Sep 262011

AHRQ Innovators Exchange features information and a video about a pilot study to improve care for low-income elderly patients with chronic illnesses.

Conducted by Ohio-based Summa Care under the leadership of Practice Change Fellows and Advisory Board Member Kyle Allen, DO, AGSF, the project reports that 70% of participants reported improved health, and 93% rated their experience as good or excellent one year after participation. The program led to cost savings of approximately $600 to $1000 per patient per month as a result of decreased hospitalizations. Summa Health is now conducting a three-year randomized controlled trial to confirm these results.

Summa Health System developed a program called the Frail Elders Care Management Program. The project involved interdisciplinary teams that provide integrated medical and social care management to low-income elderly in-patients who have chronic illnesses. The program aimed to ease the transition from hospital to home, provide preventive care, identify new and emerging problems, reduce readmissions, and prevent functional decline. Most participants were over the age of 65, had several chronic conditions and impaired activities of daily living, and had one or more problems that required an intervention. For example, nearly 40% of patients took more than 10 prescriptions, and nearly 50% had experienced one or more falls.

The project featured an interdisciplinary team whose members included a geriatrician, an advanced practice nurse, a registered nurse care manager, a social worker, and a geriatric pharmacist. Other clinicians were called on as needed. Primary care physicians, who then received a one-time fee, participated in a consultation with the nurse care manager. Over the course of three years, the Frail Elders Care Management Program served 1,272 patients. Based on promising preliminary results, AHRQ funded a three-year randomized controlled trial.

Key Words: frail elders, care transitions, quality improvement, interdisciplinary teams

Sep 262011

Fixing what’s wrong with care transitions will require changes in how systems work, both internally and with other systems. In this video, Dr. Joanne Lynn explains the importance of understanding your own health care system in order to fix problems in care transitions. Community and medical care providers need to work together to understand drivers in their own system before they can engineer effective solutions. You can also learn more about how to work locally by reading the Get Started guide, which you can find here:

Key words: Care transitions, quality improvement, community-based organizations

Jul 112011

Since many potential applicants are now figuring out how to use the financial template for Community-Based Care Transitions Program (CCTP) funding (as mentioned in our previous blog at:, here are some suggestions on mapping out a successful care transition model utilizing blended rate.  First, realize that all payments are to the Community-Based Organization, and must be paid “per eligible beneficiary.” Second, the worksheet provided by CMS must be used to convey the proposed blended rate. You’ll need to have enough experience in providing care transition services to estimate your population and costs in order to be successful in getting the funding.

Some applicants might want to focus on a particular illness or transition type (e.g., to Skilled Nursing Facilities), but we would encourage you to consider taking all Medicare fee-for-service discharges, but then using a stratified model to deliver services and estimate financials. Using just one intervention on all patients (e.g., the Care Transitions Intervention at Dr. Coleman’s site at: will meet the terms of the solicitation. However, a more sustainable model seems to have you divide the target population into three groups: low-complexity transitions, medium-complexity transitions and high-complexity transitions. Then, estimate the N, the acceptance rate, and the total costs for each of the three populations over a year.  Remember that CMS has said that initial training of staff and trips to meetings in Baltimore are not included in the budget (they must be covered from other funds or from indirects).

If a community finds it appealing to stratify as we suggest, then the blended rate is set by the number of people in the population segment, the likely complete refusal rate, and the costs of serving this population. In order to be effective, you will want to drive down the refusal rate wherever possible, and again, experience will be helpful.

One possibility for increasing patient compliance is by creating a patient-centered and patient-friendly intervention by improving cultural competency of all staff workers. Getting endorsement of relevant community leaders could also help mitigate refusal rate. We also recommend incorporating maximum family input to optimize care transitions, and thereby, reducing not only avoidable hospital readmissions but also generating Medicare savings.

This piece was written in collaboration with Dr. Joanne Lynn.


We are very interested in your experience and thoughts – and in some real examples to share.  Please respond to this blog, or send along info to [email protected].

Key words: care transitions, blended rate, Medicare savings, 3026, Coleman model, hospital readmissions

Jun 142011

In a complex system such as  transitions of sick and fragile patients from one setting to another, we are often so grateful for the few carefully done and reported research endeavors that funders and researchers easily fall into the trap of insisting upon slavish replication, assuming that this is the way to achieve the same results. If we were working with a highly standardized “system,” such as how heart cells respond to a drug, then we could reasonably assume that the curve of responses in Maine would be just about the same as the curve of responses in Arizona, and that what works for a dozen will work as well for a hundred.  Sometimes, of course, even those assumptions are wrong, but it is rare for an unmeasured characteristic of the population to greatly alter drug effects or metabolism.

However, there is every reason to assume that carefully done research on small numbers in a few settings will not be enough to guide practical implementation of process redesign.  There are two main reasons for this.  First, our paradigm for good studies is the randomized controlled trial (RCT), but some of its characteristics actually undercut the utility of the findings for guiding replication.  Specifically, the effective restrictions (stated and unstated) for eligibility make it likely that only a small sub-set of actual patients will be eligible for the trial.  Second, the fact that one is willing to randomize within one setting is good for blinded trials, but undercuts the galvanizing of the will that is often essential in fueling system reform. Consider this example – could you really generate the outrage that allows  a nursing unit to make changes to stop repeated mistakes in transitions to stop the suffering of their discharged patients — and simultaneously be expected to continue to do it wrong for all but a few of the patients?

Another challenge in the usual RCT is that the numbers affected are small — often only a small subset of the patients in the test site.  While this works for a proof of concept, improvement experts quickly note that scaling up is never just a matter of applying the same changes to a lot more people!  Instead, scaling up poses its own problems.  As one scales up improvements in care transitions, one has to work on incorporating many elements of the work into job descriptions and job routines so that the workflow is smooth.  One has to figure out fail-safe strategies, develop broad consensus in the community as to standards, train a populace to take a more active role in managing transitions for themselves and their loved ones, right-size the community’s supportive services, and a dozen additional elements.  The research model is usually a discrete “add-on” patch to a dysfunctional system.

Indeed, an RCT relies upon not changing the underlying dysfunctional system.  As one tries to implement the improvement approach more broadly, efficiency dictates that it become part of the system wherever possible.  Often, this also means that the highly skilled and motivated people involved in the research are replaced by less skilled, and, often, less motivated personnel providing routine services, with lower pay and more stresses.  Adapting the work of a research nurse practitioner to a regular home care RN, or of a skilled professional to a retiree volunteer, is real work that takes testing, innovation, and creativity.  In the work of the Quality Improvement Organizations (QIOs), for instance, as they implemented evidence-based interventions, many substantial adaptations were required.  One team trained certain nurses in a home health agency to be the bridging nurses in an adaptation of Naylor’s model. One team used senior volunteers as trained coaches for patient activation in an adaptation of the Coleman model. I don’t believe that any of the 14 communities were able to implement a research-based intervention exactly as it had been done in the research report.  The research was still quite important for laying down the path, but following the path with larger numbers in varied contexts required adaptations.

Perhaps the most substantial challenge in our work is that small numbers do not threaten the hospitals’ overall patient flow, while broad implementation could cut into occupancy rates and cause serious financial problems, especially if done too quickly for the system to adapt and right-size its services.  Scaling up requires considering the financial impact. The good news is that there are usually good reasons to absorb this impact, including the fact that most rehospitalizations and medical hospitalizations of Medicare patients do not make the hospital money, or at least not much money.

Keywords: quality improvement, model adoption, evidence-based, eldercare, community-based, Naylor Model, Coleman Model

Apr 282011

The Colorado Foundation for Medical Care (CFMC) has released a free “Introducing Care Transitions Toolkit” of materials to help guide anyone who is thinking about starting a Care Transitions project. The web-based information includes practical ideas and strategies developed by the Centers for Medicare & Medicaid Services (CMS) Care Transitions Theme. The care transitions issue is part of the Partnership for Patients initiative that will spend a billion dollars on quality improvment in the next couple of years.

The toolkit is available at

CFMC is the Medicare Quality Improvement Organization for Colorado. Their Care Transitions Quality Improvement Organization Support Center (QIOSC) assists Medicare Quality Improvement Organizations (QIOs) to promote seamless transitions from the hospital to home, skilled nursing care, or home health care.