Jul 202012

by Phil Burgess

There are two views of aging in America.

In one, a 70 year-old woman drives another to the doctor.  Across town, a later-life adult takes an even older neighbor to do her grocery shopping and then helps her bring the groceries into the house and makes sure they are properly stored.  When arthritis keeps a home-owner from installing his new storm windows, two volunteers go out to get the job done.  This is the view from the ground, where people are “aging in place,” where real people live, work and play.

There is another view.  That of the hand-wringing analysts and “big thinkers” who tell us that boomers are retiring at the rate of 10,000 a day for the next 18 years; that the number of Americans 65 years or older is about to double – from 35 million in 2000 to more than 70 million in 2030; that Social Security is headed for bankruptcy and Medicare has unfunded liabilities measured in trillions.  To some extent, they are right because our elected leaders are unwilling to address entitlement reforms and new approaches to taxes and spending that are required to get us on the right track.

But at the community level, enterprising Americans are problem solvers, not analysts and finger pointers.  They figure out who needs what and then set out to make it happen.  Somewhere along the way they invariably form a non-profit association to bring people together to get the job done.  Indeed, the American “do-it-yourself” tradition of forming local, voluntary associations to solve problems has deep roots in our culture.

The British statesman and political philosopher Edmund Burke called these voluntary associations the “little platoons” of society and argued that society’s little platoons will out-perform and out-innovate the big battalions of government on most days on most issues – especially human services.

I was privileged last week to see a pioneering and highly-effective little platoon up close.  Founded in 1993 and called Partners in Care – known as PIC – it is headquartered in Pasadena on Ritchie Highway.  Driven by feisty professional women, starting with CEO and co-founder Barbara Huston, and a steadfast, high-energy staff, PIC is dedicated to changing the experience of aging by enabling aging adults to remain in their own home, townhouse or apartment throughout their bonus years.

Last year, for example, PIC member-volunteers, most of whom are themselves seniors, contributed tens of thousands of hours to helping other seniors – including more than  9,000 rides for more than 160,000 miles of “door-through-door” and “arm-in-arm” transportation services.  Most transportation is for medical services – doctors’ appointments and the like – followed by grocery shopping and running errands such as banking and the post office.

PIC member-volunteers also provide home maintenance and handyman services that include fixing leaky faucets, changing light bulbs, painting, cutting the grass and installing home safety equipment – such as grab bars, railings, shower seats, and toilet risers.

PIC’s “lifeline” service provides a personal emergency response – e.g., “I’ve fallen and I can’t get up” – to help older adults live safely at home, providing a sense of security to those living alone and to their families, who may live down the street or hundreds or even thousands of miles away. And PIC provides advocacy services to help elders resolve issues with others in the community such as utilities and landlords.

Here’s how this little platoon works.  When PIC members provide a service, such as transportation, their time is “banked” in the PIC “time-exchange” – like a savings account.  “Though no one who needs a service is denied,” according to Huston, “the PIC exchange is based on the premise that everyone has time or talent to contribute – even if it’s to read a book to an elder with impaired eyesight.  When a member volunteer performs a task or service for another member, he or she earns credit hours that are banked for a later date or donated to another person.  By sharing skills among a large network of people, a community is created, the activities of daily living are accomplished, and people receiving help feel better because they earned it.  The result: Seniors are able to live at home, independently, well into later-life.”

The fact is most Americans in their bonus years are eager to use their gifts of time, talent, and treasure (including experience, not just money) to help others or repair that part of the world they can affect.  Part of PIC’s mission is to provide a way to channel that desire in the service of others.

PIC’s “virtual retirement community” is managed by a small staff.  Compared to assisted living, which can cost as much as $8,000 a month, aging-in-place seniors, who require fewer services, are served by PIC for less than $60 a month .  That is an advantage of a little platoon, “virtual community” approach to the growing national problem of longevity, an approach invented here in Anne Arundel County,.

Still, that $60 has to come from someplace.  The biggest single slice is earned income from The Boutique, located at 6 South Ritchie Highway, where people donate upscale used clothing, jewelry, furniture, glassware and other household items.  All donations and revenues from sales are used to support PIC programs that help older adults remain independent, living in their own homes.  The rest comes from competition for government grants (less than 10 percent), foundation grants, fundraisers and, most importantly, individual donations from community supporters and stakeholders.

Partners in Care is a community treasure.  Not just because it allows people to live out their bonus years at home.  Not just because it provides opportunities for older adults to use their gifts of time, talent and treasure to give back.  And not just because individuals aging in place dramatically reduce demand for taxpayer-funded medical and social services.  Partners in Care is a community treasure because it gives the rapidly-aging population of Anne Arundel and surrounding counties opportunities for giving back in the form of in-kind work and social engagement which, together, are the best predictors of successful aging.  As Marie Beynon Ray put it, “The only [later-life] choice that can’t be justified is retiring to a life of do-nothingness.”

Writer Phil Burgess, a columnist for the Annapolis Capital Gazette, is the author of Reboot: What to Do When Your Career is Over But Your Life Isn’t.  This post originally appeared in the Capital Lifestyle section on July 15, 2012. He is the president of the Annapolis Institute, and is interested in hearing from others about their post-career experience. You can email him at [email protected].

Key words: caregiving, community organizing, volunteer bank, aging in place, Partners In Care,

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

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

May 222012

By Joanne Lynn, M.D.

Readers of this blog are familiar with—and mostly supportive of—these two claims: (1) that social and environmental factors are stronger than health care services in shaping the population’s health, but (2) those factors are weaker than health care services in securing funding and public attention. Most of us are convinced that sending more funds and public support toward healthy food and exercise would do more to improve health than sending those funds toward high-cost medications or surgeries.

My question here is whether we can usefully apply the same perspective to the care needed for frail and disabled elders. Some will want to stop and contend that prevention of disability would still be the priority, and that argument has merit, of course. But “prevention” of disability associated with aging is really mostly delay, and most of us will have a period of serious disability before dying, no matter how well we eat and exercise.

As we age and accumulate illnesses and disabilities, we ordinarily need more and more support to get through the day, and we become less and less able to travel to get what we need. Furthermore, what we most need has to be local—no one travels to a referral medical center for spoon feeding or bed baths! So, we come to be tied to our communities, and to the housing, transportation, service supply and service coordination that our local system offers.

A community that has encouraged substantial new building with universal design and substantial retro-fitting of old buildings will have more elders able to stay at home longer, in comparison with one that is inattentive to making its housing stock elder-friendly. Some communities provide substantial non-medical services such as counseling for personal and financial planning, in-home nutrition and caregiver support, and keeping caregivers and elders in relationship with others. Those communities will have less reliance on nursing homes and hospitals, which is generally what aging persons strongly prefer. Senior-friendly housing and transportation are absolutely essential to the well-being of frail elders.

These claims appear to me to parallel the arguments for attention to social and environmental determinants of health generally. Indeed, the call for an “integrator” function to set priorities and manage systems to achieve population health locally seems also to be the right direction for elder care. If anything, elder care even more urgently needs integration across social services, housing, long-term-care services and health care services. A great deal of public and private funding goes into the uncoordinated cacophony of programs that aim to provide support and health care to frail elders, using probably about half of our lifetime expenditures on illness and disability and yielding remarkable waste, gaps, inefficiency and frustration. We need that integrator—and the integrator needs tools and authority.

In some other countries, care of the disabled and elderly is part of the public health system, alongside maternal-infant health and infectious disease. In the United States, however, services for the disabled and elderly have been outside of the scope of public health practitioners, who generally seem to lose interest when primary prevention fails (as it must). Indeed, at least for the elderly, the U.S. has mostly split the medical services into a quite separate category from the social supports. We fund health care with an open checkbook and we measure quality mostly as if each person faced at most one health challenge. In contrast, we primarily fund social services as poverty programs and rarely measure their quality at all.

From my perspective, engendering a way to manage the local system for elder care across medical and social issues is key to achieving “Triple Aim” goals. Can those advocating for attention to social and environmental determinants of health come to include frail elders and disabled persons in their scope? Well-being while living with serious and even fatal disabling conditions counts. Most of us will live for multiple years in this state—and some of us for much longer. Can’t we come to count improved well-being while ill as part of population health, and employ the tools, perspectives and personnel that now advocate for healthy built environments?

About this post:

This week (May 2012),  Joanne Lynn, M.D., Director for the Altarum Center for Eldercare and Advanced Illness, blogs on Improving Population Health. A few months ago (February 2012), David Kindig asked readers, “Where Would You Put the Money?” Dr. Lynn responded with a provocative comment, which she expands on here. This is reposted with permission of IPH, and is cross-posted on Altarum Institute’s blog, Health Policy Forum).

Key words: population health, frail elders, local integrator function, public health

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 (https://medicaring.org/action-guides/get-started/) 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,” (https://medicaring.org/action-guides/agitators-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 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

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 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