Coalition Building for Care Transitions: Communities Work to Help Frail Elders

 Posted by on February 2, 2012  No Responses »  Tagged with: , , ,
Feb 022012
 
The following blog originally appeared on the Altarum Institute Health Policy Forum blog at www.healthpolicyforum.org on Tuesday, January 31, 2012. It is co-authored by Janice Lynch Schuster and Joanne Lynn.
 

“Care transitions” is the new buzzword in efforts to improve health, improve care and reduce costs. It seems that everyone is jumping on the bandwagon, implementing evidence-based solutions to problems in transitions, launching new programs and applying for funds totaling half a billion dollars from the Centers for Medicare & Medicaid Services.

In November, CMS announced the first seven communities to receive funding under its new Community-Based Care Transition Program: Atlanta; Akron/Canton; Chicago; Southwest Ohio; Southern Maine; Maricopa County, Arizona; and the Merrimack Valley of Massachusetts. Communities have developed remarkable partnerships. Atlanta is involving six urban area hospitals serving 10 counties. Southwest Ohio has a team that includes university and community hospitals, as well as a health council and information technology groups covering areas in Ohio, Kentucky, and Indiana. Merrimack will serve patients in 33 cities or towns in the region. In short, it is an impressive array of organizations that recognize that no single organization or entity can solve the problems of care transitions. It will, in fact, take a village, one that relies on many organizations and stakeholders to craft solutions that match their community’s preferences, resources and priorities.

For those who are young and relatively healthy, care transitions (i.e., hospital discharges) may not seem like a big deal. New mothers are discharged to follow up appointments with their OB/GYNs and pediatricians and usually can enlist new fathers and grandparents to help out with the baby during the early weeks. People who have an injury or a planned surgery will be discharged with instructions to follow up with their primary care doctors, take prescribed medications and maybe participate in physical therapy. For patients who are generally young and healthy, connecting the dots and mapping out a few weeks of a new routine may present a challenge, but it is easy enough to adjust to and figure out.

It is not so for frail elders and their caregivers—people who are over the age of 65, often over the age of 85, who have functional and cognitive impairments, who rely on others for activities of daily living and whose resources limit where they can go and whom they can see. Indeed, the transition often proves so difficult or ineffective that at least 20 percent of Medicare beneficiaries will be rehospitalized within 30 days of their initial discharge.

Poor discharge planning can be calamitous. A recent Health Affairs article chronicled the horror that ensued when a terminally ill patient was discharged home to hospice, only to arrive there with insufficient oxygen and no morphine. He died, suffocating, within 20 hours. The hospice nurse showed up afterward, apologized, and instructed the family on how to flush the morphine that they had finally received.

Many models have been developed and are being tested, hoping to prevent or eliminate the kinds of errors just described. Massachusetts’ Brian Jack, M.D., leads Project RED (Re-engineering Discharge), a hospital-based program that relies on enhanced staff training and a video avatar to help guide patients and families through discharge and follow-up. Colorado’s Eric Coleman, M.D., has developed an approach that emphasizes self-care capability and teaches four pillars to a good care transition. The Transitional Care Model relies on a specially trained advance practice nurse to work with families through the discharge process. Other models have been proposed and are being studied.

In our early work for Altarum Institute’s Center for Elder Care and Advanced Illness, we have found it useful to leverage changes in five areas in order to improve the design and implementation of effective care transitions quickly: medication reconciliation, patient activation, hospital discharge process, matching patients and services and information flow. In coming months, the CECAI staff will blog about each of these issues, sharing what we learned in the course of surveying the literature and experience to date. We expect that the movement will mature toward working on right-sizing the service array, dealing with advance care planning and providing feedback to earlier providers from later providers to enable improvement. We will keep watch for these and others.

It is intriguing that the solutions now underway rely so heavily on coalition building. Public health has long relied on this strategy to solve problems and promote social changes around other issues, such as smoking cessation, impaired driving, breastfeeding, the built environment and substance abuse. There are several definitions of what makes for a coalition; according to Frances Dunn Butterfoss, “coalitions are interorganizational, cooperative, and synergistic working alliances.”(1) Coalitions appear to go through three critical but nonlinear developmental phases: formation, maintenance and institutionalization.(2) As the newly developed CCTP programs launch, they will need to learn how to organize, lead and sustain an effective coalition. Perhaps those with experience and research can help.

The usual transition of an older person from hospital to home appears to entail multiple errors. Probably no other point in patient flow has so many errors and so great a tolerance for them. The current work on improving care transitions is long overdue and likely to make major improvements in cost and quality. The social capital that this work creates by pushing all parts of the care system to communicate and learn to work in a coordinated way is important; it could be the lynchpin of a new era of cooperative endeavors to build continuity into the fragmented care system.

References

1. Butterfoss, F. D., Goodman, R.M. & Wandersman. (1993). Community coalitions for prevention and health promotion. Health Education Research Theory and Practice, 8(3), 315–330
2. Osmond, J. Community coalition action theory as a framework for partnership development. Retrieved from http://www.mycalconnect.org/sacramento/download.aspx?id=10949

 Key words: care transitions, coalition building, frail elders, CCTP

Community Organizing Webinars: Principles and Practicalities

 Posted by on January 31, 2012  No Responses »  Tagged with: , , , ,
Jan 312012
 

Starting Feb. 9, you can participate in a webinar series designed to help you understand the principles of community organizing and apply them to your work in improving care transitions. The program, jointly sponsored by the Colorado Foundation for Medical Care (CFMC) and Organizing for Health, builds on principles developed by Harvard University’s Marshall Ganz, widely credited for having created Obama’s remarkably effective grassroots organizing strategy in 2008.

The series will include webinars on topics such as introducing and developing a “story of self,” building relationships, recruiting leaders, and developing a campaign. For communities in the midst of trying to create this kind of grassroots change in care transitions, the webinar will be an invaluable resource, and will feature experts from across the country. The series will run on the 2nd and 4th Thursday of each month from February through April. The actual schedule is attached to this post. Community_Organizing_WebSeries_Flyer-1

It is free; interested readers can sign up at:

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

Scheduled seminars will run on https://qualitynet.webex.com with the password, community. Dial in at 1.866.639.0744.

To learn more about  Ganz’ s work and hear him speak about his theories and experiences, check out his  web series at: http://isites.harvard.edu/icb/icb.do?keyword=k2139&pageid=icb.page12185

Key Words: community organizing, Marhsall Ganz, webinars, care transitions

CMS Introduces 7 CCTP Sites in a National Call Focused on How to Propose a Winning Application

 Posted by on November 30, 2011  No Responses »  Tagged with: , , , , , , , ,
Nov 302011
 

In a national conference call with the first 7 sites to be awarded CCTP funding, representatives from each pointed to common elements that characterized their winning applications. (For details about each of the selected sites, go to www.cms.gov and search for CCTP; that will lead you to  project summaries and a complete list of recipients.) In addition, CMS has posted a new advisory for potential applicants at: http://www.cms.gov/DemoProjectsEvalRpts/downloads/CCTP_FactSheet.pdf

During the call, each site described programs  rooted in the development of a broad-based community coalition with experience in working on improving care transitions, and in the development and implementation of interventions closely linked to results of the root cause analysis.  Each described previous experience in working to improve care transitions, often through pilot projects and demonstrations, and extensive community-based involvement in the efforts. Each group described programs that work across multiple hospitals and health care systems, reaching a broad area of diverse populations, in most cases, spanning several counties or towns.

Dr. Paul McGann noted the importance of the CCTP program in fostering relationships, linking community-based organizations to the broader health care system. He said, “The current health care system makes it hard to do the right thing for patients. These care transition projects are the start of healing the health care system, of making it easy to do the right thing for patients.”

For the call, a representative from each site briefly highlighted some aspect of its application or proposed program; their overviews are summarized below.

The Southern Maine Agency on Aging/Aging and Disability Resource Center, described its work to closely tie results of its root cause analysis to the interventions it proposed.

The Atlanta Community-Based Care Transitions Program focused on its work to establish a community coalition and develop partnerships, pointing to its work to develop a program anchored by three sets of partners: six carefully chosen hospitals, the Georgia QIO, and community-based organizations. Atlanta noted that when it began the application process, it did not immediately seek out hospital CEOs, but rather relied on existing relationships with hospital staff, who then “took it up the ladder,” until CEOs were on board and invested.

Elder Services of the Merimack Valley, which serves areas  in New Hampshire and Massachusetts focused on its work to conduct root cause analysis (RCA) linked to a targeted intervention. Its analysis, which included focus groups with people from across the continuum, pointed to seven factors that impede good transitions. It then matched its intervention to the problems the RCA uncovered.

The Southwest Ohio  Care Transitions Collaborative explained how it selected its target population of high risk patients, who they define as Medicare fee-for-service beneficiaries with one of three common diagnoses: heart failure, heart attack, or pneumonia. Using data from a pilot program, the team identified common conditions and patient factors (e.g., whether they were coming from home, hospital, or SNF).

The Area Agency on Aging, Region One, serving Maricopa County, AZ, focused on its previous work with care transitions, and lessons it had learned in the course of conducting pilot projects. Based on this work, the team found strengths and weaknesses in its approach, and therefore altered published interventions to match particular community needs.

The Council for Jewish Elderly, based in Chicago, described the structure of its organization, and how it met the application’s eligibility criteria. In particular, the team walked through specific details of its long history in the community, providing a tradition of  “community-focused and patient-centered care.” In its application, it walked through specific elements of its forty-year history in the community. It built a team that included hospitals that had demonstrated their commitment to the issue, primarily through their use of Project BOOST or Project RED.

Finally, the Akron,/Canton Area Agency on Aging  described its previous experience in improving care transitions. In a pilot program with hospitals, the team had already demonstrated success in reducing readmissions; the issue it faced was in the sustainability of that program.  The group’s intervention features an interdisciplinary team that meets to propose solutions to complex, difficult cases.

The call concluded with a quick wrap-up by Juliana Tiongson, the CMS staff member who leads the program who reminded potential applicants to focus on several elements in their applications, and noted that CMS has a strong preference for applications that indicate the involvement of multiple hospitals and their community, led by an eligible community-based organization (CBO). Applicants should focus on their previous experience in care transitions work, take care with their root cause analysis, and evidence consumer involvement on boards. Finally, applicants should know that their programs need not be limited by patient diagnosis; rather, interventions should clearly be tied to community patterns and needs. She also noted that there was preference for applications that include multi-hospitals and CBOs in the coalition, and that single hospital sites would likely be limited to those serving very rural communities.

The presentation did not deal with the many questions on setting the blended rate, except to say again that this is not a grant program and that indirect costs and training and start-up costs should not be included. The application process is ongoing, and CMS regularly convenes panels to review applicants as they come in on a rolling basis.

 

Key Words: CCTP sites, Section 3026, care transitions, CMS site awards, technical assistance

Southwest Ohio Care Transitions Collaborative Talks to Medicaring about CCTP Award

 Posted by on November 28, 2011  1 Response »  Tagged with: , , , , , , ,
Nov 282011
 

The Southwest Ohio Care Transitions Collaborative, one of 7 sites chosen by the Centers for Medicare and Medicaid for the first cohort of 3026 funding, had lots going for it as it pulled together a broad-based community health coalition and implemented strategies to reduce avoidable readmissions for older adults. The program brought to its application a coalition that included major community-based organizations, the local hospital association, and five hospitals serving the Greater Cincinnati area. It had demonstrated success with a care transitions pilot program based on the Coleman model, and it submitted an application to CMS that clearly explained the strategy behind its blended rate calculations. The Collaborative estimates that it will serve some 5,400 seniors each year, with a cost savings to Medicare of more than $1 million. The specific intervention is built directly on the Coleman model, with some modifications to account for local needs and experiences (For the Council’s full press release on the project, see http://www.help4seniors.org/newspage.asp?ref=1192.)

The application built on the success of a pilot project implemented at UC Health University Hospital, which showed that participants had a lower-than-average readmission rate, and that most patients were discharged to their home or other community setting, rather than to a skilled nursing facility. Sharon Fusco, Director of Business Results and Innovation for the Council on Aging of Southwestern Ohio, is optimistic that the care transitions intervention will significantly reduce readmissions among hospitalized Medicare beneficiaries with diagnoses that include pneumonia, heart failure, heart attack, or multiple chronic conditions.

In building the coalition, Fusco says the group aimed to be certain to include all of the organizations that could influence and affect patients’ lives; where the root cause analysis identified gaps in care, the coalition took care to find organizations that could fill them. As a result, the coalition now includes the Greater Cincinnati Health Council, which is the local hospital association; a health information and technology exchange organization; a program that helps to coordinate patient access to physicians; and a local mental health and recovery services board.

The Collaborative used its root cause analysis to identify gaps in care, and to consider strategies that would mitigate problems. So, for instance, as Fusco explained, the root cause analysis identified mental health issues as a significant barrier to patient involvement in discharge planning and follow-up. “We had to find a way to help these individuals, and to connect them to a mental health medical home,” Fusco explained. To that end, the mental health board was enlisted, and will play a critical role in assisting patients whose mental health problems present barriers to good care.

The analysis also found tremendous problems in medication reconciliation, a problem that affected more than 90% of patients in a pilot at University Hospital. In exploring this issue more deeply, the Collaborative found that many patients did not have relationships with or access to primary care physicians, a real barrier in trying to help hospitalized patients make and keep important follow-up appointments. To this end, the Collaborative involved a group that focuses on coordinating patient access to physicians.

In general, the Collaborative found that the Coleman Model matched most of its needs in responding to problems identified by the root cause analysis. The Council on Aging added a fifth pillar to the four pillars of the Coleman model home and community-based programs for which some patients might be eligible. Meals, home care assistance, and transportation are among the services these programs offer.

Fusco and  her colleague, Communications Director Laurie Petrie ,anticipate that the Collaborative will encounter some challenges in with regard to operations and technology  differences among participating hospitals (e.g., rural versus urban settings), and to the ramp-up of health information technology  systems. Fusco noted that one challenge will be “getting the right staff and the right tools to each hospital.” But she is confident in the Collaborative’s ability to overcome  these  barriers and deliver successful interventions.

Fusco offered some advice for other potential applicants. In particular, she advises that groups take time to explain in detail how they calculate their blended rate, “really spend time explaining the rate and what goes into it.” According to Fusco, the process of calculating the blended rate was difficult but critical. She said,  “The process of [pulling together this application] turned out to be a healthy exercise for us. Costing out all the inputs that go into providing this service was challenging and time consuming, but completely necessary. We built a cost model that allowed us to account for both fixed and variable costs. In the end, the process increased our learning, and we found it very beneficial.”

She advises other potential applicants to be thoughtful and meticulous as they develop their calculations. “You need to understand what your costs are, what’s fixed and what’s variable. Then you can plug in the numbers. But you have to think about everything that goes into serving a client—what does it cost you to actually run the intervention? Not just the face-to-face time with the client, but all of the rest of the costs.”

She also feels that the Collaborative’s application was stronger for having been reviewed and critiqued by external partners, individuals with no connection to the program being proposed. To that end, she said, consultations on aspects ranging from policy to cost were helpful.

 

Key words: care transitions, CCTP, Section 3026, award sites, community coalition, quality improvement

How to Build a Community Coalition to Address Care Transitions

 Posted by on October 31, 2011  No Responses »  Tagged with: , , ,
Oct 312011
 

Community-based coalitions are critical to improving care transitions. To this end, people working throughout the community, in a variety of settings, really need to work to get to know one another, understand each other’s systems, and develop solutions that will translate into effective services for the community. Dr. Joanne Lynn describes a few steps to take to launch such a coalition.

 

 

Key Words: care transitions, coalition building, Section 3026, Joanne Lynn

Understanding a Health Care System As a Path to Improving It

 Posted by on September 26, 2011  No Responses »  Tagged with: , , ,
Sep 262011
 

Fixing what’s wrong with care transitions will require changes in how systems work, both internally and with other systems. In this video, Dr. Joanne Lynn explains the importance of understanding your own health care system in order to fix problems in care transitions. Community and medical care providers need to work together to understand drivers in their own system before they can engineer effective solutions. You can also learn more about how to work locally by reading the Get Started guide, which you can find here:

http://medicaring.org/get-started/#why-local-reform

 

Key words: Care transitions, quality improvement, community-based organizations

Building the Will for Change: A New Video from Dr. Joanne Lynn

 Posted by on September 19, 2011  No Responses »  Tagged with: , ,
Sep 192011
 

What kinds of changes are needed to improve care transitions, and thereby improve patient care and experience? It is a complex issue, and requires hard work. Building the will to face and fix these problems is essential to creating a better health care system. Dr. Joanne Lynn describes how individuals and organizations can get motivated—and get started.

Details of LTQA Innovative Communities National Summit

 Posted by on July 25, 2011  No Responses »  Tagged with: , ,
Jul 252011
 

The Long-Term Quality Alliance (LTQA) was formed to respond to the increasing demand for long-term services and support and the expanding field of providers who are delivering that care. The Alliance is working to make sure that the 11 million people who need long-term services and supports in the United States receive the highest quality of care regardless of where that care is delivered. To that end, the LTQA  and its members are deeply interested in and committed to issues surrounding care transitions—improving those transitions as a way to improve patient experience, reduce medical errors, and make care more cost-effective.

At  the  recent  2nd Innovative Communities Summit, more than 130 participants engaged in presentations and dialogue focused on learning more about how to make care transitions safe, effective, and in the best interest of patients, residents, and their caregivers.  In opening remarks, Mary Naylor, Chair of the LTQA Board of Directors, described the local, community-based solutions that are necessary to respond to breakdowns in safety and quality. She noted that the field is looking for many things, including an opportunity to learn from other communities, especially around coalition- and community-building strategies; ways to raise awareness among communities about national programs now being launched; and strategies for advancing and sustaining the kinds of learning communities that will make such improvements a reality.

Other speakers included Kathy Greenlee, Assistant Secretary for Aging, and Paul McGann, Deputy Chief Medical Officer for CMS. A full report on the day’s presentations will be released soon, with highlights that include case studies of innovative communities, resources and insights from major national endeavors, strategies for community-building, and a perspective from the philanthropic community.

The LTQA is governed by a broad-based board comprised of 30 of the nation’s leading experts on long-term care related issues. The board has representation from consumers and family caregivers, providers, health service and researchers, evaluators and quality experts, private and public purchasers of care, foundations, think tanks, and agencies of the federal government that oversee aging issues and health care quality issues.

The LTQA works to make advancements in the quality of life of people receiving long-term services and supports by:

  • Facilitating dialogue and partnerships among all provider organizations that serve people needing long-term services and supports to help break down the provider silos in which quality initiatives have occurred.
  • Bringing consumers and family caregivers together with LTC providers and government agencies to agree on goals and associated measures of greatest concern.
  • Making stronger links between quality measurement goals and evidence-based practices to achieve them.
  • Collaborating with other quality improvement organizations on common priorities and goals.

We encourage you to learn more about LTQA’s work by visiting its website at www.ltqa.org, or by emailing me at [email protected]

 

Key words: care transitions, coalition building, innovative communities, quality improvement

Care Transitions Workbook Now Online

 Posted by on July 22, 2011  No Responses »  Tagged with: , , , , ,
Jul 222011
 

Community coalitions can be an effective way to engage diverse stakeholders in achieving common goals. Establishing such coalitions to address problems in care transitions is likely to be an essential tool for ensuring that such transitions become routinely good. Shortcomings in transitions today reflect larger, systemic problems that can best be addressed by community organizations working together. Indeed, no single organization will be able to resolve the broader issues, or work on its own to improve care transitions. It will truly take a village to make transitions safe, effective, and routine.

Many organizations around the country are looking to build coalitions that focus on care transitions. For many, similar experiences building community connections will enable them to establish and lead such coalitions. But many others will need guidance and support for learning the basics of coalition building, and for understanding issues specific to care transitions.

The Center for Eldercare and Advanced Illness has just posted a workbook, “It Takes a Village,” that offers  community leaders ideas and pointers for how to get started – and how to get going. It can be read in its entirety on the MediCaring.org website at: http://medicaring.org/it-takes-a-village/

The guide provides an overview of coalition building, ranging from recruiting partners to resolving governance. It describes what to consider when setting priorities for the work. Much of the text is devoted to issues of measurement – how will coalitions know that their work is improving patient care and experience? The guide explains how to usemeasurement to advance the coalition’s goals, how to find good data sources, and how to decide on what to measure. It provides very specific information on fixing care transitions, including how to fix the hospital discharge process and how to target rehospitalizations. Because care transitions have a major effect on very sick and vulnerable patients and families, the guide also includes ideas for how coalitions can coordinate their efforts with palliative care programs and services.

Community coalitions have proven effective at addressing diverse public health issues, from improving maternal and child health to creating healthier environments. Coalitions are defined by their focus on a particular issue, by their willingness to collaborate, and by their ability to bring a range of resources and perspectives to problem-solving. The guide offers a starting point – we hope you find it compelling and useful.

We’d like to hear about your experiences – what works for you and what doesn’t, where are your successes and what have been your challenges. Please join the dialogue by offering comments here, or emailing us at [email protected]. We look forward to hearing from you!

 

Key Words: care transitions, rehospitalization, readmission, quality improvement, coalition building, data sources, measurement

 Newer Entries