Shining Stars Webinar Highlights Care Transitions Work

 Posted by on April 24, 2013  No Responses »  Tagged with: , , , , , , , ,
Apr 242013
 
doctor_0

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.
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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

Southeast Michigan CCTP Tests New Approaches to Reduce Readmissions

 Posted by on April 23, 2013  No Responses »  Tagged with: , , , , , , , , ,
Apr 232013
 
Photo_Ben_Kuder

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

Hear Dr. Joanne Lynn Discuss Care Transitions

 Posted by on April 2, 2013  No Responses »  Tagged with: , , , , , , , , ,
Apr 022013
 
doctor_0

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

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

 Posted by on March 5, 2013  No Responses »  Tagged with: , , , , ,
Mar 052013
 
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Key opportunity to learn from Dr. Joanne Lynn, who will lead the faculty for a new session from the Institute for Health Care Improvement, a seminar on building systems that work for frail elders. Program in Colorado later this month, and more details here:

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

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

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

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

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

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

 

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

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

IHI Broadcast on Reducing Readmissions

 Posted by on November 20, 2012  No Responses »  Tagged with: , , ,
Nov 202012
 

by Meghan Hendricksen

Anew WIHI Webinar, Reality Knocks with Reducing (Hospital) Readmissions, features: Patricia Rutherford, RN, MS, Vice President, Institute for Healthcare Improvement, and Leora Horwitz, MD, MHS, Assistant Professor, Internal Medicine, Yale University School of Medicine, two prominent women in public health. They discuss the issues we face when trying to reduce hospital readmissions, and the ways we can successfully accomplish this. Everyone seems to agree that this isn’t the time or place for any one approach; instead, multiple facets of different interventions need to come together to work as a whole if they are to be efficient. The hour-long discussion highlights the challenges, and praises work that has shown to reduce 30-day readmissions so far.

 

You can listen to the broadcast here:

 

http://www.ihi.org/knowledge/Pages/AudioandVideo/WIHIRealityKnocksReducingHospitalReadmissions.aspx

 

Key words:  IHI, readmissions, care transitions

RARE Campaign: Measuring Success One Pillow at a Time

 Posted by on September 24, 2012  No Responses »  Tagged with: , , , , ,
Sep 242012
 
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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

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

 

 

Reaching Rural Residents: Improving Care Transitions in Western New York State

 Posted by on August 23, 2012  No Responses »  Tagged with: , , , , , , ,
Aug 232012
 
cms_partnership_for_patients

The P2 Collaborative of Western New York represents a different spin on the Community-based Care Transitions Program (CCTP) model. It is unique in its focus on a very rural area of Western New York, and is unusual in that it is one of a few  community-based organizations in CCTP that is NOT an Area Agency on Aging. P2 is a non-profit regional health improvement collaborative, with origins as a Robert Wood Johnson-funded Aligning Forces for Quality community project. Through that work, it has engaged in various activities within eight counties in Western New York.

As Megan Havey, Manager of Care Transitions, explains, “P2 doesn’t provide direct services, but acts as a facilitator to members of the collaborative.” The scope of the project really called for coordination by a regionally based group, one that could work with and understand the diversity of partners, and that could offer the sort of infrastructure support that such a collaborative would require.

The collaborative is one of the largest in the CMS CCTP portfolio. It includes eight local community-based organizations (CBOs) and ten hospitals, and works with other community agencies, organizations, and foundations including the Health Foundation for Western & Central New York, IPRO (the QIO), the Alzheimer’s Association, local  hospice organizations, and county health departments.  The work sprawls across seven counties, with programs that aim to serve more than 2,600 patients annually. The diversity of participating organizations is remarkable, ranging from a 5-bed to a 150-plus-bed hospital.

Over the last six years, many of the participating organizations had participated in pilot programs to improve care transitions. Other groups had little experience, but, Havey says, “…were in a great position to be mentored by groups that had experience.” In building the application, IPRO helped with many tasks, such as creating templates to conduct the required root-cause analysis, analyzing admissions data, and convening partner organizations. Havey says that although IPRO has now “stepped back” from the project, P2 continues to solicit IPRO for technical assistance and support.

The application process was instructive, Havey says, in helping the partners to appreciate just how flexible the project would need to be. “Each county had a very different target population and model,” she says. “It was important  to be able to engage partners and obtain their buy in, but also to be realistic about what we could achieve in each county. We could not create a cookie cutter model.” All of the local CBOs and hospitals are using the Coleman model, the Care Transitions Intervention™, and are targeting Medicare Fee-For-Service patients.

Havey says that developing a web-based data platform that all partners could use has been an essential step. The platform had to accommodate the range of reporting capacity partners bring to the project. To that end, P2 worked with a software company to invest in and develop a platform all hospitals could use to enter data about eligible patients. The system operates within the context of the Care Transitions Intervention, and allows care managers to document data about home and hospital visits, as well as follow-up calls and evaluation information.

Havey notes special challenges in serving a rural population, particularly in terms of accessing care. There are not enough providers, she says, and transportation to get to them can be difficult. “Rural counties have very poor health outcomes, with many medically underserved areas and populations. Our goal is to reduce readmission rates with an intervention that leads to better health outcomes and improves quality of life.”

For more information about the work underway at the P2 Collaborative, contact Havey at [email protected], or read more about the group’s work at http://www.p2wny.org/

Key words: care transitions, CCTP, Section 3026, rural residents, readmissions

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