Care Transitions » MediCaring.org

Shining Stars Program Thursday, May 23

Posted by Janice Lynch Schuster on May 21, 2013 No Responses » Tagged with: care transitions, CFMC, quality improvement, shining stars

May 212013

From the Colorado Foundation for Medical Care:

Please join us in this week’s Integrating Care for Populations & Communities
Learning Session Webinar on Thursday, May 23, 2013 at 3:00 pm ET.

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

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

These sessions will be held on the 2nd and 4th Thursdays of the month. We have
a schedule of these presentations posted at: http://www.cfmc.org/integratingcare/learning_sessions.htm

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Call Information

Shining Stars: Rio Arriba County Community – New Mexico- A Quality Improvement
Organization Community

Presented by:

Lauren Reichelt, MA, Director of Health and Human Services, Rio Arriba County

Event:
Care Transitions Learning Session webinar

Date: May 23, 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 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:

http://www.cfmc.org/integratingcare/learning_sessions.htm

ONC Backs $40K App Challenge for Improving Cancer Care Transitions

Posted by Janice Lynch Schuster on May 21, 2013 No Responses » Tagged with: apps, care transitions, challenge, HIT, ONC

May 212013

by Stephanie Baum

The National Cancer Institute and the Office of National Coordinator for Health IT are throwing down $40,000 in an innovation challenge to encourage app developers to step and brainstorm ideas to improve cancer care, particularly improving transitional and follow-up care after cancer treatment, according to a statement on the ONC’s website.

The “Crowds Care for Cancer: Supporting Survivors Challenge” contest includes two parts. First, there’s the initial application in which participants submit wire frames to show a skeletal blueprint for the tool and documentation that describes how their tool or app is supposed to work and layout the plan to develop it. Up to three will be picked from this first phase and awarded $5,000. They’ll get feedback and support to improve their apps and will get promoted on Medstartr’s crowdfunding portal in the run-up to the second part of the contest.

In the second part, the competitors are judged and the winner gets $25,000.

Here are some of the areas the challenge seeks to address, according to the ONC’s website:

Optimizing patient-provider communication and customizing management of survivor care.
Follow-up care needs like medication tracking and adherence, health promotion, appointment and symptom tracking.
Improving communication across survivor care networks using tools to improve health data and interoperability standards such as Blue Button+.

Submissions will also be assessed on their ability to adapt to the evolving care needs of survivors, including the potential for integration with electronic care platforms and between family, friends and healthcare providers.

The deadline for the competition is May 28 at 11:59 pm Pacific time. To apply, click this link. The winners will be announced over the summer.

This article is used with permission from www.medcitynews.com, where it originally ran on May 15, 2013.

A Shift Happens: Care Transitions Lessons from San Diego County

Posted by Janice Lynch Schuster on May 8, 2013 1 Response » Tagged with: care transitions, CCTP, CMS, frail elders, readmissions, San Diego County

May 082013

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

By Carol Castillon

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

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

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

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

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

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

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

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

Southeast Michigan CCTP Tests New Approaches to Reduce Readmissions

Posted by Janice Lynch Schuster on April 23, 2013 No Responses » Tagged with: care transitions, CCTP, coalition building, Coleman Model, community-based, discharge planning, eldercare, hospital readmissions, Naylor Model, rehospitalization

Apr 232013

by Benjamin Kuder

Every Community-based Care Transitions Program (CCTP) in the country (of which there are now 102, funded by the U.S. Centers for Medicare and Medicaid [CMS]) aims to balance targeted, evidence-based interventions to patient needs. CCTP teams know that every avoidable readmission has a story behind it. The Area Agency on Aging 1-B (AAA 1-B), seeks to meet care transitions needs for elders in two of their counties, Oakland and Macomb, with an innovative multilayer strategy.

CMS directed communities applying to participate in the CCTP to conduct a root-cause analysis, so that they could build a CCTP that meets community needs. The AAA 1-B found that it could deliver the highest priority services by dividing the population based on five clinical needs:

1.Care Transitions Intervention (CTI) Coaching: Following the self-activation model developed by Dr. Eric Coleman, this strategy empowers participants with coaching that helps them find the strategies that enable the patient to take charge of recovery and achieve personal goals. Through increased health literacy and greater confidence, individuals with chronic conditions are better able to make decisions about their care and recovery, and insist that clinicians provide appropriate help.

2.CTI Coaching with Behavioral Intervention: Many patients experience mental health issues such as depression, anxiety, and serious mental illnesses, which contribute to frequent readmissions. In this strategy, a behavioral health coach works with patients to provide support and mitigate some of the problems that can hinder recovery.

3.CTI Coaching with In-Home Services: This strategy provides coaching and referrals to in-home services, such as meal delivery or transportation to the doctor, which help reduce risk of readmission.

4.Coaching with Multiple Interventions & Hospice: Coaches connect with patients who have little family support and who do not want home care or hospice, and try to reconnect them with supportive services and initiate longer-term care planning.

5.Skilled Nursing Facility (SNF) Transitions Coaching: Skilled nursing facilities in the area had especially high readmission rates, so this strategy provides coaching for better transitions from the hospital to the SNF and from SNF to home. Coaches meet with participants and their caregivers before hospital discharge, again shortly after nursing home admission, and then shortly before discharge from the SNF. In addition, the coach also discusses differences between the nursing home and hospital, how to pursue personal goals, and how to find help to achieve these goals at the nursing home. The coach also works with the participant and caregiver to complete the personal health record modified for the SNF and encourages them to participate in the care plan meeting. The coach also engages hospital and nursing facility partners to increase communication and improve shared processes.

Tailoring these strategies to the five distinctive categories of patients allows AAA 1-B to provide high-value transitions coaching to virtually everyone. “Many of the coaches say people have been dealing with chronic conditions so long and no one has asked them their opinion on their plan of care,” says Barbra Link, director of care transitions for AAA 1-B, “Coaches help them to get tools to self-activate. That’s the most powerful thing. That’s the foundation of the program.”

Participants in the program must be referred from AAA 1-B’s partner hospitals, have traditional Medicare, and either have one of the targeted conditions (chronic obstructive pulmonary disease, heart attack, pneumonia, or congestive heart failure) or, any condition with a readmission within the last 90 days.

The AAA 1-B Care Transitions Coach assigns each beneficiary to a category using a risk assessment completed by the hospital’s care management team. The program also allows Strategy #1 Coaches to refer the participant to a Specialty Coach (Strategy 2, Strategy 4, and Strategy 5) when appropriate. All coaches provide Strategy 1 and Strategy 3 Coaching but may consult with Specialty Coaches whenever needed.

The AAA 1-B project is about 10 months into its initial two years, with the possibility of renewal for the following three years. All five strategies are operating, and 650 beneficiaries have enrolled. Although the first strategy has the highest volume of people (67 percent), the other strategies are proving to be just as important for elders who need more support.

The CCTP team quickly recognized that project leaders and staff must watch for problems that call for different remedies. For example, when AAA 1-B leaders observed that many of the program’s vulnerable elders did not understand their nutrition needs, they reached out to a nutritionist at a partner hospital to develop simple, accessible, one-page flyers for patients regarding nutrition. One flyer explained how to cut back on dietary sodium and how to calculate sodium intake from a nutrition facts label. Through close interactions with the patients, coaches were able to identify and respond to specific nutritional problems that would not have otherwise been apparent.

In its CCTP, AAA 1-B has a coalition with three local hospitals that had some of the highest readmissions rates in the state. Creating these coalitions, while ultimately quite beneficial, did present some initial challenges. Before implementing the program, AAA 1-B leaders had to help all stakeholders understand the benefits of the program. Once this had been done, referrals from the hospitals took a major upswing.

According to Barbra Link, “We found that each hospital is unique, and lots of relationship-building was required. Once we established greater trust and better understood the system, things seemed to go well.” The future of this program involves moving toward a larger community-based coalition with more community organizations. Link explains, “We are trying to move into becoming a learning network. Our focus will be information exchange and growing as a coalition. Now that the program is up and running, we can work on this over the next year.”

AAA 1-B also collaborates with other CCTP organizations nationwide. Through regional and national phone calls and virtual learning sessions, they share best practices and solve problems together. In this way, AAA 1-B is spreading its innovative multilayer approach to reducing hospital readmissions and empowering patients.

This article originally ran on the Altarum Institute Health Policy Forum on April 18, 2013.

key words: care transitions, CCTP, community-based, Area Agency on Aging

Care Transitions 101: Dr. Joanne Lynn on the Basics

Posted by Janice Lynch Schuster on April 15, 2013 No Responses » Tagged with: care transitions, Illuminage, Joanne Lynn, NCOA, quality improvement, webinar

Apr 152013

Dr. Joanne Lynn recently led a webinar focused on care transitions: what they are, why they matter, and how to improve them. The session, sponosred by Illuminage and the National Council on Aging, streamed live on April 4. The recording is now streaming online, and can be viewed here:

http://illuminage.com/webinars/improving-care-transitions.htm

In addition to Dr. Lynn’s ideas and insights, the session featured a Q&A segment. Take a few minutes and see what you can learn!

Hear Dr. Joanne Lynn Discuss Care Transitions

Posted by Janice Lynch Schuster on April 2, 2013 No Responses » Tagged with: care transitions, CCTP, coalition building, discharge planning, eldercare, frail elders, hospital readmissions, Medicare, patient activation, rehospitalization

Apr 022013

A Thursday webinar cosponsored by Illuminage.com will feature Dr. Joanne Lynn discussing care transitions. Each year, thousands of older patients are discharged from the hospital, only to be later re-admitted. Avoiding preventable rehospitalizations has become a major cost-savings goal for our health care system. IlluminAge, in partnership with the National Council on Aging, has scheduled an online briefing to examine how older patients can play a larger role in the effort to reduce the frequency of hospital readmissions.

You are invited to join the webinar on Thursday, April 4, beginning at 1:30 p.m. Eastern time: Improving Care Transitions: Engaging Older Patients on the Issue of Preventing Rehospitalization.

Joining us as presenter will be Joanne Lynn, M.D., chair of the Center on Elder Care and Advanced Illness at the Altarum Institute. Dr. Lynn, a geriatrician, quality improvement advisor, and policy advocate, is a member of the Institute of Medicine and the National Academy of Social Insurance, a fellow of the American Geriatrics Society and The Hastings Center, and a master of the American College of Physicians.

The webinar aims to provide a fresh perspective on the increasingly important challenge of reducing hospital re-admissions, including:

The importance of educating and empowering older patients and caregivers;
The role senior care and aging service professionals can play in providing needed support services and other resources to older persons returning home following a hospital stay;
Resources you may find helpful in your own community, practice, or organization.

The April 4 webinar is free, with registration on a first come, first served basis.

To register, follow this link: https://www1.gotomeeting.com/register/581843281

Key words: Joanne Lynn, care transitions, quality improvement, patient activation

Medicaring Imperative: A Week of Sharing Our Ideas for Reshaping Care

Posted by Janice Lynch Schuster on March 31, 2013 No Responses » Tagged with: Caregiver Corps, disruptive women in health care, Janice Lynch Schuster, Joanne Lynn, Medicaring, minimally disruptive medicine

Mar 312013

In what proved to be a remarkably busy week for Medicaring/Altarum staff, we have been involved in or led a range of activities aimed at improving care for frail elders. Among these activities are:

Dr. Joanne Lynn’s keynote speech to AMDA (American Medical Directors Association), the professional association of medical directors, attending physicians, and others practicing in the long term care continuum. Dr. Lynn addressed attendees at the AMDA annual meeting, and introduced them to the framework of the Medicaring: care plans, balancing of medical care and social services, recognizing and responding to a period of frailty, coordinating community-based programs, and establishing local authority for resource management. Visit the Health Policy Forum to read more about her ideas and recommendations. http://www.altarum.org/research-initiatives-health-systems-health-care/altarum-center-for-elder-care/recent-blogs

Later in the week, she spoke to attendees at a session sponsored by the National Health Policy Forum, introducing them to the framework of care for frail elders. Background information can be found here. http://www.nhpf.org/library/details.cfm/2920

Senior Writer Janice Lynch Schuster had an exciting and meaningful week full of publications, which began on Sunday with a light-hearted essay in The Washington Post, describing the challenges she faces in the kitchen. If you need a chuckle, here’s the link: http://articles.washingtonpost.com/2013-03-22/opinions/37933738_1_industrial-arts-home-ec-beet

On a more serious note, she anchored The Sunday Dialogue feature of the New York Times, which published her letter to the editor which discussed legal aid in dying in the context of what life looks like for frail elders, and how we can improve care and quality. The article ran in print on Wednesday and triggered a tremendous response; our editor reported receiving more than 200 letters that day. A handful of letters and Janice’s reply to them can be found here: http://www.nytimes.com/2013/03/31/opinion/sunday/sunday-dialogue-choosing-how-we-die.html?pagewanted=all

Finally, a flash of inspiration (and an image of her aged grandmother, who lives far away, in Alaska), prompted Janice to launch a petition on the We the People site of the White House. That petition aims to get 100K signatures by April 5–as of Easter Sunday morning, it has a little over 1400. Response mounted thanks to an excellent by Paula Span of the New Old age, which you can read here:

http://newoldage.blogs.nytimes.com/2013/03/28/a-volunteer-army-of-caregivers/

To see what Janice herself says of the idea, you can choose from a number of blogs, including the excellent Minimally Disruptive Medicine blog. Disruptive Women, another favorite, posted a story, as did The Health Care Blog (THCB).

A quick google search will take you to the links. We’d love to hear your comments and ideas. Both are important to us as we shape our agenda, and pursue our goals.

Join Dr. Joanne Lynn for April 4 Webinar on Care Transitions

Posted by Janice Lynch Schuster on March 25, 2013 No Responses » Tagged with: care transitions, Dr. Joanne Lynn, frail elders, quality improvement, readmissions

Mar 252013

Mark your calendar for an April 4 webinar, sponsored by Illuminage and the National Council on Aging, which will feature Dr. Joanne Lynn, an expert on improving care transitions–and on creating better strategies and policies to meet the needs of frail elders, their loved ones, and their communities. Online registrations are now underway, and several hundred people have already joined in. Add your name to the list by completing the registration form at the following link:

https://www1.gotomeeting.com/register/581843281

Dr. Lynn directs the Center for Elder Care and Advanced Illness (CECAI) at Altarum Institute, and for more than 20 years, has been a national leader in quality improvement, aging services, advanced illness, and end of life care. The program is cosponsored by Illuminage Communications (http://www.illuminage.com) and the National Council on Aging (http://www.ncoa.org). Illuminage is a leader in health communications services for organizations and providers that serve older adults and their families. NCOA is a nonprofit service and advocacy organization based in Washington, DC. It aims to improve the lives of millions of older adults, especially those who are vulnerable and disadvantaged. NCOA brings together nonprofit organizations, businesses, and government to develop creative solutions that improve the lives of all older adults. NCOA works with thousands of organizations across the country to help seniors find jobs and benefits, improve their health, live independently, and remain active in their communities.

The hour-long session will be informative and engaging, and we invite Medicaring readers to join us online, 1:30-2:30 PM, EDT, on April 4, 2013.

key words: Dr. Joanne Lynn, care transitions, reducing readmissions, webinar, Illuminage, NCOA

Readmissions, frail elders, communities: So much to learn and know

Posted by Janice Lynch Schuster on March 5, 2013 No Responses » Tagged with: best practices, coalition building, community-based, frail elders, hospital readmissions, quality improvement

Mar 052013

Key opportunity to learn from Dr. Joanne Lynn, who will lead the faculty for a new session from the Institute for Health Care Improvement, a seminar on building systems that work for frail elders. Program in Colorado later this month, and more details here:

http://www.ihi.org/offerings/Training/FrailOlderAdults/FrailOlderAdultsMarch2013/Pages/default.aspx?utm_source=blast&utm_medium=email&utm_campaign=fraileldersb1

So many articles come across our screen, and we often link via Twitter @medicaring. In the meantime, here’s a link to an important study:

First, a link to an article from Population Health (thanks to the Commonwealth Fund for the link). So much to understand about how to get communities to work together to improve care transitions and reduce readmissions. Our JAMA work (read more at www.altarum.org/qiopaper) offers insights on building coalitions. Learn more here about the STAAR project:

http://www.commonwealthfund.org/Publications/In-the-Literature/2013/Feb/Turning-

Readmission-Reduction-Policies-into-Results.aspx?omnicid=20

As ever, we like to hear from our readers, who often give insights, leads, and stories we would not otherwise find. Be sure to comment. And like us on Facebook, follow us on Twitter, and share your own successes, challenges, and stories.

key words: frail elders, readmissions, IHI, Commonwealth Fund, Joanne Lynn, STAAR

QIO Care Transitions in JAMA

Posted by Les Morgan on February 25, 2013 No Responses » Tagged with: care transitions, quality improvement, video

Feb 252013

Here is a video covering CMS’s QIO Projects to improve care transitions in fourteen communities. The study described reports on findings published in the January 23, 2013, issue of JAMA. This video is part of of Altarum Institute’s YouTube series.

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