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?

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 [email protected].

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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
San Diego Logo

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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Jun 252013

Integrating Care for Populations & Communities hosts a Learning Session Webinar on Thursday, June 27, 2013 at 3:00 pm ET.

This webinar is the twelfth presentation in the Learning Session series: Shining Stars Across the Nation

During the series entitled, “Shining Stars Across the Nation”—we hear from local communities that have been successful in improving healthcare through reducing hospital readmissions. The webinars feature communities from different initiatives— those communities that are lead by CMS’ Quality Improvement Organizations (QIOs,) those that are part of Aligning Forces For Quality, those that have received state funding, Robert Wood Johnson awardees, CCTP awardees, Beacon communities, ACOs and more.

These sessions are held on the 2nd and 4th Thursdays of the month.  The complete schedule is posted at: http://www.cfmc.org/integratingcare/learning_sessions.htm
Call Information

Shining Stars: Banner Health in Phoenix, AZ – An Accountable Care Organization
Presented by:
Linda Stutz, RN, MBA, Care Coordination Senior Director, Banner Health
Tricia Nguyen, MD, MBA, Chief Medical Officer, Banner Health 

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

Please join 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 calls 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:


If you are not already receiving notifications about upcoming Learning Sessions, you may register or update your subscription preferences at http://eepurl.com/jOFqb .

key words: Integrating Care, Shining Stars, Care Transitions, Banner Health, webinar, learning session

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Jun 212013
San Diego Logo

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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May 292013
San Diego Logo

By Deborah Marquette

It was the classic conundrum: how do you fit a square peg into a round hole?

The County of San Diego is widely known for doing things a little differently, and our model for providing community-based care transitions project (CCTP) services is no different.  The San Diego Care Transitions Partnership (SDCTP) CCTP model includes the Care Transitions Intervention (CTI).  However, in addition to CTI, the SDCTP model includes a variety of interventions that are completed prior to discharge (e.g. High-Risk Health Care Coach, Inpatient Navigator, Bridges, and Pharmacy).  The model also includes additional post-discharge interventions, such as CTI Care Enhancement and non-CTI follow-up phone calls.

These additional interventions posed our first challenge for invoicing.  We quickly realized that the List Bill design (CMS’ method for billing Medicare for CCTP) wouldn’t meet our internal needs for gathering, monitoring, and tracking invoice and intervention data.  For some of our interventions, there is no clear mapping between our intervention and the List Bill’s Care Transition Services.  For others, the List Bill was too ambiguous.  For example: if we select “Telephone follow-up…” as the Patient Encounter, how will we know whether that patient received CTI or our non-CTI follow-up phone call intervention?  Hmm…thoughtful pause…we needed to find a way to meet the List Bill requirements, while capturing the data in a way that would be meaningful for us as well.  That’s how our Manual Invoicing Process was born.

I’ll be completely honest – this invoicing baby is less than attractive.  Alright, it’s downright ugly!  Picture this, an Excel worksheet 41 columns long.  With no margins, and at a scale of 75%, the worksheet still prints out on six (6) legal-size pages.  And that’s just to capture the data we need for managing and tracking our List Bills!  It doesn’t include the additional 32 columns that we use for capturing other data elements such as “Reason for Non-Enrollment” or “Reason for Withdrawal.”  Now, factor in the fact that at full-capacity we’ll be maintaining these data for 13 hospitals and roughly 21,000 patients/year.  What fun the manual process will be then!  Like I said, it isn’t pretty.  But, it does work, and it seems to work well.  We may even be sad to see the manual process go (not likely) when it’s replaced by our web-based invoicing and data collection system, ALEX.  I’ll share more about ALEX in a later post.

The format of the List Bill led to our second invoicing challenge.  Considering our size, there’s no way we can manage all of our List Bills by entering them one-by-one using the List Bill template.  Aside from increasing the risk for data entry errors, entering all of the List Bills manually would be a more-than-full-time  job for several people.  Since that isn’t an option, it was back to the drawing board.  Here we had some help.  Reaching out to our Project Officer and other CCTP sites, we asked if anyone had successfully submitted a List Bill in a format other than the List Bill template.  Our call was answered by the Southwestern Ohio CCTP!  They had figured out the Excel formulas needed to convert data into the format(s) that would meet Gentran’s requirements.  (Gentran is the online application for submitting List Bills to CMS.) With a little tweaking, we’ve tailored those formulas, and added a few of our own, to convert the information collected on our Manual Invoicing worksheet.  With just a little copy-and-paste action of data and formulas, we’re now able to create a List Bill for all of our patients in 10-15 minutes.  It doesn’t matter if we have 1 or 1,000, the timeframe is the same.  Around here, we call that a success!

Ms. Marquette is the Principal Administrative Analyst for the San Diego Care Transitions Partnership. This is part of our regular series on San Diego’s experiences launching its CCTP work.

Key words: CCTP, CMS, Medicare, care transitions, quality improvement, hospital readmissions, frail elders, San Diego County

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May 232013
Anne Montgomery

By Anne Montgomery

Leaning into the podium at the Graduate Center of the City University of New York on May 14, Judy Feder, professor of public policy at Georgetown University, is poised and intent.  She is speaking to a room full of researchers, advocates and academics who are hoping to ignite a national conversation about why now is the right moment for family caregivers to underscore their importance to the U.S. health and long-term care system.

But first, Feder administers a reality check: Despite ”overwhelming evidence” that caregivers are “the essential glue” in our health care system, they are often met with “disregard” or “disrespect” by large institutions and individual practitioners, she said.  Moreover, the very fact that family caregivers are the “dominant source” of help for 80% of ill, frail and disabled individuals living at home and in the community contributes to concerns about so-called “crowd-out” costs: The “fear of replacing” unpaid family caregiver labor, she said, has led policymakers and providers to count on their support as a “fiscal convenience.”

A classic example of this overreliance on family caregivers, according to Feder, is the massive (though rarely discussed) shift of responsibility that occurred following implementation of Medicare’s prospective payment system (PPS) for hospitals during the 1980’s.  As hospitals realized that it was in their financial interest to discharge patients more rapidly (often referred to as “quicker and sicker”) under a PPS system, the result for family caregivers was that they were asked to take on much more – often without any discussion, and with no preparatory training or sustained support. “All of this happened with no thought,” Feder said.

Concurrently, a growing body of evidence — including a recent survey conducted by AARP and United Hospital Fund (UHF) – has established that family caregivers are routinely undertaking ever-more complex medical and nursing tasks.  For example, it is now common for caregivers to be expected to assist with ostomy and wound care, administration of intravenous fluids and injections, preparation of foods for individuals on special diets who have trouble chewing or swallowing, and management of ventilators and tube feeding systems.  The net outcome, Feder observed, is that family caregivers find themselves under increasing pressure to “turn their homes into hospitals.” Changing this dynamic, she added, will require serious work.  In a call to action, Feder declared: “The support of caregivers should not be merely “assumed,” but rather it must be “thoughtfully considered….We need to turn this around and get past the lip service.”

Others at the UHF conference, titled “Transitions in Care 2.0,” (which culminated in the release of a ten-step action agenda) were in full agreement.  Susan Reinhard, Senior Vice President of AARP’s Public Policy Institute, observed that the recent AARP-UHF survey documents that more than two-thirds of respondents report significant difficulty with certain tasks — notably wound care, assisting with the use of incontinence equipment and preparation of special diets.  Helping a family member or friend cope with a colostomy is not a traditional ADL,” [Activity of Daily Living] Reinhard said.  The ADL assessment instrument, which focuses on basic, non-medical assistance with eating, dressing, toileting, bathing and transferring, was originally developed in the 1950’s as a way of measuring the help that patients recovering from hip fractures needed.

Mary Naylor, a professor and researcher at the University of Pennsylvania School of Nursing, argued that in the era of the “age wave,” providers should reframe their professional perspective to see themselves in part as “enablers of patients and family caregivers.”  Both Eric Coleman, professor of medicine at the University of Colorado and Luke Hansen, professor of medicine at Chicago’s Northwestern University, noted that it is still uncommon for physicians and hospitals to collect any data on family caregivers — and even rarer to train them. This presents problems, they acknowledged, in making various improvements in the care system “stick.”  Feminist author and caregiver Alix Shulman suggested that it is precisely the lack of “anticipatory guidance,” or training, which individuals who choose to make major changes to their lives in order to assist a seriously ill or disabled loved one find most difficult of all. “Specific conversations are needed,” she said. “Not just a list of websites or a stack of brochures.”

UHF’s David Gould and Carol Levine urged researchers and policymakers to join together to support caregiver assessments that include documentation of both the needs and limitations of caregivers as part of the routine delivery of health and long-term care services. Also needed, they said, are regular surveys of both the patient and the family caregiver’s experience with services, as well as a more sophisticated and systematic approach to identifying the networks of family, friends and neighbors who come together to form a “caregiver corps,” or circle of support, that can be assembled to collectively provide the right level of help at the right time.

Making the necessary adaptations to our rapidly evolving health and long-term care services systems in order to cost-effectively train large numbers of people who may be willing to volunteer some of their time to assist those who wish to age in place is not a simple matter.  Perhaps one way to move a conversation forward is to consider whether the Center for Elder Care and Advanced Illness concept of a Caregiver Corps of trained volunteers can be created to help teams of health care practitioners and direct care workers deliver a more seamless array of services and supports – while also giving families the confidence that they will be able to sustain assistance for the millions of frail elders and individuals with disabilities who want to remain a vital part of the community right up until the ends of their lives. Such a Corps, which would recruit volunteers young and old, would be a step toward addressing workforce shortage issues, and might give communities ideas and strategies they can adapt to solve pressing concerns. Now is the right time for family caregivers and their many allies to work together to think through the possibilities.




Key words:  United Hospital Fund, care transitions, family caregivers, Caregiver Corps, Mary Naylor, Eric Coleman

















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