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: https://medicaring.org/2011/07/08/community-based-care-transitions-program-%e2%80%93-section-3026-funding/), 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: http://www.caretransitions.org) 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

Jul 082011

Despite widespread interest in the $500 million budget allotted for Community-Based Care Transitions Program (CCTP) under the Affordable Care Act, many stakeholders are confused about the exact nature of the program. What does it aim to do? Who is eligible to apply for the funds?

Aim: CCTP aims to improve the reliability and effectiveness of care transitions as evidenced by reducing hospital readmissions. CCTP participants are paid to improve services targeted fee-for-service Medicare beneficiaries, the population requiring the most frequent care transitions. The backbone of the program in most places will be cooperation of service providers in a geographic community, since the participation and engagement of many stakeholders who share in the care of the area’s patients appears to be essential for sustained excellence.

Eligibility: To be eligible for funding, every applicant must have a minimum of one Community-Based Organization (CBO) and one hospital. While a hospital on CMS’s list of high readmission hospitals by state can lead a proposal, the payment will still go to the CBO, making lead authorship rather trivial. Priority will be given to eligible entities participating in programs run by the Administration on Aging (AoA), or that serve the medically underserved, small communities, or rural areas.

Financing: Foremost, this is not a grant! Payment is based on a blended rate proposed in the response to the solicitation, paid “per eligible discharge” and heavily based on the type of intervention. The blended rate can reflect different costs for different categories of patients and can include such elements as ongoing supervision, monitoring, administrative costs, and so on. Most important, however, it does not include initial training: Sites must have some previous experience with care transitions, so they must have paid for initial training. CMS payment also cannot directly support travel expenses for attending the required meetings in Baltimore (the cost of this must come from some other source).

Applicants are required to use the worksheet provided by CMS. No payments will be made more than once in 6 months for each beneficiary. In other words, CMS will not pay for re-treatment of patients for whom first efforts to prevent rehospitalization failed. Keep in mind that, although the program will run for 5 years, the initial award is only for 2 years, with possibility of renewal annually thereafter.

Intervention: CCTP interventions must target Medicare beneficiaries who are at high-risk for readmissions, based on criteria provided by HHS, or for substandard care post-hospitalization. Interventions cannot duplicate already required services. You must be willing to participate in collaborative learning and redesign (including data collection). Finally, and not surprisingly, your intervention must save money overall, and show savings within two years.

CMS’s measures so far include:

Outcome measures

  1. 30-d Risk-adjusted all-cause readmission rate (currently under development)
  2. 30-d unadjusted all cause readmission rate
  3. 30-d risk-adjusted AMI, HF, and Pneu readmissions

Process measures

  1. PCP follow-up within 7 days of hospital discharge
  2. PCP follow-up within 30 days of hospital discharge

“HCAHP items” – (note – includes more than HCAHPS)

  1. HCAHPS on medication info
  2. HCAHPS on discharge info
  3. Care Transitions Measure (3 – item)
  4. Patient Activation Measure (13-item, see:    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361231/table/tbl1/)

Note: There are some areas where the solicitation is unclear or internally inconsistent.

Key words: hospital readmission, care transitions, 3026 funding, evidence-based intervenitons, patient activation measure, budget worksheet, financing, medicare beneficiaries, payment rate, CMS

Jul 052011

The Agency for Health Care Research and Quality (AHRQ) Effective Health Care Program site encourages patients to be proactive in making treatment decisions, offering a series of how-to guides, treatment guidelines, and real-patient stories about making health care decisions. The site puts the results of various research studies into plain-language information for consumers and families. According to an AHRQ press release, the campaign aims to increase consumers’ involvement in their care by providing easy access to unbiased information about treatment options and tools. It features television, radio, print, web and outdoor ads encouraging consumers to visit AHRQ’s Effective Health Care Program website to find plain-language guides that summarize the scientific evidence on treatments for numerous medical conditions.

Several of the guides should prove useful to patients and caregivers, including older adults and those facing end-of-life decisions, In particular, a series of tips on how to get the most out of visits to doctors’ offices and how to work with doctors provides useful information on medication management, talking about symptoms, and understanding treatment options and decisions. Also useful is a self-assessment, the Health Priorities Snapshot, aimed at understanding quality of life issues; patients rank the importance of being able to engage in common daily activities while undergoing treatment.

The treatment option guides range from issues surrounding heart health and musculoskeletal problems to mental health and pregnancy and childbirth. None of the guidelines, however, speak directly to issues facing frail elders and their caregivers; there is nothing on living with a serious illness that will prove fatal, for instance, or on treatment decisions surrounding Alzheimer disease. The site does a good job of encouraging patients to be partners in their care, and over time, perhaps, guides of special interest to older adults and their caregivers will be added.

“We see the best outcomes when doctors and patients work together to come up with a treatment plan that takes into account the patient’s quality-of-life concerns,” said AHRQ Director Carolyn M. Clancy, M.D. “Information is power in health care, and this campaign will provide patients with the information they need to become partners with their doctors in their health and health care.” The ads and the new website features can be found at https://effectivehealthcare.ahrq.gov/.

Keywords: patient decisionmaking, patient activation, treatment options, social marketing, evidence-based treatment guidelines

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 222011

Many improvement leaders want to target the patients who need care transitions to work well.  Of course, every person moving around in the care system needs the processes to work reliably, but some either have few needs or can handle their needs on their own.  So – who is it who gets caught in snafus and errors?  The folks who either have very complicated needs or who really can’t handle much on their own.  And who is that?  First are the elderly folks with many medicines, multiple chronic conditions, poor hearing and vision, and so forth.  This is not your tennis-playing 80 year-old uncle – but his 86 year old sister living alone in fragile circumstances in a second floor walk-up.  Yes – living arrangements and availability of help really matter. 

And who else?  Those with serious chronic mental health problems – depression, delusions, addictions.  A person who has trouble “keeping it together” on a normal day is going to have challenges coping with the complexity of the health care system, and even more trouble on a day when he or she is not feeling well.

Any others?  Those are the two major groups, perhaps supplemented by any others who have proven their ability to keep recycling back into the system.  Anyone who has been in the hospital twice in six months, or in the ER a few times, is someone who is at high risk of keeping on with that pattern.

We don’t yet have good evidence-based tools that a provider could use.  If you know of any high-functioning, low-cost screening tools, let us know in comments to this blog or send it to [email protected].