A Shift Happens: Care Transitions Lessons from San Diego County

 Posted by on May 8, 2013  1 Response »  Tagged with: , , , , ,
May 082013
 
San Diego Logo

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

Learn from Successful Outliers – or Shut them Down?

 Posted by on May 2, 2013  No Responses »  Tagged with: , , , , ,
May 022013
 
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Last Sunday’s Washington Post (April 28) featured a long, thoughtful article by Ezra Klein describing an effective house visits program, Health Quality Partners, that is about to lose its CMS funding. The article, “If This Was a Pill, You’d Do Anything to Get It,” (http://www.washingtonpost.com/blogs/wonkblog/wp/2013/04/28/if-this-was-a-pill-youd-do-anything-to-get-it/) generated several hundred comments and lots of social media activity.

Klein describes CMS’ plan to end funding for a home health visit program developed by Pennsylvania’s Health Quality Partners. First developed as part of a demonstration created in the wake of the 1997 Balanced Budget Act, this little program has achieved great successes. An independent evaluation found that Partners, one of 15 in that demonstration project, reduced hospitalizations by one-third, and cut Medicare costs by one-fifth.

Despite that track record, CMS has notified Health Quality Partners that CMS funding will end in June. Over the years, it seems, CMS has learned something from the ongoing demonstration—but its attention has now turned to other projects, ones that it hopes will prove to be scalable, and in which it will invest tens of millions of dollars via the Center for Medicare and Medicaid Innovation (CMMI).

This seems—to Klein, to me, and to many people who commented on the article—a little counter-intuitive: If a new treatment or procedure had led to this kind of result, investors and patients would line up to support it and demand it.  But CMS appears to be stymied by good reports from one particular community about its own particular situation. To be sure, learning from the one gem in a demonstration program with more than a dozen that did not make the grade is difficult, perhaps more difficult to pull off than interpreting a clinical trial or testing an investigational new drug.

There are risks, to be sure, in assuming that what works in Doylestown, PA,  will be equally effective in St. Louis, Missouri, or in thinking that the concerns and solutions experienced in one community can be addressed by solutions devised by another. Communities are so varied in how they operate, and no one solution is likely to work for each.

Even so, many communities find that their frailest residents benefit from the kind of one-on-one attention to care that house calls can provide.  Each clinical service program must address real risks to effectiveness and efficiency—here, an obvious issue is how to target people for whom such a service is a necessity, one that helps them to remain independent and out of the hospital, rather than those for whom it would mostly be a convenience?  Also, how can incentives be structured so that profits are not a chief motivating factor—and so that costs are contained while care and outcomes improve? These issues require ongoing attention—from communities, from the health care industry, and from CMS, as they work to reshape  the health care industry to a framework that includes better care and services for the oldest among us.

As the country’s leaders and policymakers increasingly turn attention to the looming challenges created by aging Boomers, many look to individual communities and their successes.  In fact, it is likely that the solutions we need—and find—will hinge on what different communities are allowed to assemble: What each identifies as priorities, how each allocates resources, and where each turns its energies. Learning how other communities succeed at this hard work will be critical for others testing for inspiration and ideas. Dismantling a successful program—without even testing whether its principles can be adopted elsewhere or it can grow to scale–hardly seems to make sense.  Continuing to learn from it, and deliberately adapting it in ways that work elsewhere, seems to be a more responsible response. Throughout our history, we’ve turned to outliers to point the way—and inspire—others along the journey.

 

key words: home health care, house calls, CMS, coordinated care, frail elders

Shining Stars Webinar Highlights Care Transitions Work

 Posted by on April 24, 2013  No Responses »  Tagged with: , , , , , , , ,
Apr 242013
 
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Focused on improving care transitions? A bimonthly webinar series called “Shining Stars” gives you a chance to hear from others working on the ground to do just the same. Sponsored by The Colorado Foundation for Medical Care,  the next Integrating Care for Populations & Communities Learning Session Webinar will air on Thursday, April 25, 2013 at 3:00 pm ET.

Participants have an opportunity to hear from local communities that have been successful in improving healthcare through reducing hospital readmissions. The webinars feature communities from different initiatives— those that are led by Quality Improvement Organizations (QIOs), as well as those that are part of Aligning Forces For Quality, that have received state funding, Robert Woods Johnson awardees, CCTP awardees, Beacon communities, ACOs and more.

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

If you are interested in participating, follow the steps below.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Call Information

Shining Stars: Healthy Columbia Campaign – South Carolina – ReThink Health Community funded by the Fannie E. Ripple Foundation  
Presented by:
Kate Hilton, JD, MTS, Director, ReThink Health
Richard Foster, MD, Senior Vice President for Quality & Patient Safety, South Carolina Hospital Association

Event: Care Transitions Learning Session webinar
Date:  April 25, 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 .

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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

 

key words: QIOs, CFMC, care transitions, community coalition, CCTP, CMS

JAMA Report Finds Community Collaboration Key to Reducing Hospitalizations and Rehospitalizations

 Posted by on January 23, 2013  1 Response »  Tagged with: , , , , , , , , , , ,
Jan 232013
 
Portrait of Dr. Joanne Lynn

By Dr. Joanne Lynn

The latest issue of JAMA features our paper describing   an exciting and successful initiative from the Centers for Medicare and Medicaid Services (CMS) and fourteen of its quality improvement organizations (QIOs).  Grounded in quality improvement methodology—plan-do-study-act–this unusual project offers many insights for those aiming to reduce avoidable readmissions.  And its raises a number of important question about how we measure progress in reducing readmissions. (For more on that topic, see our earlier MediCaring blog, http://medicaring.org/2013/01/07/readmissions-count-should-cms-revise-its-calculations/ )

A Medicare patient’s ability to receive successful treatment during care transitions from one setting to another has a crucial effect on the overall cost and efficiency of the Medicare system. Errors in information transfer, care planning or community support can cause hospitalizations, rehospitalizations and unnecessary costs to the Medicare program.

This project involved a three-year, community-based effort to improve the care transition process for fee-for-service Medicare beneficiaries. Participating QIOs facilitated cooperation among providers, health care facilities, and social services programs, such as Area Agencies on Aging. They centered their efforts around each community’s unique needs.   QIOs worked with communities to understand their own particular causes of readmissions, and to implement appropriate, evidence-based models to address them.  Communities analyzed results of the intervention along the way, and changed course to stick with interventions most likely to work.

The results, when compared to 50 comparison communities, showed significant reductions in hospitalizations and rehospitalizations, both by an almost 6% average, saving Medicare $3 million in hospitalization costs per average community per year.

This correlation has already led to new national efforts such as Partnership for Patients and the Community-based Care Transitions Program. In addition, in the 10th Scope of Work, all 53 QIOs are leading community projects nationwide (so far, in more than 400 communities).

This paper may be the first time one of America’s leading medical journals has published a report based on QI methods. Doing so represents a profound change in the openness of American medicine to learn not only what works for a patient, but works for the delivery system, too.

To learn more about this complex project, you can visit www.altarum.org/QIOpaper , a special website developed by Altarum Institute, in cooperation with the Colorado Foundation for Medical Care (CFMC), which led the work. The site features background material, links to print and online materials from JAMA (including control charts from the 14 communities), a top-ten list, a clever infographic, and videos of the lead authors discussing major findings and lessons learned.

key words: quality improvement, care transitions, CMS, CFMC, Joanne Lynn, readmissions, community coalitions, JAMA

Readmissions Count: Should CMS Revise Its Calculations?

 Posted by on January 7, 2013  2 Responses »  Tagged with: , , ,
Jan 072013
 
Portrait of Dr. Joanne Lynn

by Dr.  Joanne Lynn

When community coalitions apply for funding from the Community-Based Care Transitions program of the Centers for Medicare and Medicaid (CMS), they have to show that they will reduce hospital readmissions by 20% and will save money for Medicare. Funding recipients will be held to those two outcomes in evaluating the contract.

In general, CMS intends to evaluate these programs by applying the 20% reduction to the rate of rehospitalization: that is, rehospitalizations/[live discharges]. If a community’s baseline rate in 2010 was 15%, then 20% of 15% is 3% and they’d have to reduce rehospitalizations to 12%.

If hospitalization itself remains stable, these are the same goal numerically.

However, much of what is done to reduce 30-day rehospitalization also reduces hospitalizations beyond 30 days, and sometimes even hospitalizations without antecedent hospitalizations. If patients learn more self-care, use more hospice, obtain more support in the community, and so forth, then the use of hospitalization outside of that 30-day window may decline as well. And it does not take a lot of decline in that rate to mimic the decline in 30-day rehospitalization, making it a challenge to change the rate of rehospitalization/hospitalization.

Suppose, for example, that a community had 10,000 hospitalizations and 1,500 30-day rehospitalizations in 2010. Suppose the CCTP work changed the rehospitalization number by a full 20% – cutting it to 1200 per year by 2014. But that good work also cut down on hospitalization by 10% — yielding 9000 for the denominator. Then 1200/9000 would be just a 13.3% rate, and the team would have missed the goal of 12% — even though it had actually done a terrific job.

It is always risky to use a rate where the denominator is presumed to be stable but actually can respond to some of the same interventions as the numerator.

Using the N of 30-day rehospitalizations has its risks also – a bad flu year or a decline in community-based support could push it up, as could an influx of patients that increases the denominator. It can also have spurious improvement if many patients are moved from FFS to managed care.

For now, it seems that the prudent thing to do is to convince CMS that they should keep the question open and make it legitimate for CCTP and providers to pursue the reduction in numbers only rather than the reduction in the rate.

 

key words: CCTP, readmissions rates, CMS, care transitions

New CMS Physician Payment Rule includes Codes for Post-Discharge Care Coordination

 Posted by on November 15, 2012  No Responses »  Tagged with: , , ,
Nov 152012
 

New Medicare Codes: I Want to Believe

From the Hartford Foundation’s Chris Langston comes a post about the final rule for 2013 Medicare Physician Fee Schedule–including codes for post-hospital discharge care. Originally appeared November 13 at http://www.jhartfound.org/blog/new-medicare-codes-i-want-to-believe/#more-6021

I’ve been hearing rumors that something big was coming but it sounded too incredible, too wonderful, and too good to be true, so I figured it wasn’t. Seems like I was wrong.

In the past few weeks, the Centers for Medicare and Medicaid Services (CMS) has issued its final rule for the 2013 Medicare Physician Fee Schedule. Nestled between pages 279 and 335 of this document are two new Current Procedural Terminology (CPT) codes (99495 and 99496) which are intended to pay physicians (and qualified non-physician providers like NPs and PAs) for post-hospital discharge care coordination provided to their Medicare beneficiary patients.

Sounds pretty good, as does the list of services that are supposed to be provided to Medicare beneficiaries under these codes:

  • Communication with the patient and/or caregiver within two business days of discharge (phone, e-mail, whatever
  • Non-face-to-face services provided by practice staff may include:
    • communication with home health or other community services used by patients
    • patient/family caregiver education to support self-management
    • assessment and support for treatment adherence and medication management
    • identification and facilitating access to available community and health resources
  • Non-face-to-face services provided by physician or other qualified provider may include:
    • review of discharge information
    • review and follow-up on diagnostic tests and treatments
    • interacting with other health professionals (specialists?) assuming or resuming care of “system specific problems”
    • education of patient/caregiver
    • referrals and arranging for needed community services
    • assistance in scheduling any required follow-up with providers or services
  • Medical decision making (equivalent to a usual evaluation and management visit)
  • A face-to-face visit (office or home) within 14 or 7 calendar days of discharge (while the visit may be done anywhere, people discharged to nursing facilities are not eligible for this benefit :-(  )

 

For these services, a provider stands to get paid $163.88 or $230.86, depending on the complexity of the medical decision making (E&M 3 or 4) and how quickly there is a face-to-face visit (less than 14 days or less than 7 days). That’s good money considering a regular Medicare office visit is around $45, but there is certainly a lot of work involved.

CMS is expecting 2.17 million claims under these codes for total payments of $600 million. Unfortunately, I am reminded of the Annual Wellness Visit (see new for 2011) which also looked like a great new benefit to Medicare patients (and even had no co-pay), but does not seem to be taken up by providers or patients, such that only 7 percent of those eligible had one in 2011. We shall see.

A couple of features of the fee schedule and discussion I thought were very notable: It is clear that CMS expects much of this work will be done by non-physician practice staff. The practice expense component of the work is big and meant to support 70 minutes of RN/LPN time for non-face-to-face activities (see page 324). And the beneficiary co-pay is quite substantial.

Despite some comments suggesting that CMS call these services “preventative” and therefore not subject to co-pays or deductibles, CMS balked. In fact, one reason that the face-to-face encounter with the physician provider was baked into the service package was the hope that it would make the co-pay fee less of a surprise to patients. And finally, the rumors were wrong about one thing—any physician can make use of this benefit; it is not limited to primary care providers (see page 309). The first provider to see the patient and submit a bill will “win” the payment.

So what does it mean? Will we see a reduction in readmissions? Will primary care become a more attractive career? I have to admit that I really don’t know. Despite more than 50 pages of discussion of this new benefit in the final rule and many, many comments, I haven’t seen any comparison between this benefit and the cooperative agreement for post-discharge care coordination offered under ACA section 3026, the Community-Based Care Transitions Program. That program requires community agencies in formal partnership with hospitals to propose an evidence-based model of care such as Eric Coleman’s Care Transition Intervention and negotiates fees with agencies between $250 and $500 per eligible discharge (or so I hear, these “cooperative agreements” are not as public as the physician fee schedule).

Will primary care offices know what to do to coordinate care? Will this payment provide sufficient incentive for practices to do the extra work it takes to prevent hospitalizations? Hire the extra staff? The AAFP, AMA, AGS, and others who advocated for this new benefit think so, but I have my doubts.

For one thing, the primary care stakeholders are quite vehement that they ALREADY provide these services and have just been cheated out of their rightful pay. If so, we shouldn’t expect any different outcomes for patients, just financial ones for providers—not a bad thing, but not enough in my opinion.

In accepting these new CPT codes, CMS has clarified at least three issues in the care of older Americans. First, it plants another giant flag on the issue of readmissions and throws the ball back into the provider court. Medicare beneficiaries have high rates of 30-day rehospitalization, much of which seems preventable with more vigorous efforts at discharge follow-up and coordination of care. As Eric Coleman and others have shown, some fairly simple interventions can reduce 30-day readmissions and improve outcomes for older adults. So one could say that CMS wagering this $600 million against a potential reduction in the $17 billion spent on hospital readmissions is a pretty good bet, even if the odds aren’t that good.

Second, primary care providers have long argued that conventional fee-for-service payment rates do not cover their real expenditures of time and effort to coordinate care for their complex patients. After many years of repeating that payments for evaluation and management do include substantial support for non-face to face services, CMS has reversed itself, and in a big way. These new codes and payments are a powerful precedent and will have more consequences down the line.

And last, but not least, CMS continues to find ways to bring additional revenue to primary care providers, perhaps to encourage them to provide more or better services, but for sure to increase their practice revenue and make primary care a more viable enterprise. This new payment comes on top of innovations such as medical homes with per person/per month fees, the 10 percent bonus primary care incentive payments, and “shared savings” vehicles such as Accountable Care Organizations. Assuming that a primary care physician has 3,000 patients in reasonably regular care, 20 percent (n=600) of whom are Medicare beneficiaries of whom 20 percent might have a hospitalization in a given year, the revenue from 99495 and 99496 (given the 70-30 split in usage CMS expects) would be $21,972. A lot of that income will go directly out in new staff costs (in my view), but I’m sure some will stick.

I want to believe.

 

key words: public policy, Medicare, physician fee schedule

Time to Comment on Care Transitions Provisions in New CMS Physician Payment Rules

 Posted by on August 27, 2012  No Responses »  Tagged with: , , , , ,
Aug 272012
 

Each year, Medicare releases a schedule of physician payment rules, which set the amounts doctors are paid for Medicare beneficiaries. The public is always invited to comment on those rules. This year, for the first time, Medicare is considering allowing physicians to bill for services rendered in the course of managing hospital discharge. For those new to this world, now is an opportunity to comment on those rules—and to let the Centers for Medicare and Medicaid hear your voice. Comments can be positive or negative—but every comment counts. Don’t be intimidated or put off by the bureaucracy of the effort. Medicaring is here to help you through!

The rule can be found in Section H of the “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face to Face Encounters, Elimination of the Requirement for Termination of Non-Random Prepayment Complex Medical Review and Other Revisions to Part B for CY2013 [CMS-1590-P]”. It proposes to pay doctors to coordinate care for beneficiaries following a discharge from a hospital or nursing facility.

This would be the first time Medicare would explicitly pay physicians for the care required to help a beneficiary transition back to the community following a discharge from a hospital or nursing facility.

This “postdischarge transitional care management” code would be added to the fee schedule.  The service would include telephone or electronic communication with a beneficiary within two business days of discharge, medical decision-making of moderate or high-complexity, and face-to-face visit with the beneficiary 30 days prior to the transition of care or 14 business days following the transition.

The rule compares the new service to hospital discharge and high-level evaluation and management care that is currently covered.  The fee for the new services would be approximately $95 using current rates for 2013.

MediCaring suggests that folks comment on a few key provisions of the rule, especially on:

  1. 1.     The post-discharge transitional care management section,  for which: CMS seeks comment about the best ways to ensure that all the activities of the discharge day management codes for hospital and nursing facility discharge, including the care coordination activities, are understood and furnished by the physicians or qualified nonphysician practitioners who bill these services, noting that potential ways could include physician education or MEDLEARN articles.

 

  1. 2.     Whether and how the visit needs to be face-to-face, for which: CMS seeks comment about whether it should require a face-to-face visit when billing for the post-discharge transitional care management services, and how it might incorporate such a required visit into the payment for the proposed G-code.

 

CMS must receive comments on for before September 4, 2012. Full text of the Regulation, along with information on how to comment, can be found at: http://www.gpo.gov/fdsys/search/pagedetails.action?granuleId=2012-16814&packageId=FR-2012-07-30&acCode=FR Here’s how and where to submit comments:

Comments must be received by CMS on for before September 4, 2012. In commenting refer to file code CMS-1590-P. Comments may be submitted to CMS in the following ways:

  • · Electronically. You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the instructions for “submitting a comment.”
  • · By regular mail. You may mail written comments to the following address ONLY:

Centers for Medicare & Medicaid Services

Department of Health and Human Services

Attention: CMS-1590-P

P.O. Box 8013

Baltimore, MD 21244-8013

  • · By express or overnight mail. You may send written comments to the following address ONLY:

Centers for Medicare & Medicaid Services

Department of Health and Human Services

Attention: CMS-1590-P

Mail Stop C4-26-05

7500 Security Boulevard,

Baltimore, MD 21244-1850

 

If you’d like a hand preparing your comment for submission, feel free to contact us at [email protected].

 

 

 

Key words: care transitions, CMS, Centers for Medicare and Medicaid, Physician Payment Rules, comment period

 

 

CCTP Project in Delaware County, PA,Testing a Modified Transitional Care Model

 Posted by on August 2, 2012  1 Response »  Tagged with: , , , ,
Aug 022012
 
cms_partnership_for_patients

On the heels of a successful pilot program to reduce hospital readmissions, The Delaware County Office of Services for the Aging (COSA) in Pennsylvania, has been selected among the first 30 organizations around the nation to participate in the Community-based Care Transitions Program (CCTP) for its work in southeastern Pennsylvania.  COSA, the project’s community-based organization, is anchoring a collaboration among five of the county’s six acute care hospitals, which serve an area of more than   half-a-million residents.

The pilot program, funded by the Administration on Aging (AoA), included a partnership with the Crozer-Keystone Health System, and a demonstration program at Taylor Hospital and Springfield Hospital. That project initially aimed to enroll 235 patients but, to date has enrolled 395. It has achieved a readmission rate of 7.06 percent from 13.33 percent. The project used a modified version of the Transitional Care Model (TCM), originally developed by Dr. Mary Naylor. While TCM relies on advance practice nurses working with patients and caregivers, COSA’s new CCTP is a modified version, as it includes hospital-based registered nurses and social workers. The social workers, who are affiliated with COSA, work closely with the RNs to deliver patient education and arrange referrals for follow-up services.

In the AoA pilot program, an advanced practice nurse enrolled patients based on screening criteria that included patients over the age of 65 who were, because of their diagnosis, at risk for an avoidable readmission. The hospital had a COSA assessor, who offered patients a level of care assessment at bed-side for potential enrollment into COSA programs. Once assessed, patients were assigned to a COSA care manager who followed them in the community. The advance practice nurse followed patients for up to 60 days, while the COSA care manager could follow them for much longer.

In the modified Centers for Medicare and Medicaid Services (CMS) CCTP program, a registered nurse will screen hospital admissions for patients who are 60 years old and older with Medicare Fee-for-Service with both Parts A and B, all-cause hospital admissions, and meet any of several criteria, such as at risk for readmission, poly-pharmacy, lack of informal supports, living alone, lack of follow-up with a primary care physician (PCP) in a previous hospital discharge, or hospital readmissions within the previous 180 days.  Once the nurse has identified an eligible patient, the nurse will meet with him or her at the bedside to discuss enrolling in the program.

Patients who agree to participate will receive a visit from the project’s social worker. Together, the nurse and social worker will provide the patient with user-friendly transfer and discharge forms, and teach the patient how to use AHRQ’s Taking Care of Myself.  That booklet, which is customized to the patient’s needs, includes information about medications, diagnosis, nutrition and activity, follow-up appointments, and so on. Patients will be encouraged to take the booklet with them to follow-up appointments, and to have physicians update it as needed. The CCTP nurse is scheduled to make two home visits to the patient, as the first visit will be with-in 72 hours of the hospital discharge and another at week 4, before the completion of the program. The COSA CCTP social worker will meet with patients weekly and also follow-up by phone. The nurse and social worker will follow the patient for 30 days.  The COSA social worker will work with the patient, according to his or her needs and preferences. If the patient would like, the social worker will accompany him or her to the first post-discharge PCP visit.  If additional COSA services are needed, the patient can be assessed at bedside or in the community by a COSA Assessor, and then assigned to a COSA Care Manager who would follow the patient much longer if needed.

In addition, social workers have over-sized business cards that will feature their photographs and contact information. The cards give social workers a face—patients can share the cards with family members at home, so that they can see who will be visiting the patient. For patients who have people in and out of the home daily, the card is a visual reminder about the social worker.

The CCTP is an initiative of the Partnership for Patients, a nationwide public-private partnership launched in April 2011 that aims to cut preventable errors in hospitals by 40 percent and reduce preventable hospital readmissions by 20 percent over a three-year period.  CCTP’s goals are to reduce hospital readmissions, test sustainable funding streams for care transitions services, maintain or improve quality of care, and document measurable savings to the Medicare program.

The CCTP project, which received funding late this spring, is ready to hit the ground running. Two hospitals will launch the work on August 6, and three others will join in by October. According to the COSA CCTP Project Director, Terry Levine, the project’s success hinges on the relationships among   COSA and all the participating hospitals.  In planning it, he said, it was important to communicate with the hospitals and to let them know that the CCTP work is not meant to replace their discharge planning, but to supplement it.  Over the course of the next two years, the project aims to enroll 4,282 patients; with hopes that successful work will lead to subsequent years of funding.

For more information about the project, contact Mr. Terry Levine, the COSA CCTP Project Director at [email protected]

 

key words: CCTP, CMS, Naylor model, care transitions

Getting There From Here: CMS Advises Potential CCTP Applicants on What It Takes to Win

 Posted by on July 16, 2012  No Responses »  Tagged with: , , , , , , ,
Jul 162012
 
cms_partnership_for_patients

Eager to apply for Community-Based Care Transitions Program (CCTP) funds from the Centers for Medicare and Medicaid (CMS)? CMS is equally eager to make awards. Aiming to encourage organizations to apply to the final round of the CCTP funding, CMS sponsored a 90-minute webinar that featured tips from program administrators on how to write a winning application, along with insights from communities that have recently been funded. The webinar offered just about everything applicants need to know to be successful.  It highlighted insights on what to do—and what to avoid—as you pull together a team and submit your application.

CMS Chief Medical Officer Paul McGann, MD, introduced the session by stating that, in terms of the Partnership for Patients (PFP), the 3026 program is critical to helping CMS achieve its goals to improve patient safety while reducing costs. He noted that the program is the first-time ever that communities have been invited to define and price a Medicare benefit. The program represents an opportunity for organizations coordinate and collaborate to deliver services that help residents experience better health outcomes. It is, he said, “a new way of reaching out.” The webinar represented CMS’ effort to push out as much information as it can so that organizations can successfully apply to become CCTP communities. A final round of funding decisions will be made in late September. To be considered, applications must be received no later than close of business on September 3, 2012.

Details about application requirements and parameters can be found on the CMS Innovations website at http://www.innovations.cms.gov/initiatives/Partnership-for-Patients/CCTP/index.html. In addition to providing an overview of the program, the site includes links to the RFP, the application package, and the budget worksheet. In general, to be eligible, programs must represent a partnership between an acute care hospital and a community-based organization; if it is the anchoring organization, the acute care hospital must be on CMS’ list of high readmit hospitals. Otherwise, it need not be. CBOs must provide care transitions services. They must have a governing board that includes consumer representation, they must be non-profits, they must be located in the community they aim to serve, and they must have previous experience in care transitions work. Closed systems—those in which, for example, a hospital and a home care agency are part of the same organization—are not eligible to apply. Preference is given to applications that include organizations supported by the Administration for Community Living (ACL, formerly the Administration on Aging), and that serve medically underserved and rural areas.

Successful applicants from around the country talked about various aspects of their applications and their work. These groups included P2 collaborative from Western New York, Carondolet in Arizona, Age Options in Illinois, and Delaware County, Pennsylvania. Potential applicants would do well to read the one-page summaries written by each of these sites and posted at:  http://www.innovations.cms.gov/initiatives/Partnership-for-Patients/CCTP/partners.html . In the coming weeks, MediCaring aims to interview staff at each of these sites to learn more about what made their applications stand out, and what they plan to do in the coming years.

Ashley Ridlon of CMS described some of the lessons learned by organizations that have already successfully applied to the program. These organizations have found that a number of factors contribute to readmission, including those on the individual level, as well as those on a systems level. Individual problems include poor patient-provider interactions, medication mismanagement, and avoidable returns to the emergency department. Systems-level problems include the absence of standardized forms and processes, poor cross-setting communication, and a failure to “activate” patients—to ensure that they are engaged and informed partners in their care. The root cause analysis required by the CCTP application process is designed to help communities uncover their own problems and gaps in care transitions, and to consider and implement relevant interventions. This process is at the heart of a successful CCTP application. Ridlon emphasized that applicants must conduct “community-specific root cause analyses,” and develop an implementation plan that is in line with those findings. She also noted that those plans need to align with other care transitions activities currently available in a community. In addition, relevant, documented experience providing care transitions services is essential to writing a successful application. In describing that experience, CMS urged applicants to be explicit with details, describing not only reductions in readmissions, but methodology, evaluation, characteristics of patients enrolled (or not enrolled), and outcomes. They should also describe in detail any care transitions training their staff have received—who participated, when and where, and how others will be trained.

Ridlon urged participants to engage their CMS Regional Quality Improvement Organizations (QIOs), an invaluable resource. QIOs can help applicants to conduct their root cause analyses, collect data, identify partners, arrange meetings, and select interventions.

Juliana Tiongson, also of CMS, described issues surrounding the budget process. It is essential that applicants read and understand what the RFP calls for. To some extent, the program can be defined, budget-wise, by what it is not: It will not pay for services already required by Medicare’s conditions of participation. It is not a grant program. It will not pay for activities that are not directly related to providing services to beneficiaries. It will not support ongoing care management or disease management. Many applicants, Tiongson said, have completed the required budget worksheet, but fail to complete the equally important budget narrative, outlining at length exactly what is to be covered by the program’s blended rate. She also noted—and this is critical—that that rate is not likely to be competitive if the blended per-person rate is over $400.

The blended rate is not a set figure. It will vary by community and by intervention. Patient volume and expected reductions in savings will also affect the blended rate.

Tiongson listed a series of pitfalls about which applicants should be wary. These include:

  • Partnering with an ineligible CBO, or being unclear about the CBO’s structure. Problems include not identifying board members, not including consumers on the board, failing to complete audit forms, or being part of a closed system.
  • Failing to conduct a community-specific root cause analysis.
  • Completing the root cause analysis, but failing to describe the methodology behind it.
  • Failing to link the root cause analysis findings directly to the selected care transitions intervention.
  • Not having all required signatures on all required letters of commitment.
  • Not including the budget narrative along with the budget worksheet.
  • Providing insufficient detail on everything from the budget to staff training.
  • Being overly broad or subjective about the target population.
  • Not describing the readmission risk assessment tool.
  • Proposing hybrid intervention models that have not been tested, or using bits and pieces of various interventions to come up with something new and untested.
  • Being fuzzy about the nature of relationships, and being unclear about how fees will be shared among the partnership.
  • Not listing board members and not including consumers on those boards.
  • Being too slow to get started—at the very most, organizations should take three months to hit the ground running. More than that is too slow for CMS’ purposes.

In terms of the budget itself, Tiongson noted several errors that applicants have made, including:

  • Using a per member per month rate, rather than a per eligible discharge
  • Failing to include the budget narrative
  • Basing the rate on 100% participation of the target population
  • Making unreasonable assumptions about the number of admissions avoided, which inflates the savings estimates (CMS recommends assuming a 20% reduction over two years as a reasonable expectation)
  • Building the budget as a grant application, rather than as a per-eligible-discharge fee
  • Offering providers financial incentives to participate.

In closing, Ridlon and Tiongson suggested that applicants reflect on the following points as they develop their applications:

  • Focus on implementing an effective intervention closely tied to the findings of the community-specific root cause analysis
  • Consider collaborating with other payers, including the private sector, Medicaid, and Medicare Advantage programs
  • Build strategic partnerships in communities to bridge gaps, and encourage members to share resources and learn from one another.

For a sample partnership agreement, follow this link: https://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/Downloads/CCTP_Program_Agreement.pdf. To view the entire slide deck, visit the July 12 blog posting on MediCaring.org, which links to the PDF.

To find the QIO for your region, go to: http://www.cfmc.org/integratingcare and click on Contact Us.  For questions, email [email protected]

And be sure to follow Medicaring—like us on Facebook, follow us @medicaring, and join us on the blog.

 

Key words: CMS, CCTP, Section 3026, care transitions, applications, strategic planning, program implementation, budget, QIO, CFMC

 

CMS Offers Tips and Pitfalls for CCTP Applications

 Posted by on July 12, 2012  No Responses »  Tagged with: , , , , , ,
Jul 122012
 

In today’s CMS phone call and webinar, CMS officials offered tips and pitfalls that applicants for CCTP funding should keep in mind. You can find those by scrolling through the slides from today’s webinar. And Medicaring will post more information early next week, detailing what we heard in the call–and what we learned.

 

Note one correction to the slides: Do NOT use the $9600 average cost of readmission as the baseline for calculating your blended rate. It is only to be used to project savings.

 

everything_you_wanted_to_know_to_apply_to_the_cctpfinal_slides

 

 

Key words: CCTP, CMS, Section 3026, root cause analysis, tips, applications

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