Jan 072013

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

Aug 232012

The P2 Collaborative of Western New York [name was changed to Population Health Collaborative in 2017] 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.”

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

Jul 232012

By Dr. Kyle Allen and Susan Hazelett

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

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

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

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

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

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

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

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

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

Jul 102012

Older residents (with fee-for-service Medicare) of a four-county region around Rochester, New York, are likely to benefit from the innovative programs being launched by a community-based care transitions project (CCTP) in that region. The “Community-wide Care Transitions Intervention” is anchored by Lifespan of Greater Rochester, a non-profit organization funded mostly by the Administration on Aging. The collaborative effort includes four acute care hospitals , two home health care agencies, and the regional independent health planning organization.

Of particular interest to MediCaring readers may be the involvement of the hospital pharmacist in this endeavor, which seems to be a key development to addressing the common problems of medication mismanagement. MediCaring talked to pharmacist Andrew Smith of Strong Memorial Hospital, and Brenda Bartock, RN, MPA, director of program development for Visiting Nurse Service of  Rochester and Monroe Co., Inc.

Smith explained that he receives a daily list of hospital admissions from which he selects the best candidates for the pharmacist intervention. The “best” candidates include those with what the program characterizes as an active Preventable Quality Indicator (PQI) diagnosis, or characteristics that put them at risk for re-hospitalization, such as comorbidities, polypharmacy, previous hospital admissions in the last year, or other risk factors such as living alone, absent social supports, or no transportation.  Smith then follows these patients during their hospitalization, meeting with them as soon as possible to discuss the enhanced hospitalization program and his availability to help them with medication. He will meet with them again near discharge, when he reviews medications with each patient (and family), focusing on what’s changed during the admission and what’s new, and letting them know that he is available to answer their questions. Using software called the Medication Action Plan, Smith gives patients an easy-to-read yet comprehensive medication list that they review together. He makes sure that prescriptions match insurers’ formularies and that schedules are workable for patients and family caregivers. Five days after discharge, he calls patients to follow up, making sure that they have not run into problems obtaining or using prescribed medications.

This is quite different from the usual process, in which there is no formal discharge planning with the pharmacist. Ordinarily, hospital pharmacists review what a patient has been prescribed during the stay, and not what was being used before the hospitalization. And although the pharmacist might occasionally see patients, that is not the norm.

Smith told MediCaring that, just three weeks into the program, he has seen some changes  being made. He offers services that the medical team often simply does not have time to address, such as helping patients to understand the need for a new medication and  helping them to reconcile pre-hospitalization medication routines with post-hospitalization routines.

Because the program was just launched in June, Smith says there has not really been an opportunity to see its effect on patients. He is not yet sure that the five-day follow-up call is the best timing. Smith also notes that the process enables him  to work more closely with physicians to develop medication management plans, providing doctors with information they welcome because it helps them to ensure that patients have workable routines.

According to Bartock, the pharmacy intervention helps to strengthen the program, and the case management it provides.  She says patients coming into the transitions program who have received the pharmacy intervention tend to be “in better shape than those who don’t have it.” In general, patients who are offered the intervention agree to participate in it. In just under three weeks, Smith says, he had seen approximately 20 patients.

Those interested in learning more about the Lifespan work can contact Mary Rose McBride at  585-244-8400, ext. 112 or  585-787-8376.

Key words: CCTP, care transitions, pharmacist, polypharmacy, frail elders, discharge planning

May 242012

Your 80-year-old mother, who can’t recognize you due to severe Alzheimer’s dementia, has developed pneumonia after being hospitalized with a broken hip. Her doctor has told you that she might pull through and that the medical team needs your input on how and where she will live after this episode: at home, or at a nursing home, and with what help—family, home care agency, and/or hospice. You realize that you don’t know what her wishes are—and that she can no longer express them. You also don’t know how you, as her sole family caregiver, will be able to take care of her or afford professional help in doing so. Meanwhile, the doctor is asking what measures should be taken, and for how long, to keep her alive. You don’t have the answers to those questions either. Suddenly, you feel very much alone, bewildered and overwhelmed.

In one sense, you’re not alone, as five prominent women writers recently explained during a roundtable discussion that Altarum Institute’s Center for Elder Care and Advanced Illness held on April 13. During the roundtable discussion, “The Last Word: Influential Women Discuss What Matters When Loved Ones Face Aging,” (watch it online on YouTube) the presenters—three of them geriatricians, and all of them influential social commentators and family caregivers—discussed their experiences in caring for aging loved ones and patients. The writers warned that the number of aging Americans who are struggling with these issues, along with their families and friends, is already substantial and growing rapidly.

Pulitzer Prize winning columnist Ellen Goodman introduced the panel with an overview of the state of aging in America, noting that the first members of the huge baby boomer generation will turn age 85 in 2031. This demographic “cannonball” is already hurtling toward us: each day, 10,000 baby boomers are turning 65. Goodman described her own experiences as a caregiver to her mother and related the constant and seemingly impossible decisions she had to make on her mother’s behalf. She noted that her experience has led her to develop a soon-to-be-launched program, The Conversation Project, aimed at encouraging people to think and talk about their preferences and priorities for the end of life.


Indeed, many of us haven’t given any thought to how we want to live out our final months; nor what role loved ones are likely to play during this final phase of life. Without such planning, the last months, when they come, are likely to be disorienting, frightening and overwhelming.

Geriatrician and family caregiver Cheryl Woodson, M.D., speaking from a decade of experience caring for a sick and aging parent, urged caregivers not to feel that they are not doing enough. Many have unrealistic expectations about what they can and should do, and failing to live up to these expectations can leave many feeling guilty and alone.

In fact, Dr. Woodson said, caregivers need to recognize and understand that we are facing social, cultural and demographic times unlike any in our history. We are facing a future with millions more “old old” people who will be more disabled and frail for longer than any previous generation. Caring for these aged loved ones, Woodson said, means “This is not your mama’s caregiving.” Indeed, it is a whole new world.

Dr. Muriel Gillick, a Harvard professor and geriatrician, addressed other unrealistic expectations many hold: The notion that if we simply eat well, exercise plenty and live right, we will live to a ripe old age and die in our sleep. That scenario is not likely to play out for the majority of us, who will, in fact, grow old and sick and die after many years of living with a serious chronic condition.

Author Susan Jacoby echoed this sentiment, pointed to the ways in which we deny the realities of aging and instead rely on the images we see in Viagra ads: That we will all be paragliding in our old age, living out fantasies and walking into the sunset hand-in-hand with our equally spry spouse. Instead, Jacoby suggested, we must pay attention to what we really face and acknowledge the hard realities of that future and find ways in which we can cope with frailty, illness and death.

Journalist Francine Russo gave a slightly different take on the world of caregiving during the roundtable, describing the dynamics of sibling relationships in the context of caring for aging parents. She noted that many of us will revert to roles we played as children, and that those old roles will not serve us well in our efforts to serve our parents—indeed, they can tear families apart.

Finally, geriatrician Joanne Lynn described her experiences as a physician and a family caregiver, noting that in the years when she herself cared for a very sick child and a very frail in-law, she could always find people willing to support her in the former work, but very rare to offer help in the latter. She spoke of the need for neighborliness in the future, for finding ways that communities and individuals can come together to share the common work of caring for the aged. She suggested that reforms must come at the local level and that communities need to set priorities for elder care and advanced illness and determine the shape and course of their own programs and services for frail elders.

The panelists agreed on various steps proposed—ranging from policy changes to discussions families can and should conduct—to plan for the provision of supportive services that preserve the comfort and dignity of frail elders. Such steps should also take into account both the elder’s and their caregivers’ emotional wellbeing and financial solvency from the onset of aging-related disability through death.

Feb 232012

CJE SeniorLife, a community-based organization that serves some 18,000 older adults annually, is among the first cohort of recipients for  Section 3026 or  Community-Based Care Transition Program (CCTP) funding from the Centers for Medicare and Medicaid. One of seven early awardees, CJE will anchor a project that includes three large hospitals in Northern Chicago, as well as long-term services and supports organizations that serve frail older adults.

Medicaring talked to Heather O’Donnell, JD, LLM, CPA, then CJE’s Director of Planning for Healthcare Reform. She said that the process that led to funding has been underway for more than a year, and began when the group first began to consider opportunities that were arising as a result of health care reform, and how it might further its effort to bridge gaps between social services and medical care.

CJE, which had already been involved in care transitions improvement efforts, began to reach out to hospitals in its community, approaching them to find out whether they would be interested in partnering for the CCTP opportunity. Ultimately, three hospitals were selected:  Northwestern Memorial Hospital (a major academic medical center), Provena-Resurrection Saint Joseph Hospital, and Provena-Resurrection Saint Francis Hospital. The team also includes Telligen, the Illinois Quality Improvement Organization and local Care Coordination Units. These state-run units, housed in communities throughout Illinois, address the needs of older adults who have complex, ongoing health care needs. Patients who have  diagnoses of pneumonia, congestive heart failure, or AMI are targeted, as well as those who have complex conditions or take multiple medications.

The intervention is based on Eric Coleman’s model, which focuses on coaching patients and families to improve self-management skills for chronic conditions and medication management. The 30-day intervention aims to help people access home and community-based services and features a follow-up home visit by a transitional care nurse within 72 hours of discharge. These nurses, who have participated in the Care Transitions Intervention training program, help patients and families to set 30-day post-discharge goals, and to make and keep followup appointments. In addition, CJE received foundation funding which is enabling it to include a social work intervention; very high risk patients are identified and receive followup with a social worker for six months post-discharge.

“We had to adapt the Coleman protocols,” says O’Donnell. “We felt that for some patients, those with chronic conditions and psychosocial problems, thirty-days of followup were insufficient. We found that about 10 percent of the patients in our program would need more support services. That part of our program is not covered by CMS but is funded with private foundation funds.”

O’Donnell says that pulling the project together has taken a great deal of collaboration with the participating hospitals—from the on-the-ground work of finding the right contact people to developing specific strategies for the intervention. “But we felt that this was a good fit with what the hospitals were already doing,” she said. “It is very exciting work, getting every provider in the community to think about the quality of care from the standpoint of preventing an unnecessary readmission.”

Asked whether there had been any problems in bridging the divide between social services agencies and hospitals, O’Donnell said there had not. “This isn’t about us versus them. This is about everybody pulling together and undertaking a new initiative that’s good for everybody—good for the hospital, the nursing home, the patient. It’s a new approach.”

CJE meets regularly with its partners at each participating hospital, although the three are some miles apart and there is no reason to try to pull them all into one meeting. Orchestrating such a meeting, O’Donnell said, would be quite difficult, given how busy people are, and how hard it is to accomplish specific tasks when so many people are involved. “We’ve found it’s more effective to address each hospital and their concerns and our strategies individually.” CJE is, however, convening quarterly meetings of participating nursing homes, at which it hopes participants will talk about their successes, challenges, and processes. CJE is also mindful of the role to be played through partnerships with its local AAA (Area Agency on Aging), which is in the midst of applying for separate CCTP funding. It is also keeping the Department of Health Care and Family Services apprised of its work.

The process of actually launching the program took several months of work with CMS to address questions and concerns and finalize a contract. The application, submitted in August, received final approval in November. The first wave of projects will begin in one hospital on March 1, with other hospitals launching in April and May; ultimately, the project anticipates serving some 2,700 people each year.  As O’Donnell notes, “It is a significant undertaking, and there are lots of details to be sorted out.”

She also noted that the relatively quick launch can be attributed in part to ongoing planning for implementation, addressing in advance issues that were likely to come up as the project rolled out. “We had these conversations internally and with hospitals before the application was even approved.” 

Key words: care transitions, Section 3026, CCTP, CMS, Coleman model, CJE


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

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.


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:

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

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

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