Jan 042016

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mar 242014

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

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

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

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

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

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

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

Where are the good models for care planning?

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

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

Aug 072013

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

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

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

Presented by: 

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

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

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

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

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

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

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

Attendee Instructions:

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

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

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

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

Jun 212013

By Carol Castillon

By developing a feedback loop so that community-based organizations and hospitals can communicate more effectively about shared patients, San Diego’s Community-based Care Transitions Project  (CCTP) has opened a door for improving patient health improvement. Over the past few months I have witnessed first-hand the development of this crucial piece of the program. In the San Diego CCTP,  anchored by Aging & Independence Services, a community-based organization, we offer two CCTP-approved interventions: the Care Transitions Intervention (CTI) and Care Enhancement. Our partnership includes four health systems and 13 hospital campuses.

When I think of hospitals and medicine, I think of answers.  Individuals seek attention from hospitals and physicians for answers as to why they are ill or why their bodies are not reacting as they should. Clinicians and other professional caregivers witness health problems within the clinical environment, or only hear about them from a patient or caregiver.  For those individuals who are in a high-crisis mode, accuracy can become a problem.  And often,  as soon as a patient is admitted to the hospital, he or she  patient expresses the desire to go home—and, in order to get home, they will say or agree to just about anything clinicians recommend.  I know this from my own experience, as someone who believes quite sincerely, that “there’s no place like home.” At the same time, patients and their loved ones often are unprepared for the functional decline that is often associated with a hospital admission, often not fully appreciating how depleted they are until they actually get home.

To respond to this, CCTP has engineered a merging of the hospital and home perspectives. My organization, AIS, is a real partner in this process; we have had the opportunity to collaborate closely with each hospital. One of our approaches has been to participate in bi-weekly internal meetings or huddles. We use these meetings to debrief one another about patients; smooth work flow processes; review data to ensure that we are on target to meet performance targets; present success stories and conduct a root-cause analysis whenever a patient is readmitted.

These meetings are truly multidisciplinary and include all members of the partnership assigned to a particular hospital. As we go around the table and discuss our pre- and post-discharge interventions, we have found that our feedback circle is gaining a presence of its own.  The feedback circle enables us to bridge the clinical to home environment in ways we have not experienced before.  We are able to immediately feed information back to hospitals about successes, accomplishments and challenges.  In some cases, the feedback circle has even enabled hospitals to change internal processes.  The home assessments conducted by  our CTI Coaches and Care Enhancement Social Workers are beginning to be incorporated into the patient’s hospital medical records and even into primary care physician’s records!

We’ve had physicians contact our coaches to commend the CCTP team on a job well done.  One particular physician was amazed in how much a patient had changed, and even commented, “You guys have done more for this patient with your interventions than I could ever do.” Such feedback is almost music to our ears.


Carol Castillon works with AIS to manage the San Diego CCTP . 

key words:  CCTP, care transitions, evaluation, feedback loops, quality improvement, community partnerships, San Diego,

May 292013

By Deborah Marquette

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

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

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

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

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

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

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

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

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

Sep 242012

The Minnesota-wide RARE (Reducing Avoidable Readmissions Effectively) Campaign is tracking success one pillow at a time: Its metric is whether or not a patient sleeps in his own bed, with his own pillow. The RARE website (www.rarereadmissions.org) tells the story. A graphic shows individuals, sleeping soundly. Each face represents 250 prevented readmissions, and 1,000 nights at home.  The RARE Campaign aims to prevent 4,000 avoidable hospital readmissions within 30 days of hospital discharge between July 1, 2011 and December 31, 2012. Achieving this goal would reduce Minnesota’s overall hospital readmission rate by 20% as measured by the Minnesota Hospital Association’s Potentially Preventable Readmissions (PPR) data. All 82 hospitals participating in the RARE Campaign have signed on to each reduce their overall readmissions by 20%.

The campaign relies on three operating partners to organize collaboratives, collect and analyze data, and provide coaching to participating hospitals. The Institute for Clinical Systems Improvement (ICSI) (http://www.icsi.org/), the Minnesota Hospital Association (MHA) (http://www.mnhospitals.org/)and Stratis Health (which serves as the state’s Medicare Quality Improvement Organization, and can be found at: http://www.stratishealth.org/index.html) manage operations. A growing base of some 75 community partners, including long-term care, home health, professional associations, and hospice, are supporting the work.

Deb McKinley, RARE communications manager for Stratis Health, explains that the group began its planning process two years ago. Each organization had been leading some work in the area of reducing readmissions: Stratis Health focused on Project RED, MHA on the Safe Transitions of Care, and ICSI on the Eric Coleman’s Care Transitions model. McKinley says, “Minnesota has a long history of collaboration in health care, and good working relationships among partners. The RARE Campaign is a natural relationship. We had the foundation that we’d built and nurtured over time, and this builds on that.”  Organizations around the state were involved in different care transitions models; the operating partners decided to join forces, rather than to force organizations to choose among them.

Participating hospitals are making progress toward preventing 4,000 avoidable readmissions by Dec. 31, 2012, based on the Potentially Preventable Readmissions (PPR) data for the first quarter of 2012. Results show a reduction of approximately 13%. To date, the Campaign is about two-thirds of the way to its goal.

Mickey Reid, Patient Safety Quality Manager and RARE Project Manager for MHA explains that the hospital association has been using a roadmap format in its efforts, helping organizations conduct self-assessments to understand more about where opportunities for improvement lie in their work, and how they might best approach problem-solving. The hospital association collects and analyzes data, which it shares with participating hospitals. “All of the data for potentially preventable readmissions are collected by MHA. We get the data and send it out to ICSI, which creates run charts for each hospital in the campaign. Hospitals use the individual PPR data to see their progress.”

Reid notes that while hospitals are concerned with the pending Medicare penalties for avoidable readmissions, they are actually driven more by staff wanting to “do the right thing for patients.” There is also, she suggests, some peer pressure to participate in the work, and to improve processes. “We’re just not communicating well enough across levels of care and not doing enough to keep patients out of the hospital. We are looking at what we are missing in the process. Did we miss stressing to the patient how important it is to get followup appointments? Did we change drugs and not followup? There are so many things that can happen. Everyone does their part, but we are just not communicating that information.”

Reid’s colleague at Stratis Health, Kim McCoy, echoes these ideas. “We want to remember why we are doing this work, we want to emphasize keeping the patient at the center of the focus. We want to improve the quality of life for our patients, keeping them in their own homes. We want to give them the best quality of life that we can.”

Kathy Cummings, RARE project manager for ICSI, says, “We wanted hospitals to be the instigators of change, recognizing that readmissions are not just a hospital problem, but a continuum of care problem.”

To that end, the RARE Campaign helps hospitals engage more with partners in the community, to understand where gaps in care are, and to develop and implement ways to close them. As Reid says, “We don’t want [patients] to have to be in the hospital. If we can get people community resources, we can help them. People haven’t used these resources, and don’t know the abundance of them. We need to connect patients to their available resources, especially those with complex chronic disease. Our focus is really communicating with out-of-hospital groups.”

Cummings explains that hospitals who sign up for the project engage in an organizational self-assessment to understand just where problems lie in their current care transitions. RARE encourages hospitals to focus on at least one of five common problems: medication management, a comprehensive discharge plan, patient/family engagement, transition support for the patient, and improved communication among providers. Hospitals declare an area in which to work, and the Campaign partners then provide them with tools and resources they need to develop a plan. The cost of participating is covered by the three operational partners, with some funding from the Medicare Quality Improvement Organization program, Aligning Forces for Quality, the Partnership for Patients, and the Health Research and Education Trust.

Each hospital is assigned a RARE resource consultant affiliated with one of the operating partners. Consultants work with hospitals quarterly to review data, what’s happening with the project, and how they are adapting their plans to be more effective. A twice annual RARE Action Learning Day brings participants together to share experiences, ideas, and lessons learned. In addition, monthly webinars cover an array of topics, from conversations about the end of life to medication management in ambulatory settings.

To learn more about RARE—to see the pillows at work!—visit the Campaign’s website at: www.rarereadmissions.org


Key words:  care transitions, readmissions, Coleman model, community collaboration

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 info@medicaring.org.




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



Jul 232012

By Dr. Kyle Allen  and Susan Hazelett

The Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project(SAGE) is a collaboration between an integrated health system and the local Area Agency on Aging which was begun in 1995. SAGE  provided the organizational structure to develop the resources and processes needed to effectively integrate geriatric medical services and community-based long-term care services. Such integration is essential to bridging gaps between acute medical care and community-based care, enabling medical and social services providers to reach frail older adults living in the community with multiple chronic conditions, and to improve their quality of life. The SAGE project, which operates in the Akron, Ohio, metropolitan area, has managed to do just that. Results of the 17-year collaborative indicate that consumers, health care systems, health care providers, and payers have all benefited from the focus on integrating service delivery.

In the early 1990s, Summa Health System (SHS), an integrated not-for-profit health delivery system, had launched several projects aimed at improving care for frail elders. Summa comprises six community teaching hospitals with more than 2000 beds, as well as its own health plan, skilled home care, hospice, and a foundation. Summa’s insurance plan has 150,000 covered lives, including a Medicare Advantage Plan of 23,000.One of the projects being tested at Summa was the ACE (Acute Care for Elders) model, a model of hospital care delivery aimed at improving the functional status and clinical outcomes for hospitalized older adults. Recognizing that this model did not have the necessary patient connection in the outpatient setting, Summa realized it would need to expand its reach to elderly patients across the continuum of care. To this end, it created the Center for Senior Health (CSH), an outpatient consultative service that supports primary care providers by offering an interdisciplinary, comprehensive geriatric assessment; high-risk assessment; a geriatrics resource center; a clinical teaching center; inpatient geriatric consultation and outpatient consultation followup. The CSH attempts to treat and reach the whole patient by addressing acute and chronic medical needs, psychosocial needs, and family concerns. Despite the range of services provided, the CSH continued to be limited in its scope because it did not have access to patients in their homes, nor could it provide long-term case management. As a result, it began to rely increasingly on community-based long-term care agencies for this kind of information and management.

At about the same time, the Area Agency on Aging 10B, Inc. (AAA) found itself managing a growing number of consumers with functional decline, geriatric syndromes, and multiple chronic illnesses. The AAA, which serves more than 20,000 elders in Northeast Ohio, recognized that it needed to be better integrated with the acute medical sector if it were to achieve its goal of delaying and preventing nursing home admissions.

Leaders from Summa Health and the AAA recognized the challenges and deficits each one faced in providing continuity of care to patients/consumers, and began meeting to discuss how they could build a new, integrated model of care. They realized that they shared a common goal and vision to improve care for frail elders, and launched SAGE, which provided the organizational structure needed to effectively integrate their services. SAGE had no grants or funding, just a spirit of collaboration and cooperation, and a common desire to do more than just business as usual.

A SAGE task force was created comprised of staff from both organizations, including physicians, nurses, and social workers, as well as senior leaders, to promote communication, provide feedback, and create initiatives that linked the two. The group met monthly for two years, and now meets quarterly. Among its early objectives were the development of protocols to screen and identify at-risk older adults, to establish mechanisms for information sharing and resources, to identify gaps and duplication in service delivery, to locate a AAA case manager at the CSH, to educate staff from both organizations, to collect data and information, and to identify and address barriers to implementation.

Eventually SAGE created an RN care manager assessor program, in which placed an AAA assessor in the acute care hospital. The assessor works closely with the ACE team to identify hospitalized patients who can benefit from community-based programs, as well as patients who are eligible for PASSPORT, the state’s Medicaid waiver program. This was a new initiative for the AAA, which had traditionally conducted these assessments post-discharge, in the patient’s home. That assessment now occurs before the patient is even discharged from the hospital, thus helping to determine needs for  community based services and facilitating the process for eligibility  and approval for Medicaid long term care benefits.  This is beneficial because patients will typically receive Medicare covered services for skilled needs but long term care needs are not addressed as well and the Medicare skilled benefits are provided for only a limited time usually < 30 days.   Without the other supports this vulnerable population is at risk for poor health care access, emergency department visits and  hospital readmission. The AAA then assumes case management for the consumer, and offers periodic geriatric follow-up.

This program has facilitated improved capacity management for complex patients in the acute care hospital. It improved AAA communication with primary care and hospital staff, reducing repeat hospitalizations, ED visits, and nursing home placements. It improved outcomes for complex patients, and decreased discharges from PASSPORT to nursing homes. During the pilot period,  referrals to and enrollments in the PASSPORT program doubled.   The AAA was also successful in replicating this model at other hospital systems in the Northeastern Ohio AAA service area.  A more recent positive outcome  related to this collaboration work was the awarding for AAA 10b Inc. one of the first seven  Community Based Care Transitions projects from CMS/CMMI as part of the The Community-based Care Transitions Program (CCTP), created by Section 3026 of the Patient Protection and  Affordable Care Act

In developing SAGE, several barriers had to be overcome, primarily those affecting leadership of the program, development of an effective multidisciplinary workgroup, and resources (in terms of staff time). The program can be adapted by other communities around the country, offering their acute medical system and community-based programs a way to align their services and collaborate in ways that better address the needs of frail older adults.



Key words: community collaboration, SAGE Project, ACE Units, CCTP, 3026, pilot programs