Care Transitions Archives - Page 3 of 6

SASH: How One Community Is Meeting the Challenge of Care for Frail Elders

Posted by Les Morgan on February 5, 2012 No Responses » Tagged with: care transitions, coalition building, community-based, PACE, SASH, Vermont

Feb 052012

Earlier this year (2012), the Agency for Health Care Research and Quality (AHRQ) released an innovation profile about Vermont’s Support and Services at Home (SASH – https://sashvt.org/) program, which provides onsite assistance to older adults and other Medicare beneficiaries so that they can age in place. As AHRQ describes it, SASH offers key evidence-based services, such as “an initial assessment by a multidisciplinary onsite health team, creation of an individualized care plan, onsite nursing and care coordination with team members and other local partners, and community activities to support health and wellness.” Basically, SASH combines supportive housing with critical medical and nursing services on-site. In a year long pilot study with 65 residents, the program reduced hospital admissions and readmissions, had decreased falls, improved nutritional status, increased levels of physical activity, and no bounce backs to nursing homes.

Cathedral Square Corporation (CSC) Executive Director Nancy Eldridge spent an hour talking with MediCaring to offer more insights into the successful program. Conceived in 2006, she says the program came in reaction to a realization that the community faced a “backlog of people in need in our communities, people who had significant complex physical needs, cognitive impairment, depression, and medication management issues.”

“We were involved in looking at models that would be scalable, replicable, and sustainable,” says Eldridge. “We need a system in this country of making sure that people can stay in their homes, a system that is as comprehensive and robust as our public education system, which was developed in response to the needs of the same population, the Boomers. We needed a system then to make sure Boomers were educated, and we need an equally comprehensive and sustainable system for the long term care they will need.”

Cathedral Square owns or manages 24 sites throughout four Vermont counties. Originally funded through a combination of state funds and philanthropic donations, SASH is currently funded through Medicare’s Multi-Payer Advanced Primary Care Practice Medicare Demonstration program, one of 8 states in the country funded for this 3 –year endeavor. As part of the demonstration, SASH will expand to 112 sites throughout Vermont.

Building on its successful SASH pilot, leaders at Cathedral Square approached leaders at other affordable housing organizations, going “organization by organization until we had covered all corners of the state,” says Eldridge. SASH is now operating in 7 counties, and will be statewide by the end of 2012. The program’s partners include all five state Area Agencies on Aging, Visiting Nurse Associations, and PACE Vermont, as well as every hospital in the seven counties currently participating. Each participating housing organization commits one person to the SASH site. For example, the community’s Area Agency on Aging would commit one case manager to one SASH hub site; she is the point person for all AAA clients at the hub site.

When SASH rolls out to the planned 112 sites and their neighborhoods, the new projects will include public and non-profit housing programs and their catchment areas, with the aim of reaching out to the entire community. Affordable housing sites are widely dispersed throughout Vermont, and bringing the core SASH services to very rural areas is a key element of the program. Eldridge says they are “using that core as a platform to integrate with other work. For example, we are helping with the use of CDC tobacco cessation funds as a way to convert all of these properties to smoke-free facilities.”

In another collaborative program, Cathedral Square is working with the housing collaborative and other stakeholders to support a broadband initiative, one that would get connectivity into affordable housing sites, making them anchor sites for free fiber optic networks. This helps to advance goals around health information exchange. “If we start looking at the system, and we approach problems in long-term care, we find we can raise many boats. We don’t benefit only the elderly, but families and the housing network as well.”

To read the full innovation report, go to http://www.innovations.ahrq.gov

To learn more about Cathedral Square, and to see a video about the SASH program, visit http://cathedralsquare.org/

Key words: care transitions, supportive services, SASH, AHRQ, innovation

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

Posted by Les Morgan on February 2, 2012 No Responses » Tagged with: care transitions, coalition building, frail elders, Section 3026

Feb 022012

The following blog originally appeared on the Altarum Institute Health Policy Forum blog at www.healthpolicyforum.org on Tuesday, January 31, 2012. It is co-authored by Janice Lynch Schuster and Joanne Lynn.

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

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

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

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

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

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

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

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

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

References

1. Butterfoss, F. D., Goodman, R.M. & Wandersman. (1993). Community coalitions for prevention and health promotion. Health Education Research Theory and Practice, 8(3), 315–330
2. Osmond, J. Community coalition action theory as a framework for partnership development. Originally retrieved from mycalconnect.org/sacramento/download.aspx?id=10949 but which is now available from:
https://www.dshs.texas.gov/wellness/PDF/ccat-10.29.08.pdf

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

Family Caregivers: The Missing Link in Transitional Care

Posted by Les Morgan on December 22, 2011 No Responses » Tagged with: care transitions, family caregivers, quality improvement, toolkits

Dec 222011

by Carol Levine

Carol Levine is director of the United Hospital Fund’s Families and Health Care Project, which coordinates the Next Step in Care campaign.

Family caregivers often say that they feel invisible in hospitals and other health care settings. I know what they mean from my own 17 years’ experience caring for my late husband. Even now, when I speak at a program on transitional care, I am usually the only one who talks about family caregivers’ critical roles and responsibilities. This situation is changing but very slowly. Transition protocols now sometimes mention the caregiver but only as the add-on to “patient,” as in “patient/caregiver.”

This modern chimera is as fantastical as the fire-breathing lioness/goat/snake of the Iliad. In reality the patient and caregiver are not mirror images of each other. Failing to acknowledge caregivers’ individual limitations and needs for information, training, and support is as misguided as ignoring their intimate knowledge of their ill family member or friend.

For 15 years the United Hospital Fund has been working to change provider practice and give caregivers accurate, pertinent, and accessible information to help them become true partners in care.

The Fund’s Next Step in Care campaign has three main components:

A website (www.nextstepincare.org), with 23 free downloadable guides for family caregivers available in English, Spanish, Chinese, and Russian. Other guides for health care providers help them work more effectively with family caregivers.
Outreach to community-based organizations to train staff to be able to use the Next Step in Care guides in their interactions with family caregivers.
The Transitions in Care-Quality Improvement Collaborative, now in its second round, which brings together teams from New York City hospitals, nursing home rehab programs, home care agencies, and hospices to work on processes that involve family caregivers in transition care planning and implementation.

The Next Step in Care guides are organized around four main categories: (1) information for all caregivers, (2) hospital stays (including discharge planning), (3) rehabilitation services, and (4) home care. In the first category are guides, for example, on becoming a family caregiver, HIPAA and privacy regulations, emergency room visits, and hospice and palliative care, as well as a medication management guide and form. In the hospital stay category are a guide to help caregivers do a self-assessment of needs and concerns, a guide to discharge planning options, and a discharge checklist. The rehab and home care sections include guides that introduce these services and tell the caregiver about likely roles and responsibilities, as well as financial aspects.

These resources can be used in conjunction with or independent of any formal transition program. They provide a basis for identifying and acknowledging family caregivers as the missing link between hospitals or rehab programs and community services.

Key words: family caregivers, care transitions, toolkits, quality improvement, caregiver information, caregiver support

MATCH: AHRQ Toolkit Offers Guidance for Standardizing Medication Reconciliation

Posted by Les Morgan on December 12, 2011 No Responses » Tagged with: care transitions, discharge planning, medication reconciliation, patient safety

Dec 122011

Groups looking to improve their medication reconciliation process, a critical element of improved care transitions, will find how-to guidance in a just-released Agency for Healthcare Research and Quality toolkit, Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation (http://www.ahrq.gov/qual/match/match.pdf). Based on an online toolkit (https://www.ahrq.gov/patient-safety/resources/match/index.html) developed by Gary Noskin, M.D., and Kristine Gleason, R.Ph., the toolkit offers step-by-step information on how to launch and sustain a standardized medication reconciliation process.

Doing so is an essential element of many patient safety and quality initiatives, including those sponsored or supported by The Joint Commission and the Centers for Medicare and Medicaid. Communication about medications is one of eight key areas covered by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), and is a critical element in standards related to meaningful use of electronic health records.

The toolkit authors explain that medication reconciliation involves a complex process of finding discrepancies between a patient’s current medications compared to those included in doctor admission, transfer or discharge orders. Such discrepancies need to be identified and discussed with the provider and patient; if necessary, orders must be revised. The process includes getting a medication list of prescription and non-prescription drugs, either when a patient is admitted or seen; considering these medications when ordering new medications or continuing treatment; verifying discrepancies; and providing an updated list and communicating its importance to the patient and caregiver.

Groups can use the toolkit to evaluate their existing processes and to identify and respond to gaps in them. It offers strategies for standardizing the process for physicians, nurses, and pharmacists, emphasizing the need for clearly defined roles and responsibilities. A standardized process can ensure that the most accurate and complete documentation is developed for each patient, that inpatient and home medications are reconciled, and that information is available to the entire health care team.

The guide features seven sections covering topics that range from how to encourage facility leadership to support a medication reconciliation endeavor to how to recognize and manage high-risk situations.

Key words: medication reconciliation, discharge planning, care transitions, patient safety

Dr. Joanne Lynn on the Need for Rapid Follow-up Post Discharge

Posted by Les Morgan on December 5, 2011 No Responses » Tagged with: best practices, care transitions, discharge planning, frail elders, quality improvement, rapid follow-up, rehospitalization

Dec 052011

Patients just discharged from the hospital urgently need rapid follow-up in the community. Dr. Joanne Lynn describes the care coordination needed among patients, community providers, hospitals, and other settings, and what’s needed to make it work.

Key words: rapid follow-up, care transitions, discharge planning, quality improvement, rehospitalization

Southwest Ohio Care Transitions Collaborative Talks to Medicaring about CCTP Award

Posted by Les Morgan on November 28, 2011 1 Response » Tagged with: care transitions, CMS, coalition building, community-based, frail elders, quality improvement, rehospitalization, Section 3026

Nov 282011

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

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

Dr. Joanne Lynn on the Role of Palliative Care in Improving Care Transitions

Posted by Les Morgan on November 28, 2011 No Responses » Tagged with: care transitions, Dr. Joanne Lynn, palliative care, quality improvement

Nov 282011

Hospice and palliative care can play a major role in improving care transitions for patients who have serious chronic conditions. Dr. Joanne Lynn explains how the hospice/palliative care model can improve patient care, offering 24/7 support, excellent symptom management, and wraparound services. People will need to realize what they’re up against, and turn to these important resources.

Key Words: care transitions, palliative care, hospice quality improvement

CMS Announced First Awards for CCTP Funding

Posted by Les Morgan on November 18, 2011 No Responses » Tagged with: care transitions, CCTP, hospital readmissions, Section 3026

Nov 182011

CMS announced the first sites selected for the Community Based Care Transition Program. Please see the links below for the list of sites and an updated fact sheet. As noted above, we continue to accept applications and look forward to selecting additional sites in the near future.

The following overview of the selected sites offers a glimpse into where things will be happening as these programs launch. We at Medicaring.org hope to interview leaders from many of these sites, and to gain their ideas and insights about what made for a successful application, and where others might learn from their work.

The Atlanta Community-Based Care Transitions Program (Atlanta CCTP), a collaborative partnership serving ten counties in the Atlanta region, including the Atlanta Regional Commission (an Area Agency on Aging), and six urban area hospitals: Emory University Hospital Midtown, Gwinnett Medical Center, Piedmont Hospital, Southern Regional Hospital, WellStar Cobb Hospital and WellStar Kennestone Hospital.

The Akron/Canton Area Agency on Aging (A/C AAA), working in partnership with 10 acute care hospitals located within, or geographically contiguous to, the A/C AAA service area in Ohio: Affinity Hospital, Aultman Hospital, and Mercy Medical Center in Stark County; Akron General Medical Center, Summa Akron City Hospital, Summa Saint Thomas Hospital, Summa Barberton Hospital, and Summa Western Reserve Hospital in Summit County; Robinson Memorial Hospital in Portage County; and Summa Wadsworth Rittman Hospital in Medina. County.

The Southwest Ohio Care Transitions Collaborative, serving the Cincinnati Metropolitan Statistical Area and surrounding counties in Kentucky, Indiana, and Ohio, including the Council on Aging of Southwestern Ohio, the Greater Cincinnati Health Council, HealthBridge, Health Care Access Now, Healthcare Improvement Collaborative, Hamilton County Mental Health and Recovery Services Board, Clinton Memorial Hospital, Jewish Hospital, Mercy Hospital Fairfield, The Christ Hospital, and UC Health University Hospital.

The Southern Maine Agency on Aging/Aging and Disability Resource Center (SMAA/ADRC), serving five counties in southern and mid-coast Maine in partnership with the Maine Medical Center Physician-Hospital Organization and five MaineHealth hospitals: Southern Maine Medical Center, Maine Medical Center, Mid-Coast Hospital, Miles Hospital, and PenBay Medical Center.

The Area Agency on Aging, Region One, serving Maricopa County in Arizona, in partnership with John C. Lincoln North Mountain Hospital, West Valley Hospital, Scottsdale Healthcare Osborn Medical Center, John C. Lincoln Deer Valley Hospital; APIPA, a Medicaid Acute Care Plan that serves dually-enrolled Medicare fee-for-service beneficiaries; and Sunwest Pharmacy.

Elder Services of the Merrimack Valley, Inc., in partnership with Anna Jacques Hospital, Saints Medical Center, Holy Family Hospital, Lawrence General Hospital, and Merrimack Valley Hospital, and serving 23 cities/towns in the Merrimack Valley of Massachusetts and ten bordering cities/towns in southern New Hampshire where patients using these hospitals also reside.

Council for Jewish Elderly (“CJE SeniorLife”) in Chicago, IL, partnering with Northwestern Memorial, Saint Joseph Hospital, and Saint Francis Hospital and working closely with Area Agencies on Aging in Chicago and suburbs, local Care Coordination Units (CCUs), and Illinois’ Quality Improvement Organization, IFMC.

Key words: 3026 funding, CCTP sites, care transitions, CMS

Dr. Joanne Lynn Explains the 10th Statement of Work for QIOs

Posted by Les Morgan on November 14, 2011 No Responses » Tagged with: 10th SOW, care transitions, QIO, quality improvement

Nov 142011

Under the 10th Statement of Work, QIOs nationwide will be launching exciting new programs to improve care transitions. This three-year endeavor builds on promising working undertaken by QIOs in 14 states. Dr. Joanne Lynn explains what’s coming and how to get involved.

Key words: care transitions, QIOs, 10th SOW, 10th Statement of Work, quality improvement

Dr. Joanne Lynn on the Community-Based Care Transitions Program

Posted by Les Morgan on November 7, 2011 No Responses » Tagged with: care transitions, community-based, quality improvement, Section 3026

Nov 072011

The Centers for Medicare and Medicaid launched Community-Based Care Transitions Program, or CCTP, to reimburse the costs of coordinating care across settings. Dr. Joanne Lynn gives an overview of the program, and how it will work to engage community-based organizations engaged in improving care transitions.

Key words: Care transitions, Community-based care transitions, Section 3026, quality improvement, community-based organizations, Centers for Medicare and Medicaid

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