strong and complete guide to serious reform, and just in time for the aging of the Boomers which will escalate the needs dramatically during the 2030’s. Now is the time to act.

You can read extracts online.

Advance Praise for MediCaring Communities

“For decades, Joanne Lynn’s has been the clearest, strongest, most soulful voice in America for modernizing the ways in which we care for frail elders. This essential book is her masterpiece. It offers a magisterial, evidence-based vision of that new care, and an entirely plausible pathway for reaching it. Facing a tsunami of aging, our nation simply cannot afford to ignore this counsel.”
—Donald M. Berwick, MD, President Emeritus and Senior Fellow, Institute for Healthcare Improvement, and former Administrator, Centers for Medicare & Medicaid Services.

“MediCaring Communities integrates good geriatrics and long-term services and supports, and building upon an expanded PACE program can be a tangible start. We should try this!”
—Jennie Chin Hansen, Lead in Developing PACE; Past President, AARP; and Past CEO of On Lok Senior Health Services and the American Geriatrics Society.

About Joanne Lynn

Joanne Lynn, MD, MA (Philosophy and Social Policy), MS (Quantitative Clinical Sciences), is Director of Altarum Institute’s Center for Elder Care and Advanced Illness. Dr. Lynn has served thousands of persons in their last years of life in home care, office practice, hospice care, and nursing homes. She was one of the first hospice physicians in the United States. Dr. Lynn has been a tenured professor at Dartmouth and George Washington University, a quality measurement expert on the staff at the Centers for Medicare & Medicaid Services, the Bureau Chief for Cancer and Chronic Disease in the public health office for Washington (DC), a senior researcher at RAND, and on the Institute for Healthcare Improvement’s quality improvement faculty. She is a member of the National Academy of Medicine, a Master of the American College of Physicians, a Fellow of the Hastings Institute and the American Geriatrics Society, and an author of more than 280 peer-reviewed publications, 80 books and chapters, and a dozen amicus briefs and publications for public commissions.

The reader can learn more about our work and give us advice and insights at MediCaring.org.

About Altarum Institute

Altarum Institute (Altarum.org) is a nonprofit research and consulting organization based in Ann Arbor, Michigan. Altarum integrates independent research and client-centered consulting to create comprehensive, systems-based solutions that improve health. One focus has been addressing the challenges of living with advanced illnesses and disabilities in old age through the Center for Elder Care and Advanced Illness. The dozen staff at the Center aim to help the United States achieve social arrangements that ensure that, when we must live with serious chronic illnesses associated with advancing age, we can count on living meaningfully and comfortably, at a sustainable cost to our families and society.

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Jan 042016

By Anne Montgomery and Leslie Fried of the National Council on Aging

One of the hallmarks of the 21st century—increased longevity of the population—will increasingly drive federal, state, and local health care programs to focus on optimizing coordination of services across a range of medical care and community services providers. Discharge planning will play a central role in these efforts, particularly discharge to home.

In November, the Centers for Medicare & Medicaid Services (CMS) issued a proposed regulation for hospitals (defined as including critical access hospitals, long-term care hospitals, and inpatient rehabilitation facilities) and home health agencies. Overall, it is a solid effort and a welcome step forward in calling for Medicare and Medicaid to interface with Older Americans Act providers and disability programs under the jurisdiction of the Administration for Community Living. All of these programs and others are centrally concerned with managing beneficiaries who have complex chronic conditions. They are also well-positioned to set out criteria that can help providers establish systems of joint management of complex patients over extended periods.

However, while the rule prominently references Aging Network providers—Area Agencies on Aging, Aging Disability Resource Centers, and Centers for Independent Living—in the preamble, it does not carry substantive discussion through to actually require health care providers to coordinate with these community-based organizations.

We see this as a shortcoming, since the array of services offered by these organizations, which include home and physical environment modifications, access to assistive technologies, transportation, meals, household services, and housing support, are essential to millions of Medicare beneficiaries who cannot function day-to-day without some assistance. Absent clear requirements for health care providers to coordinate with social services organizations, risks will remain high that many fragile, complex older adults living in the community will fall through the cracks and into crisis, cycling in and out of high-cost health care settings.

If we think about discharge planning in a larger context, it is effectively only the start of a successful transition. Keeping information about patients with chronic conditions in the hands of a “sending” health care provider only, with no explicit requirements to make adequate provisions for communications and preparations with “receiving” community-based organizations, is likely to result in frustration for families and missed opportunities. By comparison, to maximize opportunities for success, CMS could bring the Aging Network into discharge planning discussions as soon as health care providers start to prepare for a patient’s transition—and could determine the actual availability of these services. If it turned out that publicly funded community services were not available (possibly due to waiting lists and/or underfunding), health care providers could be asked to explore alternatives. In all cases, figuring out what options are actually available and affordable must be done in consultation with the patient and family caregiver.

To improve the chances that community social services organizations can be better funded, we believe that CMS should direct nonprofit hospitals to assess services shortages as part of their Community Benefit Needs Assessments, and take subsequent steps to mitigate and augment critically needed services in the community. For-profit hospitals should be similarly required to work with public health offices and Aging Network providers to assess and correct any inadequacies in service supply.

On a related point—assessment of the discharge planning process—we strongly encourage CMS not to limit these reviews to assessment of the impact on readmissions (§482.43(c)(10)). Rather, in the spirit of the regulation’s frequent references to Aging Network providers, we urge that hospitals be required to establish advisory committees to conduct periodic reviews that include community social services organizations and other stakeholders in order to track the full impact of discharge planning on patient outcomes over time.

In another area—the specific elements that must be covered in discharge planning documents—the regulation proposes varying requirements for different providers. In the case of home health agencies, for example, discharge and transfer summaries must include demographic information; contact information for the physician; an advance directive, if available; the course of the illness/treatment; procedures; diagnoses; lab tests and other diagnostic testing; consultation results; a functional status assessment; a psychosocial assessment, including cognitive status; social supports; behavioral health issues; reconciliation of discharge medications; all known allergies; immunizations; smoking or nonsmoking status; vital signs; unique device identifiers for implantable devices; recommendations for ongoing care; patient goals and treatment preferences; the current plan of care, including goals, instructions, and the latest physician orders; and “any other information necessary to ensure a safe and effective transition of care that supports the post-discharge goals for the patient.”

In contrast, there is a much shorter list for critical access hospitals to consider in the context of “areas where the patient or caregiver/support person(s) would need assistance.” It includes admitting diagnosis or reason for registration, relevant co-morbidities and past medical and surgical history, anticipated ongoing care needs post-discharge, readmission risk, relevant psychosocial history, communication needs (e.g., language barriers, diminished eyesight and hearing), patients’ access to non-health care services and community-based care providers, and patients’ goals and preferences. Yet another list of criteria pertains to “discharge to home” situations, which requires instruction on post-discharge care to be used by the patient or the caregiver/support person; written information on warning signs and symptoms; prescriptions, including the name, indication, dosage, and significant risks and side effects; medication reconciliation; and written instructions for patient follow-up care, including appointments, diagnostic tests, and pertinent contact information.

Logically, there should be a list of core elements that could also be the foundation for a common care plan, and which could then be readily shared across providers working in different settings. Requiring a list of core elements would simplify care coordination and basic communication between providers, and decrease confusion and chaos for families who are often confronted suddenly with very difficult tasks when taking a seriously ill or disabled person home. Perhaps the list of required elements outlined for home health agencies could be the basis for crafting standardized core elements for all covered health care providers, along with a person’s likely future course, strengths, treatment preferences, and goals.

Concerning the critical role played by family caregivers, the rule recognizes and acknowledges the importance of families in many places – yet does not clearly establish the voluntary nature of this support: In other words, the primary consideration in discharge planning with regard to family caregivers should be to determine their willingness to provide services. To address this, we hope that CMS will consider requiring health care providers to engage in a conversation and subsequently document that a family caregiver has been asked about specific supports that he or she may need, taking into account the family’s economic resources.

The regulation features thoughtful discussion medication reconciliation and health information technology (HIT). For beneficiaries with complicated medication regimens or a track record of medication problems, we believe that CMS should encourage covered providers to use a pharmacist or physician (as compared to a software program or a nurse) whenever practicable. To make strides on HIT, there may be scope for the agency to require a standard format for recording a care plan, in order to improve interoperability and to make care plans an integral part of standards for certified electronic medical records.

Finally, the regulation should guarantee that discharge planning documents are immediately accessible to patients and family caregivers. Under current protocols governing medical records, it is often difficult for family caregivers to obtain a medical record from a hospital until after discharge, even with a patient’s signed consent (which is not always possible to get if the patient is seriously ill). This is unhelpful and counterproductive for families and should not be allowed to be extended to discharge planning documents.

CMS’ discharge planning regulation is moving in the right direction. As the agency considers these and other ideas for improvement, we hope that the agency will take the opportunity to advance a national conversation on how discharge planning can play a key role in health and social services delivery system reforms.

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Oct 262015
Tab 6 of CPT spreadsheet

By Elizabeth Rolf and Holley Stanley

Physicians caring for frail elders have long complained that they cannot provide optimal care and stay in business, given how Medicare pays for services. Over the last decade, CMS has developed and implemented new payment strategies within the Fee-for-Service Medicare Physician Fee Schedule (MPFS), aiming to encourage primary care for persons facing chronic illnesses. This shift in coverage and payment signals an evolving appreciation that prevention, non-face-to-face care management services, and care delivery by an interdisciplinary team (IDT) of health care professionals contributes to better health at lower cost. However, many physicians and other stakeholders do not use the new codes, in part from unfamiliarity and in part from their requiring some changes to how services are organized. Many of these practitioners do not realize how much revenue they are leaving “on the table.” So, we have developed a complete but readily usable form that would allow anyone to estimate their potential revenue and to test the effects of making various assumptions about uptake by patients or adding staff.

The attached Excel spreadsheet is organized as follows: Tab 1 briefly overviews important factors considered in determining payment for Medicare services. Tabs 2 and 6 provide a useful resource for details in the appropriate use of the included codes: Initial Preventive Physical Exam (IPPE G0402); Annual Wellness Visit (AWV G0438 and G0439); Transitional Care Management (TCM CPT 99495 and 99496); and Chronic Care Management (CCM CPT 99490). Because payment varies by geographic location, Tabs 4 and 5 guide the user through determination of the Geographic Cost of Practice Index (GCPI)-payment which then auto-fills cells on Tabs 7 and 8 to allow a calculation of potential revenue. Because CCM is billed per eligible calendar month, the worksheet in Tab 9 allows for estimates of the willingness to participate of patients in a provider’s practice that are anticipated to meet the eligibility criteria for CCM and this value is auto-filled to the appropriate cells on Tabs 7 and 8, which calculate total revenue.

Here is an example of the helpful tables that you’ll find in this spreadsheet, and a link to the spreadsheet:

Tab 6 of the CPT resource file


CMS’ decision to provide payment codes is a step in the right direction. Although there have been some obstacles, we hope that the final rule in November will provide more direction and clarity. Providers and clinics should recognize the opportunity they have to hire appropriate staff (full or part-time, employees or contractors) to counsel for wellness visits, to attend to transitions with care, and to develop care plans and implement them over time. Wellness visits were established in 2011 and establish a Personalized Prevention Plan and Health Risk Assessment. Transitional Care Management (TCM) recognizes that care gaps may occur when transitioning from one facility to home. TCM provides assistance and follow-up to improve outcomes and increase savings after a complex beneficiary has been discharged. Chronic Care Management (CCM) codes cover services that use at least twenty minutes of the clinician’s time to establish, implement, monitor, or revise a patient’s care plan. The patient must have two or more chronic conditions that put the patient in a state of functional decline, and the conditions are expected to last more than twelve months, or until death.

By establishing chronic care management codes, CMS is recognizing the value that prevention and comprehensive care management has in primary care and understands that it leads to better health for beneficiaries and lower costs. The new codes indicate that CMS is beginning to appreciate the need for non-face-to-face clinical services, and CMS has allowed physicians to bill for these services now that there is a new awareness of the tasks of elderly persons living with disabilities and the conditions that come hand-in-hand with aging. The codes begin to incentivize discussions with beneficiaries and families dealing with multiple chronic conditions and the codes recognize the need for awareness for the tasks of elderly persons living with disabilities and the conditions of aging. The new codes cover at least some of the time that clinical staff needs to carry out the evaluations and discussions that are essential to better address the complex situations of the beneficiary population. Incentivizing providers to coordinate care for beneficiaries living with chronic conditions is an important step for ensuring continuity and meeting personal goals of frail elders and their families.

We recognize that there can be many obstacles to practices for using these codes. In the preliminary ruling, CMS has acknowledged these obstacles and is soliciting comments about potential solutions. Undoubtedly, there will be ongoing improvements, but first, clinicians in various settings need this sort of help to take up the new codes and develop focus as to what else is needed.

We applaud the ongoing efforts by CMS to improve capture of the physician work and practice expense necessary to provide these important services. Likewise, it is also encouraging that CMS has acknowledged a need for refinements in these services to remedy the slow uptake in their use by providers. In their July 15, 2015 Proposed Rule (https://www.federalregister.gov/articles/2015/07/15/2015-16875/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions), they explicitly asked for comments from stakeholders and their response to these comments will be available in the MPFS Final Rule which will be available in November 2015.

Please follow the MediCaring link to download the spreadsheet: http://medicaring.org/wp-content/uploads/2015/10/altarum_cpt_spreadsheet_oct2015.xlsx

Please do let us know how you found it useful and any improvements you would recommend. Contact us at info@medicaring.org.

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Jan 262015
Portrait of Dr. Joanne Lynn

by Joanne Lynn

The Centers for Medicare and Medicaid Services (CMS) has quietly put out two evaluations of the readmissions work– and both documents are remarkable for their failure to evaluate the programs fairly or to provide insights as to what works in what circumstances.

The Community-Based Care Transitions Program (CCTP) pays community-based organizations (often Area Agencies on Aging) to work with hospitals to improve transitions from hospital to home. This first evaluation, covering the 48 programs that started before 2012 [http://innovation.cms.gov/Files/reports/CCTP-AnnualRpt1.pdf], found just four of them to have made statistically significant gains in reducing the ratio of readmissions to discharges from the participating hospitals.

The readmissions/discharges metric that CMS and its evaluators use for categorizing success or failure is seriously flawed. CMS has known this for a long time: In 2009, that metric had to be changed during the Quality Improvement Organization (QIO) work in 14 communities because the numerator and denominator were declining together [http://jama.jamanetwork.com/article.aspx?articleid=1558278&resultClick=3]. We recently published a review of the conceptual issues [http://medicaring.org/2014/12/16/protecting-hospitals/] and a data-driven example of the problem [http://medicaring.org/2014/12/08/lynn-evidence/]. There is no easy switch to population-based metrics in programs that were never set up to be population-based. Indeed, much of the problem with the measures probably has roots in national leadership still conceptualizing the transitions work as being dominantly the responsibility of hospitals and their staffs, while people living with serious chronic conditions need a more comprehensive, community-anchored, population-based approach. Even so, responsible evaluation would require, at the very least, a close examination of actual numerators and denominators in order to interpret the simplistic and routinely misleading ratio.

There are bound to be terrific success stories in the sites that did not “win” according to the malfunctioning readmissions/discharges metric. Some sites probably had reduced their denominator, hospital discharges, at the same rate (or higher) than they reduced 30-day readmissions. The four sites that the CMS report considered successes might well have included some sites where a shift in the local market increased their hospital utilization with lower-risk patients. Moreover, the 30-day limit on tallying readmissions does not mark a magical divide: Nearly everything that works to help in the first 30 days will continue to have a positive effect for much longer, and better support arrangements and care planning in the community will end up reducing index admissions.

This CCTP evaluation also observed the speed of start-up and the success of efforts to achieve targeted enrollment — both interesting and potentially important process components of success, though neither is actually essential. A delay in starting might be imposed by contracting issues, business associate agreements, software development, or any of an array of challenges that do not affect long-term success. And the proposed target enrollment figures are much less important than whether the sites targeted enough high-risk patients who had opportunities to reduce risk and enrolled enough of those patients to demonstrate a difference.

Of course, the most important issue is whether the CCTP program is helping to improve transitions and keeping people who are living with fragile health in a more stable condition while living in the community, thereby reducing hospitalization. It would be easy for the evaluation to show that the supplemental services are desirable. Evaluators could test whether enrolled patients had many fewer medication errors, many more patients and families confident in their self-care, many more social services in place, and much more medical support in the community. However, the current evaluation does not address these points.

Consider that the CCTP program pays “per person served.” In a very important sense, then, the program is a winner if it reduces hospital utilization enough to cover the program’s costs. For example, if one program reduces hospital utilization by 1,000 hospitalizations per year in an area where Medicare’s average hospitalization cost is $15,000, then it saves $15,000,000 per year. CMS pays community-based organizations a modest fee, around $300 per intervention patient. The CCTP program would have to be serving 30 people to prevent one readmission in order to break even. Clearly, the ratio is likely to be more like 10 or 15 people to save one readmission – and get a return on investment of 2:1. This suggests that the return on investment with even modest success is wildly favorable and would be so at virtually any revised estimate of cost and effectiveness (which an evaluation could provide). So why does the evaluation not address these central issues?

Further, there is no reason why a 20% reduction in the now thoroughly discredited readmissions/discharges ratio is the best target. A more informative target would clearly focus on providing a reliable, well-characterized set of services that work to the advantage of patients and families and that also reduces total costs. The CCTP program and other efforts to improve care transitions have already met that criterion, so the question now needs to be, “What are the next prudent steps for health care managers and policymakers?”

To answer that question, it makes sense to look to the other recently released evaluation of readmissions work, developed for the Partnership for Patients [http://innovation.cms.gov/Files/reports/PFPEvalProgRpt.pdf ]. This report claims that readmissions reductions may have saved Medicare $2.8 billion (out of $3.1 billion saved by all of the hospital-acquired conditions reductions; Table 3 in the report), but this presentation only attributes improvement to the Partnership for Patients (PfP) and its Hospital Engagement Networks (HENs). The CCTP, the hospital penalties under the Hospital Readmissions Reduction Program, and the QIO’s extensive work in supporting community efforts are not mentioned, let alone cited as possible parts of the causal chain. The metrics supporting the claim of gains (pages 3-2 and 3-3) are similarly inconsistent: One figure uses 30-day readmissions/discharges in Medicare, one uses the QIOs’ readmissions/1,000 beneficiaries per quarter (but does not report any statistical tests), and one uses the hospital-reported 30-day all-cause, all-payer readmissions/discharges. The report aims to have the reader believe that the PfP and the HENS generated a number of positive results, including saving money. On closer inspection, however, it becomes clear that the authors are counting the reductions in admissions as well as the reductions in readmissions in estimating the savings, a tacit admission that at least some people at CMS recognize that good practices in transitions and in longer-term community support reduce both the numerator and the denominator in the readmissions/discharges metric.

There are other evaluations to come, with some presumably already in the works. Many site visits have been made and much data are available. Let’s hope that the next round of evaluation reports starts to answer serious policy questions about how to proceed. Now that we have come this far, what combinations of services should become standard and expected by beneficiaries and family caregivers, and which ones tend to be useful only in particular settings? Which specific interventions should be used for targeted patients, and which should become part of the ordinary operations of high-quality health care delivery? What have we learned about care planning, interoperability, feedback loops, community action, and useful measures?

Recently, the Patient-Centered Outcomes Research Institute (PCORI) has announced a multi-million dollar, multiyear contract focusing on care transitions. Maybe that work will start identifying better measures of quality care during transitions and leading to better support of people with fragile health in the community. Perhaps that work and future evaluations could synthesize data and reports from a wide array of sites and efforts and provide guidance for future management and policy actions. CMS and the Office of the National Coordinator for Health Information Technology (ONC) should be working toward better metrics based on information in electronic records, and the IMPACT act [http://medicaring.org/2014/10/28/impacts-impact/] will generate better databases to work from.

But these first forays into evaluation of the readmissions work are quite disappointing. There are contractors and participants who know much more, and there are evaluation methods that would be much more revealing. The work on care transitions has been a powerful catalyst toward more comprehensive care planning and service support for people living with fragile health. It is time to push CMS and PCORI and any other funding agency, contractor, or grantee to do the work that informs managers and policymakers about what to do next, given what we’ve learned in the work so far.

Want to Know More?

Evaluation of the Community-Based Care Transitions Program:

Project Evaluation Activity in Support of Partnership for Patients: Task 2 Evaluation Progress Report

For an essay by Stephen Jencks giving more of the context see:

The Evidence That the Readmissions Rate (Readmissions/Hospital Discharges) Is Malfunctioning as a Performance Measure

Hartford Foundation blog: Care Transitions Evaluation Is Premature and Confusing

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Oct 282014
Portrait of Dr. Joanne Lynn

By Joanne Lynn

What matters in the lives of frail elders centers on function — and understanding an elderly person’s course, over time, requires that everyone involved learn to measure functioning in the same way. That’s the core of the new Improved Medicare Post-Acute Care Transformation (IMPACT) Act, passed by Congress in September 2014. Within a few years, we will have a uniform way of measuring what matters, including at least functional ability, across all post-hospital settings. The work that Medicare will have to do to implement IMPACT provides a remarkable opening for advocates to get Medicare measuring the things that matter.

About a decade ago, I started working at the Centers for Medicare & Medicaid Services (CMS) in the Quality Measurement and Health Assessment Group. In straightening up my cubicle on the first day, I was dumbfounded to find a small cache of notepads emblazoned with “HCFA” and even more yellowed ones saying “Social Security Administration.” But the real gem was a set of transcripts from hearings nearly 30 years ago that addressed the wisdom of having a Uniform Assessment Instrument (UNAI) for the elderly. The arguments were cogent, and many of those testifying were well-known in geriatrics and gerontology to this day. But the world did not turn their way.

CMS ended up with some assessment instruments: the Minimum Data Set (MDS) for nursing homes, the Outcome Assessment and Information Set (OASIS) for home care, and the Inpatient Rehab Facility-Patient Assessment Instrument (IRF-PAI) for rehabilitation hospitals. There was little consistency between them. One instrument might ask whether an elder could do a task, another asked if he did do the task, and the last could ask how quickly he did it. If a person were in a sequence of settings that used different instruments, there was no way to see whether the person changed or it was just that the specific questions were different. This inconsistency was crazy! It precluded doing a serious study of outcomes across settings, characterizing populations of frail elders who used multiple settings, or even training practitioners to optimize the quality of data.

CMS has done one remarkable study, the Post-Acute Care Payment Reform Demonstration (PAC-PRD), in which elderly hospitalized persons were measured with a standardized tool, called the CARE Instrument. The findings have slowly surfaced and show that most outcomes are not affected by the setting of treatment, but the costs are dramatically different. This has led the Medicare Payment Advisory Commission (MEDPAC), in its June 2014 Report to Congress, to take notice and call for more site-neutral payments. This would mean that Medicare would not pay differently for treatment in settings that are not shown to make a difference in outcomes.

But for any rationalization of the increasingly expensive period just after hospitalization, one really needs the UNAI, a uniform way of measuring what matters, including at least functional ability, across all settings and time. That is the core of IMPACT. The Act requires that CMS promulgate a standard assessment and that all post-hospital providers use it and report data in that form. This meshes with an entirely separate project by the same name, Impact, an Office of the National Coordinator for Health Information Technology project that has identified and standardized hundreds of elements that might be part of an assessment and care plan and is beginning to pilot-test the interoperability of records across sites in long-term care. The IMPACT Act makes UNAI real, with various deadlines, mostly 2018.

Having uniform data that will allow identification of functional disability and other important clinical categories creates the possibility of developing quality measures that reflect the priorities of frail elders, and the Act and the Executive Action Fact Sheet that accompany it give clear instruction to build measures of this sort.

How do the IMPACT Act and the associated executive actions give us a window of opportunity? IMPACT, in its section on quality measures, requires that care preferences of the individual and the family caregiver be part of the data to be reported at the time of a transition in setting of care. In a section on quality measure use, the Act requires that conditions of participation include procedures to address the patient’s treatment preferences and goals of care. The Act also calls for studies of the effects of socioeconomic factors and beneficiary activation on quality measures. The Act requires stakeholder input, and all of us are stakeholders. We hope to grow old, and we hope our loved ones do also.

What matters most when we are living with disabilities, chronic conditions, and frailty associated with advanced age? Most people still want to live a bit longer if possible. But most of us become more aware with age that we are working with a truncated timeline and long-term outcomes are no longer relevant. For that and other reasons, many additional considerations start crowding the stage. Some want to be sure that a disabled adult son has assets to live on; others have no dependents. Some want to honor their faith traditions; others want to solidify their departure from those beliefs. The endless variations make it impossible to have one care plan that fits all people.

So why do we now measure quality for frail elderly people as if everyone wanted mainly just to live longer with better health? Often, our metrics just comply with professional (mostly physician) guidelines on how to take care of (somewhat younger) bodies. People become more and more individualized with their particular family, finances, dreams, and fears as they age. We really must learn to measure the quality of health care by the degree to which it serves the individual’s priorities. We must learn to ask, “What matters to you, and what matters most to you?” and to judge quality by how well the services actually deliver on what matters most.

Could we do that? Sure! First, we need to document what matters most to the frail elderly person (and family) and what strategies will most likely accomplish the feat — commonly termed an “assessment and care plan.” Then we need to measure whether the elderly person (and family, as appropriate) feels that the services help to achieve what matters most. We could start with a simple scale: “Working against my interests,” “Not clear or not particularly helpful,” and “Completely or mostly aligned with what matters to me.” We would learn how to do it better, but the important thing is to start caring about what matters to the individual person.

Of course, some things are important to so many people that we might learn to measure them across the frail elder population. Metrics of “what really matters to me” could include, for example, “the rate at which the care system spends down my financial assets,” “the likelihood that I can stay in my home as long as I want to,” “my confidence in having adequate preparation for adverse events and adequate backup for challenges,” and “the stress that my family and friends feel as they try to ensure that I have what I need.” Most people care about avoiding falls and injuries and living where they want to live. While we are at it, let’s start measuring important things about family caregivers: availability, skills, stresses, and challenges. These are what most often really matter when you are living your last years with disabilities and limitations. How different this is from the usual “percentage with diabetes under control” or “percentage with colon cancer screenings”!

Let’s do what we can to help CMS commit to building the metrics that we need. Here are some suggestions:

  1. Contact the organizations to which you belong and encourage them to include advocacy on behalf of quality measures appropriate for frail elderly people in their work with Medicare and Medicaid.
  2. Write to CMS and your congressional representatives to push for metrics that really reflect the concerns of frail elderly people and their families.
  3. If you are funding or doing research in this arena, stretch the scope to include what really matters.
  4. When you look at Nursing Home Compare, Home Health Compare, or any of the quality information for the public sites, send a comment to CMS, your congressional representatives, or your Quality Improvement Network that the metrics are not yet what you hope to see. You can offer some of the ones that I listed above as examples of what we should have.
  5. Some responsive and forceful advocacy for frail elderly people is at Consumer Voice, OWL, and Gray Panthers and caregiver groups. Join them and encourage their work in these arenas.
  6. Write to us with suggestions and plans. The time is upon us! We will watch for CMS requests for information, proposed regulations or conditions of participation, and RFPs. You can also let us know if you see something potentially important going by.

This is important, and an opportunity has opened up that might move us along well.

Want to know more?

“The Impact of IMPACT” by Anne Montgomery

Post-Acute Care Payment Reform Demonstration: Final Report

CARE Instrument

Medicare Payment Advisory Commission (MEDPAC) June 2014 Report to Congress

S&I Framework: LCC Long-Term Post-Acute Care (LTPAC) Transition SWG

S&I Framework: LCC Pilots WG

White House Fact Sheet on Executive Actions to Improve Quality of Care

PDF Download of the full text of HR 4994 (the Act)

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Aug 262014
Portrait of Dr. Joanne Lynn

By Joanne Lynn and Steve Jencks

Work to reduce readmissions has started to yield remarkable improvements in integration of care for frail elderly people – by prompting hospital personnel to talk with community-based service providers, by teaching patients and families how to manage conditions and navigate the health care system more easily, and by paying more attention to trying to fill gaps in the community’s services. But the measure being used to track improvement is seriously misfiring in some settings, and if CMS does not mitigate the adverse impacts, they may become destructive to the momentum and the good that has been done. This is much more than an issue of imperfect risk adjustment or inadequate identification of planned readmissions: it is a punitive error that undermines program goals.

Since CMS mostly aims to assign responsibility for readmissions to the discharging hospital, the key metric has been the risk of readmission for the average person discharged, which is the number of readmissions, divided by the number of live discharges. Any time outcomes are monitored with a ratio, one has to watch out for whether interventions that affect the numerator also affect the denominator. Here, that’s happening enough to completely obliterate the usefulness of the metric – at least in some circumstances.

Here’s a quick hypothetical example: At baseline, a hospital has 1,000 Medicare fee-for-service (FFS) discharges per quarter, with 200 of them back within 30 days. Subsequently, the hospital team and various community-based providers work together and drop the readmissions to 160 per quarter. Does the readmission rate go down to 16% under the metric? No. First, they no longer have the 40 readmissions that are also admissions and in the denominator. But more important – the very things that are reducing the readmission rate also affect the likelihood of coming back in 45 days, or 6 months, or ever! Patients are supported in learning to take care of themselves and to advocate for themselves in the care system, they make good care plans (including advance care plans), and they encounter a more supportive care system in the community. These things are still affecting the patient many months after the hospitalization. Indeed, as the care system learns how to support fragile people in the community better, fewer patients will need to come to the hospital in the first place. The result for our hypothetical hospital is that it ends up with 800 discharges per quarter, and it has not budged its readmission rate! Officially, it has not improved, even though the work done by the hospital, by patients and families, and by community-based providers has improved care substantially, and has saved millions of dollars for Medicare. Yet, using the current flawed metric, the hospital is still likely to be penalized for having a high rate of readmissions!

This is not a new observation. The first sizable pilot project that CMS sponsored involved 14 communities, and the readmissions/discharges metric functioned so poorly that the outcome measure was changed during the project to a population-based measure: readmissions per 1,000 Medicare FFS beneficiaries in the geographic community [See: http://jama.jamanetwork.com/article.aspx?articleid=1558278]. That measure works to track changes in the experience of those living in a community, but it does not help in assigning credit or blame to particular providers (unless there is only one provider in the area). It is intrinsically community-anchored. The rub is that while good care of frail, chronically ill persons is at heart a community endeavor, Medicare has few tools to incentivize or penalize communities.

Furthermore, it is not clear what the “right rate” of readmissions should be. Very little work has been published on how well the various metrics perform in various circumstances, though NQF has a score of new ones under consideration [See: http://www.qualityforum.org/ProjectDescription.aspx?projectID=73619]. The hospital penalty measure has a very complicated risk adjustment, but should the population-based measure also be risk-adjusted (perhaps at least for the population age structure and whether the person is in Medicare due to disability or age)?

The problem here is more urgent than other controversies regarding the Medicare readmission measure such as higher readmission rates in disadvantaged populations and whether communities with low total hospital utilization should be expected to have higher readmission rates. In the case of measuring change, the measurement flaw directly punishes hospitals and communities for doing what the Affordable Care Act and the Medicare Readmissions Reduction Program otherwise encourage them to do: reduce preventable hospitalizations.

What should a responsible system manager like Medicare do? Below are some suggestions.

In the short-term:

  1. Quickly sort out how to exclude certain contexts, perhaps as part of risk adjustment – e.g., whether CMS is authorized to limit application of the readmissions/discharges metric through regulation, or whether the issue has to go back to Congress.
    1. For safety net hospitals – don’t penalize hospitals primarily serving poor beneficiaries.
    2. For reducing admissions – see which of these approaches works best (or combine them)
      1. Hospitals with declining admissions (and the same bed size), when the decline is at roughly the same rate (or more) than declining readmissions
      2. Hospitals with >50% of their Medicare FFS utilization in counties with admission rates in the lowest quartile in the nation
  2. Allow hospitals in a particular geographic area to propose accountability for a population – jointly or singly – so long as they together supply more than, for example, 70% of the hospital use for that population. Then measure their success on a population basis (readmissions/1,000 relevant people living in the area/quarter, and admissions/1,000/quarter)

In the longer-term:

  1. Develop useful metrics for continuity and quality of care, especially for:
    1. Reliability, patient/family sense of trustworthiness/preparation; and
    2. Patient/family driven care plans, evaluated for quality with feedback
  2. Develop useful metrics for the global costs of care, including private and Medicaid costs, for longer terms of illness, not depending upon hospitalization as the trigger, and including long-term services and supports.

What Can You Do Now?

If you agree, let’s talk about how to make improvements to the metric with the National Quality Forum, CMS, hospitals, and other interested organizations and colleagues. Feel free to add comments and suggestions here, too. Let’s build a commitment to evolving toward measures that really reflect optimal care, rather than staying with the under-performing and often misleading ones we have.

Want to know more?

Update as of January 26, 2015: Initial CMS Evaluations of Readmissions Have Serious Flaws

Jencks et al.’s New England Journal of Medicine article on readmission statistics:

The Hospital Readmissions Reduction Program:

The Community-based Care Transitions Program:

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Mar 242014

Two very different programs in Minnesota have been improving care plans for frail elderly clients. Coherent and effective care plans, so essential to good care for frail elders, are simply missing from most clinical practices.

Medicaid recently issued regulations requiring care plans in home-based primary care. Care plans are centrally important in the work of the few geriatric or palliative care teams,  hospice programs, and PACE. But in most care settings, no plan coordinates the half dozen specialist referrals, community-based services, and various care manager and discharge planner assessments. How can we improve that?

Geriatric Services of Minnesota (GSM) has teams of full-time primary care doctors and nurses working to create a safe system of care for frail elders in Minneapolis. They negotiate a written plan with patient and family within 2 months of an elder coming into their care. The plan characterizes the person’s life story, the current situation, and likely future course. It also lists the goals upon which all have agreed, the implications for any acute situation, and the plan for ongoing support. Virtually all patients have a POLST, which summarizes instructions and key decisions for an emergency and identifies the surrogate decision maker. For GSM, the responsible clinician documents the care plan and ensures continuity of care across time and setting by always being available to the on-call physician or nurse practitioner (NP). Dr. Nick Schneeman, the project’s lead physician, says, “Physicians, the NPs, and the entire clinical team are trained to think about and access the patient’s goals of care for every interaction and before any prescriptions, testing or referrals are even contemplated. Sounds simple, and in a way, it is; but it is transformational.”

The LifeCourse project at Allina Health System takes a different path to a similar end. That project builds a deep understanding of the patient’s life story and provides trained lay persons (community health workers known as “Care Guides”) who help inform and guide clients and their families through the experience of living with serious illness and progressive disability. They work with a team that includes nurses, pharmacists, and behavioral therapists. They have contact with the patient’s primary care physician, and, although the team includes a physician, its primary focus is to provide support for physical, emotional, spiritual, and social issues, along with a practical plan for daily needs. LifeCourse has enhanced its EPIC medical records system with a “What Matters Most” feature to record goals as the patient or family member says them. You can learn more about the LifeCourse project at LifeCourseMN.org.

These are two very different approaches, but they share some important strategies.

  1. They ensure that the care team knows enough about the patient and family and the likely future course to help make workable plans that suit the situation and their priorities.
  2. They effectively integrate and implement the plans across time and settings.
  3. They are engaged with their community’s resources and are clever and thoughtful about creating a workable plan.

Of course, they are quite different from one another in emphasizing a physician coordinator or a layperson guide, and it will be very interesting to see how they affect the experience of elders and their families and the costs of care.

Where are the good models for care planning?

Do you know of a program that is doing a good job of care planning for frail elders? Who is working on these issues? What do you think, and what do you see happening? How could we measure the quality of care plans and care planning? What could encourage caregivers to demand good care plans? We are eager to hear from you.

Post a comment below or send email to info@medicaring.org.

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Sep 112013

Greetings; Please join us in this week’s Integrating Care for Populations & Communities Learning Session Webinar on Thursday, September 12, 2013 at 3:00 pm ET. During this session we will hear from the Rhode Island Beacon Community – Beacon Community Program Grantee Learning Objectives Participants will: – Identify how to improve the coordination and cost efficiency of care through use of inpatient and emergency department (ED) alerts. – Learn best practices from a clinical perspective to promote the adoption of admission, discharge, and transfer (ADT) alerts. – Learn how to use health IT to prevent hospitalizations and emergency department (ED) use by using lessons learned found in the “Improve Hospital Transitions and Care Management Using Automated Admission, Discharge and Transfer Alerts” Learning
Guide. Presented by: Gary A. Christensen, Chief Operating Officer and Chief Information Officer, Rhode Island Quality Institute (RIQI) Gary A. Christensen has served as Chief Operating Officer and Chief Information Officer of Rhode Island Quality Institute (RIQI) since 2009. He directs program and Institute operations using best practice disciplines, and drives business goals through health IT innovation. He has nearly two decades of IT and operations leadership experience in domestic and global financial services, during which he served as divisional CIO for businesses at Capital One Financial, Deutsche Bank, and Bankers Trust Company. Mr. Christensen was named one ofInformationWeek Healthcare’s 25 CIOs Transforming HealthCare in May 2012. He earned both a bachelor’s and master’s degree from Stanford University.

Jonathan Leviss, MD, Chief Medical Officer, Rhode Island Quality Institute (RIQI) Jonathan Leviss, MD, is the Chief Medical Officer for the Rhode Island Quality Institute (RIQI). Dr. Leviss provides strategic leadership across RIQIs initiatives to transform quality and efficiency of health care in Rhode Island, including the RI Beacon Communities Program and the Health Information Exchange. Prior to joining RIQI, Dr. Leviss led HIT initiatives at large and small health systems in the US and internationally. He was the Vice President, Chief Medical Officer, at Sentillion, the market leading health care identity and access management vendor acquired by Microsoft in 2010 and then served as Director of Clinical Solutions at Microsoft Health Solutions Group. Dr. Leviss was the first CMIO at the NYC Health and Hospitals Corp., consulted at Cerner and Deloitte, and was faculty at NYU and Columbia University. Dr. Leviss has chaired and served on several RI state-wide committees on HIT and was a founding board member of Medical Informatics NY. He regularly writes and presents on health information technology, health care, and physician leadership, and was the editor of HIT or Miss: lessons learned from health information technology implementations. Dr. Leviss is an internist at the Thundermist Health Center, RI. Dr. Leviss received his BA in international relations from Tufts University and MD from NYU School of Medicine. Event: Care Transitions Learning Session webinar Date: September 12, 2013
Time: 3:00 PM – 4:00 PM ET Teleconference: 866-639-0744 (No pass code needed) https://qualitynet.webex.com Meeting Password: community Please join us 15 minutes prior to the presentation to ensure the automatic system set-up has been properly established.

Attendee Instructions:

1) Click or Copy and Paste this to your web browser: https://qualitynet.webex.com 2) Locate the event you wish to join
3) Click on Join Now (located to the right of the event title)
4) Enter your name and email address as prompted
5) Enter the password: community
6) Dial in to the teleconference. The number is 866-639-0744 or 678-302-3564. The access code is none.

If you have any questions or problems accessing the meeting, please call the Buccaneer WebEx Helpline at 540-347-7400 x390

Presentation slides will be posted prior to the call at http://www.cfmc.org/integratingcare/learning_sessions.htm .

These sessions will be held on the 2nd and 4th Thursdays of the month and are open to all, please invite anyone who wants to learn along with us. As a reminder, these sessions are recorded and all previous Learning Sessions are available at: http://www.cfmc.org/integratingcare/learning_sessions.htm If you are not already receiving notifications about our upcoming Learning Sessions, you may register or update your subscription preferences at http://eepurl.com/jOFqb .


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Aug 072013

As part of its ongoing series on reducing readmissions, the Integrating Care for Communities project from the Colorado Foundation for Medical Care, hosts a webinar on Thursday, August 8, at 3 ET. Details about the program can be found here, with information provided by CFMC.

During this session we will hear from ARC – Avoiding Readmissions through Collaboration, California – Community-Based Care Transitions Program (CCTP) Awardee

Learning Objectives 
Participants will:
– Identify the structure and tactics used by the collaborative to drive readmission reduction in participating hospitals
– Trace the collaborative’s efforts to develop a Patient Advisory Council
– Examine how to develop and deploy a successful relationship between a hospital and their SNFs to optimize care transitions

Presented by: 

Cheryl Reinking, RN, MS, Interim Chief Nursing Officer, El Camino Hospital 

Cheryl Reinking, RN, MS has served 25 years at El Camino Hospital in progressive nursing leadership roles, her most recent being as Interim Chief Nursing Officer which she assumed in July 2013. Cheryl has led a number of hospital-wide initiatives and was key to the hospital’s implementation of the nationally recognized Nurses Improving Care for Healthsystem Elders (NICHE) program, which was designed to create increased patient-centric care for hospitalized older patients. She developed the hospital’s site-specific program.

Pat Teske, RN, MHA, Cynosure Health 
Pat Teske, RN, MHA is the implementation officer for Cynosure Health. In her role she strives to implement the company’s vision through strategic planning and execution of projects on time and within budget that yield successful outcomes. Previously she held the position of vice president of Quality Improvement and Care Management for Catholic Healthcare West, Pasadena, CA where she lead the regions: chief nursing officers, quality directors, case managers and medical staff directors to accomplish their annual goals. As an independent contractor Pat supported BEACON, the Bay Area Patient Safety Collaborative, as well as other state and local collaboratives.  She is currently leading the Avoid Readmissions through Collaboration (ARC) effort in CA and working nationally with HRET on the Partnership for Patients HEN. A requested public speaker at national, state and local conferences, including; IHI, NPSF and TJC Ms. Teske has developed and offered numerous educational programs designed to support performance improvement and system reliability. Pat received her MHA from the University of LaVern and her BS in Nursing from the University of Virginia.

Lisa Ehle, MPH, Program Manager, Cynosure Health 
Lisa Ehle, MPH is a Program Manager at Cynosure Health and currently oversees the Avoid Readmissions Through Collaboration (ARC) program and the ARC Patient Advisory Council. Before joining Cynosure Health, Lisa served as the State Director of Program Services with the March of Dimes Massachusetts Chapter where she co-founded the MA Perinatal Quality Collaborative and directed a Program Services Committee charged with addressing the perinatal needs of the state.  She has been an advocate for maternal and child health issues including preterm birth prevention, routine HIV screening, smoking cessation, and improving hospital discharge practices.  Lisa has worked at the state level for the MA Department for Public Health creating policies and guidelines for infectious disease prevention and screening programs. Lisa received her Bachelor of Science in Physical and Psychiatric Rehabilitation Counseling from Boston University, Sargent College and a Masters of Public Health from Boston University School of Public Health specializing in Social and Behavioral Sciences.

Event: Care Transitions Learning Session webinar
Date:  August 8, 2013
Time:  3:00 PM – 4:00 PM ET

Teleconference: 866-639-0744  (No pass code needed)
Meeting Password: community

Please join us 15 minutes prior to the presentation to ensure the automatic system set-up has been properly established.

Attendee Instructions:

1) Click or Copy and Paste this to your web browser:  https://qualitynet.webex.com
2) Locate the event you wish to join
3) Click on Join Now (located to the right of the event title)
4) Enter your name and email address as prompted
5) Enter the password: community
6) Dial in to the teleconference. The number is 866-639-0744 or 678-302-3564. The access code is none.

If you have any questions or problems accessing the meeting, please call the Buccaneer WebEx Helpline at 540-347-7400 x390

Presentation slides will be posted prior to the call at http://www.cfmc.org/integratingcare/learning_sessions.htm .

key words:  readmissions, rehospitalizations, care transitions, quality improvement organizations, CMS, CFMC

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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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