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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

Webinar Tomorrow: Mary Naylor on Transitional Care Model

 Posted by on November 16, 2011  4 Responses »  Tagged with: , , ,
Nov 162011
 

This week’s Colorado Foundation for Medical Care (CFMC) program, Integrating Care for Populations & Communities Learning Session Webinar will be held tomorrow, Thursday, November 17, 2011 at 3:00 pm ET.  This webinar is the seventh presentation in the 10-part series: Navigating Care Transitions: Intervention Opportunities – Next Exit

 The series is designed to give participants an opportunity to hear directly from developers of various care transitions interventions, and to learn more from them about resources, techniques, and tools available for partners to use in their community efforts to improve care transitions.

 Tomorrow’s program will feature Mary Naylor, PhD, RN, who developed the Transitional Care Model, an approach that features an advance practice nurse who helps to coordinate care. Dr. Naylor will speak from 3-4 PM ET. Dial in to the teleconference at 866.639.0744 or join via webinar at https://qualitynet.webex.com, password: community.

A  final schedule of these presentations is posted at: http://www.cfmc.org/integratingcare/learning_sessions.htm

 

Key words: Care transitions, Mary Naylor, Transitional Care Model, Colorado Foundation for Medical Care

Dr. Joanne Lynn on the Naylor Model: How the Transitional Care Model Works

 Posted by on October 17, 2011  No Responses »  Tagged with: , , ,
Oct 172011
 

Advanced practice nurses can be very effective in helping to bridge transitions from hospital to home. Dr. Joanne Lynn describes the Transitional Care Model, developed and tested by Dr. Mary Naylor and her colleagues at the University of Pennsylvania.  You can learn more about TCM from its website: http://www.transitionalcare.info/, and by watching the video below.

 

 

Keywords:  Transitional Care Model, Care Transitions, Joanne Lynn, Advanced Practice Nurses

 

Evidence-Based Interventions: Replicate or Adapt?

 Posted by on June 14, 2011  No Responses »  Tagged with: , , , , , ,
Jun 142011
 

In a complex system such as  transitions of sick and fragile patients from one setting to another, we are often so grateful for the few carefully done and reported research endeavors that funders and researchers easily fall into the trap of insisting upon slavish replication, assuming that this is the way to achieve the same results. If we were working with a highly standardized “system,” such as how heart cells respond to a drug, then we could reasonably assume that the curve of responses in Maine would be just about the same as the curve of responses in Arizona, and that what works for a dozen will work as well for a hundred.  Sometimes, of course, even those assumptions are wrong, but it is rare for an unmeasured characteristic of the population to greatly alter drug effects or metabolism.

However, there is every reason to assume that carefully done research on small numbers in a few settings will not be enough to guide practical implementation of process redesign.  There are two main reasons for this.  First, our paradigm for good studies is the randomized controlled trial (RCT), but some of its characteristics actually undercut the utility of the findings for guiding replication.  Specifically, the effective restrictions (stated and unstated) for eligibility make it likely that only a small sub-set of actual patients will be eligible for the trial.  Second, the fact that one is willing to randomize within one setting is good for blinded trials, but undercuts the galvanizing of the will that is often essential in fueling system reform. Consider this example – could you really generate the outrage that allows  a nursing unit to make changes to stop repeated mistakes in transitions to stop the suffering of their discharged patients — and simultaneously be expected to continue to do it wrong for all but a few of the patients?

Another challenge in the usual RCT is that the numbers affected are small — often only a small subset of the patients in the test site.  While this works for a proof of concept, improvement experts quickly note that scaling up is never just a matter of applying the same changes to a lot more people!  Instead, scaling up poses its own problems.  As one scales up improvements in care transitions, one has to work on incorporating many elements of the work into job descriptions and job routines so that the workflow is smooth.  One has to figure out fail-safe strategies, develop broad consensus in the community as to standards, train a populace to take a more active role in managing transitions for themselves and their loved ones, right-size the community’s supportive services, and a dozen additional elements.  The research model is usually a discrete ”add-on” patch to a dysfunctional system.

Indeed, an RCT relies upon not changing the underlying dysfunctional system.  As one tries to implement the improvement approach more broadly, efficiency dictates that it become part of the system wherever possible.  Often, this also means that the highly skilled and motivated people involved in the research are replaced by less skilled, and, often, less motivated personnel providing routine services, with lower pay and more stresses.  Adapting the work of a research nurse practitioner to a regular home care RN, or of a skilled professional to a retiree volunteer, is real work that takes testing, innovation, and creativity.  In the work of the Quality Improvement Organizations (QIOs), for instance, as they implemented evidence-based interventions, many substantial adaptations were required.  One team trained certain nurses in a home health agency to be the bridging nurses in an adaptation of Naylor’s model (see: http://www.innovations.ahrq.gov/content.aspx?id=2674).  One team used senior volunteers as trained coaches for patient activation in an adaptation of the Coleman model. I don’t believe that any of the 14 communities were able to implement a research-based intervention exactly as it had been done in the research report.  The research was still quite important for laying down the path, but following the path with larger numbers in varied contexts required adaptations.

Perhaps the most substantial challenge in our work is that small numbers do not threaten the hospitals’ overall patient flow, while broad implementation could cut into occupancy rates and cause serious financial problems, especially if done too quickly for the system to adapt and right-size its services.  Scaling up requires considering the financial impact. The good news is that there are usually good reasons to absorb this impact, including the fact that most rehospitalizations and medical hospitalizations of Medicare patients do not make the hospital money, or at least not much money.

Keywords: quality improvement, model adoption, evidence-based, eldercare, community-based, Naylor Model, Coleman Model