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

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

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

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 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

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

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

Oct 312011

Community-based coalitions are critical to improving care transitions. To this end, people working throughout the community, in a variety of settings, really need to work to get to know one another, understand each other’s systems, and develop solutions that will translate into effective services for the community. Dr. Joanne Lynn describes a few steps to take to launch such a coalition.

Key Words: care transitions, coalition building, Section 3026, Joanne Lynn

Oct 272011

 by Larry Beresford

The Hospital Association of Southern California, which convened a Palliative Care Committee to provide mutual support among its members working on palliative care initiatives, recently changed the committee’s name to the Care Transitions Committee, reflecting the affinities between these two major quality currents within America’s hospitals. But as the cover story in the most recent Quarterly newsletter of the American Association of Hospice and Palliative Medicine asks: “Where is Palliative Care in the Readmissions Boom?”

A growing body of research has documented palliative care’s ability to help seriously ill, hospitalized patients clarify their goals for treatment, manage their symptoms, and plan for the next stages of their care in alignment with their values, often at lower cost of hospital resources and higher patient satisfaction. Palliative care teams in the hospital often see the patients with the most serious illnesses, psycho-social complications and multiple chronic conditions, who are also at higher risk for readmission. Palliative care, in contrast to hospice, does not require a terminal diagnosis or time-limited prognosis. It can be offered from the point of diagnosis of a serious, chronic or incurable condition, in conjunction with any other treatment modality. Palliative care focuses on quality of life, relief of pain and suffering, and support for emotional and family concerns.

But palliative care is also serious and complex specialty care, with board certification offered in Hospice and Palliative Medicine, accredited medical fellowship opportunities, and advanced certification for hospital palliative care programs offered since September by the Joint Commission. A growing body of quality measures used in palliative care has been recognized by the National Quality Forum. Although it has been slower to develop outside the hospital’s four walls, the number of hospital-based palliative care services has steadily grown to 1,568, 63 percent of all hospitals with 50 or more beds. The same way that hospitals and hospital medicine groups are coming to recognize their responsibility for the outcomes of their discharge plans after the patient leaves the hospital, palliative care teams are now exploring their role post-discharge.

So why isn’t palliative care, with its specialty recognition and demonstrated positive outcomes, more front-and-center in current national efforts to improve care transitions across the health care system, thereby contributing to preventing unnecessary rehospitalizations? Some places, like the Hospital Association of Southern California, have acknowledged the connection. Others have given palliative care representatives a seat at the table when cross-setting teams meet to work on improving care transitions in their communities.

But Dr. Diane Meier, director of the Center to Advance Palliative Care, tells AAHPM’s Quarterly that the biggest barrier is the absence of research demonstrating the impact of palliative care consultations in the hospital on 30-day readmission rates — in contrast to data that convincingly demonstrates palliative care’s value equation within the hospital. “I think that is an urgent, high-priority research question for our field,” Dr. Meier says. “I am concerned that we are going to miss this window of opportunity, even though our patients are a big part of the readmission problem.” (For more information on palliative care, see the Center to Advance Palliative Care.)

 Key words: palliative care, care transitions, discharge planning, readmissions

Oct 242011

Dr. Joanne Lynn describes Project RED (Re-Engineered Discharge), a program developed by Dr. Brian Jack and his colleagues at Boston University. It is designed to help hospitals to re-engineer their discharge processes, and offers some free online materials and guidance, as well as IT-enabled patient transition aids. You can read more about the details of the program on its website at:

And you can listen to Dr. Lynn describe it below.

Key words: Care transitions, discharge planning, health information technology, Project RED

Oct 192011

In a factsheet from AARP’s Public Policy Institute, Lynn Feinberg and Allison M. Reamy  detail how provisions of the Affordable Care Act (ACA) will lead to better recognition of and support for family or informal caregivers. An estimated 40 million Americans are family caregivers, and provide everything from help with transportation to assistance with daily living. As boomers age, the need for caregivers will grow tremendously—but their numbers will note. It is essential that we have public policies that address the social, financial, and health care realities of people who are family caregivers. The ACA takes a step in that direction.

Noting that the ACA explicitly mentions the term “caregiver” 46 times, and “family caregiver” 11 times, the authors are hopeful in their analysis of how caregivers might benefit from programs and policies enacted under various sections of the Act. In particular, they note that progress will be made in four critical areas: engaging individuals and families in shared decision making and addressing family experience of care; recognizing caregivers as part of the care team in new models of care;  improving education and training not only of the health care workforce, but of family caregivers; and improving support for services at home and in the community.

Of special note is the effect Section 3026, the Community-Based Care Transitions Program, will affect the lives of caregivers.  Under that program, grantees will have to carry out at least one transitional care intervention, which could include any of several scenarios, with a focus on engaging beneficiaries and their caregivers. Topics might include discharge education, help to ensure timely follow-up appointments  with post-hospital and outpatient providers, self-management education, and help with comprehensive medication review and management.

The entire factsheet is available free and online at:

Key Words: care transitions, Section 3026, public policy, health care reform, ACA, family caregivers