May 112022

This is an explanation of the Provider Network Analyses that the Colorado Foundation for Medical Care Analytic Services team created for the communities participating in the Using Data to Drive Improvement/Supporting Data and Communities Special Innovation Project.

As used on this web site, Provider Network Analysis (PNA) characterizes relationships among healthcare service providers in a network and enables the user to visualize the network as a diagram of interconnected nodes. PNA is a specialized example of a more general methodology called Social Network Analysis (SNA), and you may find that term used in some documentation on this web site when discussing PNA. Applied to the parties-to-transition table (PTT) from the Integrating Care for Populations and Communities Aim, PNA can inform intervention strategies by identifying the sender-receiver relationships that account for a large proportion of the community’s transitions.

Care transitions network diagrams depict the flow of transitions among providers in the community. Providers are shown as colored nodes, with a unique color for each provider type (e.g., Hospital, SNF, HHA). Transitions between providers are represented by an arrow connecting the two nodes. Unidirectional ties – where transitions flow only from sender to receiver – are depicted as black, single-headed arrows. Bidirectional ties – where transitions flow in both directions between providers – are depicted as red, double-headed arrows. The size and weight of the arrow indicate the tie’s relative strength: thicker arrows represent more transitions, and larger arrowheads represent higher flow in the direction indicated. The relative distance between providers is not intended to depict any specific aspect of their relationship. The position of the provider nodes is not based on geography. Node placement is determined by the “closeness” of providers measured by their frequency of interaction with one another.

Provider Network Analysis Example

Presented below is one product of PNA: the network diagram. This example is based on the Monroe, Louisiana, Hospital Referral Region Provider Network Analysis.

Provider Network Analysis of Monroe HRR

Monroe, Louisiana Hospital Referral Region Provider Network Analysis

The visual conventions used in the diagrams are presented in the picture below.

Example of Provider Network Analysis

Coding of Provider Network Analysis

The diagrams were derived from the PTT for the community of interest, depicting fee-for-service Medicare Part A (non-outpatient) claims during the calendar year 2011. Each diagram is filtered by a threshold number of transitions shared.

Filtering of ties by number of transitions may result in red, single-headed arrows, which indicates the threshold number of transitions being met only in the direction of the arrowhead. When the threshold of shared transitions is met in total, but not in either single direction, the tie will be red with no arrowheads.

Some things to look for

  • Thick, red arrows (especially if one node is a hospital; high back-and-forth flow suggests high readmissions associated with the downstream provider)
  • Hub and spoke patterns (often a hospital and its prominent downstream providers)
  • Several arrows pointing to a single node (leverage point for receiver intervention)
  • To enable sharing of the network diagrams among community stakeholders, provider identifiers have been replaced with an alias referencing provider type (e.g., “Hospital 1”). For Medicare provider numbers (hsp_id), the analyst should refer to the community’s provider identifier list. Moreover, the actual numbers of transitions shared among providers during this time period, which determines the thickness of the arrow, may also be useful.

Provider Network Analysis Filtering Example

Provider Network Analysis diagrams can be very confusing if many relationships are shown at once. To make major parts of the network more clear, simpler versions of the diagrams can be shown. By increasing the number of interactions required to show a relationship, the number of qualifying relationships will be reduced. This produces diagrams that show fewer connections.

Here is an example of a very complex diagram that conveys little information:

All providers for Cincinnati (CY 2011). Connections indicate one or more transitions shared.

Cincinnati provider network analysis, one or more transition filter, 2011.

All providers for Cincinnati (CY 2011). Connections indicate one or more transitions shared.

In the next diagram we only show connections with 10 or more interactions:

Providers connected by a minimum of 10 transitions (CY 2011)

10 or more transitions filter on a 2011 Cincinnati provider network analysis

Providers connected by a minimum of 10 transitions (CY 2011)

In the next diagram we only show connections with 30 or more interactions:

Providers connected by a minimum of 30 transitions (CY 2011)

30 or more transitions filter on a 2011 Cincinnati provider network analysis

Providers connected by a minimum of 30 transitions (CY 2011)

In the next diagram we only show connections with 100 or more interactions:

Providers connected by a minimum of 100 transitions (CY 2011)

100 or more transitions filter on a 2011 Cincinnati provider network analysis.

Providers connected by a minimum of 10 transitions (CY 2011)

Source material

Introduction to Social Network Methods (Hanneman & Riddle, 2005; This is an explanation of the Provider Network Analyses that the Colorado Foundation for Medical Care Analytic Services team created for the communities participating in the Using Data to Drive Improvement/Supporting Data and Communities Special Innovation Project.

UCINET documentation (Borgatti, Everett & Freeman, 2002;

Acknowledgements: Qualis Health, Colorado Foundation for Medical Care

Nov 282018
Photo of Anne Montgomery and Aging Today Logo
Anne Montgomery

By Anne Montgomery

Originally published in AgingToday Volume xxxix: Number 6; November–December 2018 and is reposted here with permission.

In America and worldwide, the “age wave” has gathered in force—no more so than in Japan, where 27 percent of the population is already older than age 65, a number that will rise to 40 percent by 2060. Policymakers, spurred by widespread public interest in Gratton and Scott’s influential book, “The 100-Year Life” (London, UK: Bloomsbury Publishing, 2016), recently em¬braced this stark demographic fact.

International Efforts to Help Family Caregivers

Japan’s Prime Minister Shinzo Abe in 2017 convened a “Council for Designing 100-Year Life Soci¬ety,” directing members to expand “social security for people across all generations,” and institute free early childhood education and daycare and other “measures to secure the necessary caregiv¬ing personnel for reducing the number of people who leave employment to provide nursing care to zero.” The Council has met nine times, each time chaired by Abe.

A relatively new advocacy community that has sprung up to support family caregivers wel¬comed Abe’s efforts. Founded in 2010, the nonprofit organization Carers Japan has developed ini¬tiatives and objectives, notably enactment of a law to outline carers’ rights. The organization is helping and advising the Liberal Democratic Party, and others, to set up a parliamentary group for carers. Carers Japan also is sponsoring study groups for local politicians interested in amending city regulations to champion carers’ needs and priorities.

In the labor sector, advocates are pressing for added employment flexibility, to make it possible for carers to both work and support an ill or disabled loved one living at home. A recent change al¬lows Japanese workers supporting family members who need full-time medical care to take unpaid leave in up to three installments ( The maximum leave for years has been 93 days, and the legal entitlement belongs to the cared-for person, who has that amount of time to spend across his or her lifetime, which family members may use ( Japanese companies are not required to pay employees during family care leave; if no wages are paid or only a partial wage below 80 percent of the worker’s base wage is paid, an employee can draw 40 percent to 80 percent of his or her base pay from unemployment insurance (

These issues are becoming more prominent in many other countries. In the Middle East, Care¬givers Israel, launched in 2014, formed solid corporate relationships, and sponsors advocacy ini¬tiatives focused on paid and sick leave, new social security support for those caring for an ill family member and severance pay for people who must leave employment to care for a disabled family member.

In Asia, Carers Hong Kong formed to engage the government on pressing challenges—the need to invest in building a much larger workforce of paid aides, nurses and other personnel to support older adults and individuals with disabilities. In Europe, Carers Denmark organized in 2014 around a “Carers Charter,” which includes developing standardized caregiver training; creating caregiver consultants in all local municipalities to organize respite and daycare, and to conduct outreach to families and carers; and promulgating policies for political parties that speak to carers’ “rights and circumstances.”

Progress Being Made, but Challenges Remain

Making sustained gains that support family caregivers requires investing in more reliable communi¬ty services, and realizing a clearer understanding of family caregiver needs and wants. Underfunded community care and fragmented medical and community services across multiple providers and siloed settings could easily thwart significant progress. This is a particular challenge for America, where accountability for “whole person care” remains diffuse and elusive. Further reforms to promote employment flexibility—unpaid leave and teleworking—are needed, along with more focused pol¬icy discussions about the importance of paid leave to support family caregivers and people strug¬gling to cope with unexpected periods of illness and disability.

Among Organisation of Economic Co-operation and Development (OECD) nations, the U.K. has the richest history of advocacy and political work on behalf of carers. Founded in 1988, Carers UK is a continuation of earlier organizations, including the National Council for the Single Woman and Her Dependants, which secured the first tax benefit for carers in 1967, the Dependant Relative Tax Allowance. Following devolution 30 years later, Carers UK expanded into associated organiza¬tions—Carers Wales, Carers Scotland and Carers Northern Ireland.

Today, Carers UK champions rights to paid care leave and increased flexibility in the labor mar¬ket. Its 2013 report, The Case for Care Leave (, notes that “with the public expenditure costs of carers feeling unable to continue to work estimated at £1.3 billion a year, it is crucial that we take steps to help carers in work. There is an opportunity to turn these losses into economic gains, with public finances seeing an estimated £1 billion in additional tax revenues if car¬ers can be supported back into the workplace.”

The report argued that “a statutory entitlement to care leave would help many carers to juggle their caring responsibilities with work in a sustainable and manageable way, making them more productive and less stressed, and saving businesses and the economy money in the long run.”

In the healthcare sector, policymakers are preparing to issue in November 2018 a new Long-Term Plan for England’s National Health Service (NHS), which will extend until 2028 ( Carers UK and other advocacy and political organizations are consulting with government officials to help shape the NHS plan with regard to carers.

New Policies on “Caregiver Strategies”

Though “caregiver strategies” are being developed in various countries, a 2016 OECD chart (; p. 5-12) makes clear that countries are all over the map on how they structure care¬giver leave rights. Italy allows two years of paid leave over an employee’s lifetime, at 100 percent of earnings up to a ceiling, and Sweden provides paid leave at 80 percent of earnings up to a ceiling in episodes that can be up to 100 days. Cyprus allows only seven days of unpaid leave per year. The United States, under the Family Medical Leave Act, provides up to 12 weeks of unpaid leave for employees who have a year’s worth of service and work for medium-size and large firms.

Currently pending in the U.S. Congress is the Family and Medical Insurance Leave Act, which would provide paid leave for up to 60 days a year. Several states, including California, New Jersey, Hawaii, Rhode Island, New York and the District of Columbia, have already enacted state paid leave programs (

In recent developments, the Progressive Policy Think Tank’s 2016 report, Caring for Our Carers: An International Perspective on Policy Developments in the UK (, notes that “Australia’s and Canada’s Human Rights Commissions are leading the way in emphasising what a human rights approach to care and caring can bring, in starting to articulate a right to care, and in setting out the frameworks needed to make caring a real choice for carers and those needing sup-port.” The report also notes that “Japan, Germany, France, Belgium, Sweden and other countries are now using their long-term-care insurance schemes and tax systems to stimulate the develop¬ment of a wider range of care, household and personal services to ensure there is good support for care at home.” In America, there are plans to craft a federal blueprint for action following enact¬ment of the RAISE Family Caregivers Act in early 2018 (

In Europe today, there are an estimated 100 million caregivers, according to Carers UK. In Amer¬ica, though estimates vary, the number of family caregivers supporting older adults is reported to be about 44 million. In other surveys, four in 10 Americans report they are caregivers (; in Canada, half of the population reports having provided support to a chronically ill or disabled loved one or friend at some point during their life ( The reach of politically organized family caregivers seems primed to grow—and for families across the globe, that’s good news.

Anne Montgomery, M.S., is deputy director at Altarum Institute’s Program to Improve Eldercare, in Washington, D.C.

Jan 232013

By Dr. Joanne Lynn

The latest issue of JAMA features our paper describing   an exciting and successful initiative from the Centers for Medicare and Medicaid Services (CMS) and fourteen of its quality improvement organizations (QIOs).  Grounded in quality improvement methodology—plan-do-study-act–this unusual project offers many insights for those aiming to reduce avoidable readmissions.  And its raises a number of important question about how we measure progress in reducing readmissions. (For more on that topic, see our earlier MediCaring blog, )

A Medicare patient’s ability to receive successful treatment during care transitions from one setting to another has a crucial effect on the overall cost and efficiency of the Medicare system. Errors in information transfer, care planning or community support can cause hospitalizations, rehospitalizations and unnecessary costs to the Medicare program.

This project involved a three-year, community-based effort to improve the care transition process for fee-for-service Medicare beneficiaries. Participating QIOs facilitated cooperation among providers, health care facilities, and social services programs, such as Area Agencies on Aging. They centered their efforts around each community’s unique needs.   QIOs worked with communities to understand their own particular causes of readmissions, and to implement appropriate, evidence-based models to address them.  Communities analyzed results of the intervention along the way, and changed course to stick with interventions most likely to work.

The results, when compared to 50 comparison communities, showed significant reductions in hospitalizations and rehospitalizations, both by an almost 6% average, saving Medicare $3 million in hospitalization costs per average community per year.

This correlation has already led to new national efforts such as Partnership for Patients and the Community-based Care Transitions Program. In addition, in the 10th Scope of Work, all 53 QIOs are leading community projects nationwide (so far, in more than 400 communities).

This paper may be the first time one of America’s leading medical journals has published a report based on QI methods. Doing so represents a profound change in the openness of American medicine to learn not only what works for a patient, but works for the delivery system, too.

key words: quality improvement, care transitions, CMS, CFMC, Joanne Lynn, readmissions, community coalitions, JAMA

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

Jun 192012

Since 1995,  Ohio-based Summa Health System and its partners have led a collaborative, the SAGE Project (Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project), which has worked to improve care for the state’s most vulnerable elders by integrating the aging network, and its social services, with health and medical care. The project aims to integrate a comprehensive hospital-based clinical program with the community aging network to improve the health and functional status of older adults, and prevent institutionalization for those at risk for nursing home placement.

More recently, members from the SAGE project have been working on the PEACE Trial (Promoting Effective Advanced Care for Elders), an initiative funded by the National Palliative Care Research Center and the Summa Foundation. In addition to Summa and the AAA, the project involves the University of Akron, Kent State University, and the Northeastern Ohio Universities Colleges of Medicine and Pharmacy. The randomized controlled pilot study features a geri-palliative care case management intervention for Ohio consumers who are participants in the state’s long-term care Medicaid waiver program, PASSPORT. The intervention involves collaborative care between a hospital-based interdisciplinary care team, the AAA, and the consumer’s own primary care provider.

Like other older adults throughout the nation, Ohio’s community-dwelling patients who had poor symptom control and coordination of care often experienced exacerbations that led to hospitalizations. Frequently, these elders  have not documented their advance care preferences, and so arrive in the hospital, where family members are left to make critical decisions for which they are unprepared.

The PEACE Trial seeks to change this dynamic by focusing on health coaching and patient activation for self management,  while promoting advance care planning discussions with primary care providers. The target population includes new PASSPORT enrollees over the age of 60 who are living with one of 9 life-limiting conditions. Nurse assesssors—care managers—from the AAA screen patients at the time of their initial PASSPORT assessment; patients are then randomized to the control or intervention group.

AAA nurse or social worker care managers engage with consumers in a variety of activities. Care managers make two home visits, for example, centered on symptom assessment and advance care planning. They review findings with an interdisciplinary team, which makes appropriate recommendations for the patient and the primary care provider. The care manager next accompanies the consumer to one visit with the primary care provider to discuss advance care goals. Following this, the care manager and the palliative care nurse supervisor make an additional home visit to begin to implement the care plan. The consumer then receives up to one year of monthly follow-up visits from the care manager.

Researchers are tracking outcomes, measured at 3-, 6-, 9- and 12- month intervals. Outcomes include symptom management, quality of life/death, relationships, patient activiation and decision making, and depression and anxiety.

An initial challenge was in getting buy-in from care managers, and in changing the culture of the AAA. However, all care managers eventually expressed their appreciation of the value of the project for improving consumer outcomes. The project is working to get more “top-down” support from the AAA so that participating care managers receive the support they need to work with consumers, including education and skills to engage them.   The researchers and case managers also realized they needed more formal curriculum to teach effective methods and skills for advanced care planning discussions and goal settings. A second project was developed to create an online learning curriculum through the support of the First Merit Foundation and led by the University of Akron College of Nursing.  A key challenge has been to avoid “medicalizing” the care plans, making sure that they attend to human/emotional factors as well as health and medical status.

The program’s strength lies in the strong working relationship among all the partners, particularly in the commitment of the AAA to improve care for frail elders. Partners report that they are “becoming bilingual”, that culture sensitivity and knowledge sharing between the aging network and acute care providers has grown.

For more information, see Results of the promoting effective advance care planning for elders (PEACE) randomized pilot study (2014) by Dr. Skip Radwany et al.

Key words: PEACE trial, palliative care, geriatrics, AAA, collaboration

Mar 212012

By Janice Lynch Schuster

During two days of sessions at the Institute for Healthcare Improvement’s 13th International Summit, I was struck by repeated messages from plenary speakers and learning lab leaders. No matter the particulars of their presentation, each riffed in one way or another on the fact that we can all act now to change and improve health care so that we obtain better care, better outcomes, and lower costs. More than that, each pointed to the unique convergence of social, political, and health care factors that have set us up to get it right this time, to improve care for patients and their loved ones, to create a better environment for health care providers, and to imagine and implement a system in which health and health care are seen as human rights.

In his keynote address, former CMS Administrator and IHI founder Don Berwick, MD, left the audience with five principles on which to base change. In a nutshell: Put the patient first. Protect the disadvantaged. Start at scale—think big and act big. Return the money—drive waste out of the system and return that money to the community. And act locally.

In the spirit of acting locally, Altarum’s Center for Elder Care and Advanced Illness has developed two guides that we hope will help you to apply Dr. Berwick’s five principles to your work. The first of these is our “Get Started” guide ( to help activist service providers and community leaders imagine, design, and implement community-based systems to improve care transitions. The second of these, “The Agitator’s Guide,” ( offers specific things you can do—RIGHT NOW—to improve the lives of frail elders in your community. Both documents embody the principles Dr. Berwick outlined, and give you an opportunity to test out the improvement mantra: What can you do by Tuesday?

If you test these ideas, we’d like to hear about and report your experiences, insights, and progress. Send a note to ([email protected]).

Key Words:  IHI, Don Berwick, Agitator’s Guide, local improvement

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 – 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

To learn more about Cathedral Square, and to see a video about the SASH program, visit

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 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 but which is now available from:

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

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