The Southwest Ohio Care Transitions Collaborative, one of 7 sites chosen by the Centers for Medicare and Medicaid for the first cohort of 3026 funding, had lots going for it as it pulled together a broad-based community health coalition and implemented strategies to reduce avoidable readmissions for older adults. The program brought to its application a coalition that included major community-based organizations, the local hospital association, and five hospitals serving the Greater Cincinnati area. It had demonstrated success with a care transitions pilot program based on the Coleman model, and it submitted an application to CMS that clearly explained the strategy behind its blended rate calculations. The Collaborative estimates that it will serve some 5,400 seniors each year, with a cost savings to Medicare of more than $1 million. The specific intervention is built directly on the Coleman model, with some modifications to account for local needs and experiences.
The application built on the success of a pilot project implemented at UC Health University Hospital, which showed that participants had a lower-than-average readmission rate, and that most patients were discharged to their home or other community setting, rather than to a skilled nursing facility. Sharon Fusco, Director of Business Results and Innovation for the Council on Aging of Southwestern Ohio, is optimistic that the care transitions intervention will significantly reduce readmissions among hospitalized Medicare beneficiaries with diagnoses that include pneumonia, heart failure, heart attack, or multiple chronic conditions.
In building the coalition, Fusco says the group aimed to be certain to include all of the organizations that could influence and affect patients’ lives; where the root cause analysis identified gaps in care, the coalition took care to find organizations that could fill them. As a result, the coalition now includes the Greater Cincinnati Health Council, which is the local hospital association; a health information and technology exchange organization; a program that helps to coordinate patient access to physicians; and a local mental health and recovery services board.
The Collaborative used its root cause analysis to identify gaps in care, and to consider strategies that would mitigate problems. So, for instance, as Fusco explained, the root cause analysis identified mental health issues as a significant barrier to patient involvement in discharge planning and follow-up. “We had to find a way to help these individuals, and to connect them to a mental health medical home,” Fusco explained. To that end, the mental health board was enlisted, and will play a critical role in assisting patients whose mental health problems present barriers to good care.
The analysis also found tremendous problems in medication reconciliation, a problem that affected more than 90% of patients in a pilot at University Hospital. In exploring this issue more deeply, the Collaborative found that many patients did not have relationships with or access to primary care physicians, a real barrier in trying to help hospitalized patients make and keep important follow-up appointments. To this end, the Collaborative involved a group that focuses on coordinating patient access to physicians.
In general, the Collaborative found that the Coleman Model matched most of its needs in responding to problems identified by the root cause analysis. The Council on Aging added a fifth pillar to the four pillars of the Coleman model home and community-based programs for which some patients might be eligible. Meals, home care assistance, and transportation are among the services these programs offer.
Fusco and her colleague, Communications Director Laurie Petrie ,anticipate that the Collaborative will encounter some challenges in with regard to operations and technology differences among participating hospitals (e.g., rural versus urban settings), and to the ramp-up of health information technology systems. Fusco noted that one challenge will be “getting the right staff and the right tools to each hospital.” But she is confident in the Collaborative’s ability to overcome these barriers and deliver successful interventions.
Fusco offered some advice for other potential applicants. In particular, she advises that groups take time to explain in detail how they calculate their blended rate, “really spend time explaining the rate and what goes into it.” According to Fusco, the process of calculating the blended rate was difficult but critical. She said, “The process of [pulling together this application] turned out to be a healthy exercise for us. Costing out all the inputs that go into providing this service was challenging and time consuming, but completely necessary. We built a cost model that allowed us to account for both fixed and variable costs. In the end, the process increased our learning, and we found it very beneficial.”
She advises other potential applicants to be thoughtful and meticulous as they develop their calculations. “You need to understand what your costs are, what’s fixed and what’s variable. Then you can plug in the numbers. But you have to think about everything that goes into serving a client—what does it cost you to actually run the intervention? Not just the face-to-face time with the client, but all of the rest of the costs.”
She also feels that the Collaborative’s application was stronger for having been reviewed and critiqued by external partners, individuals with no connection to the program being proposed. To that end, she said, consultations on aspects ranging from policy to cost were helpful.
Key words: care transitions, CCTP, Section 3026, award sites, community coalition, quality improvement