Jul 292011

As a frontline hospital or nursing home professional, you may be feeling increasingly frustrated with the lack of support, community follow-up and caregiver training for your vulnerable patients and residents. Despite your hard work these complicating factors are likely to send your patient or resident back to the hospital. Your administrators may have suggested to you that you focus on reducing readmissions and avoidable hospitalizations, or you may have caught wind of all the efforts underway to improve care transitions. Whatever has brought you here, you certainly have a sense that you need to get started now on ways of caring for your patients and residents differently.

Chances are, you are not in this alone, and others throughout your organization share your concerns—and have ideas for how to improve them. To learn more about what others are doing to fix care transitions and reduce transfer trauma, you might contact your state’s quality improvement organization, which is now charged with coordinating state and local endeavors to improve care transitions. You can find your state’s organization at: http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1144767874793  You might contact your Area Agency on Aging (for a national list, visit: http://www.n4a.org/about-n4a/?fa=aaa-title-VI) to learn more about its plans to respond to funding opportunities created by the Community-Based Care Transition Program (CCTP), also referred to as Section 3026 funding. If you haven’t already, you might reach out to your colleagues or peers in other local organizations, and find out what they’ve been doing, or what they plan to do.

Once you have a feel for what is going on in your own community, you might join forces with others who are motivated to make improvement happen.  You might find that a team already exists, or you might lead the formation of one. You will need someone—usually, several people—who are willing to embody the vision, take some risks, forge coalitions, and anchor the work. You may want to gather data about the experience of people using your community’s health care systems. You may want to gather stories—they are  a powerful way to communicate about experiences, to share ideas, and to learn from one another.

More than anything, start the process! Find something that you can do to get things underway. Try your ideas and learn from what works. Encourage others to join you—generate and build on their enthusiasm, and your own. Things may change slowly—but notice that they do.

Refer to the “Get Started” module on improving care transitions, now available online at www.medicaring.org. Based on the experiences of several organizations working to improve care, “Get Started” offers advice, guidance, and examples of how to build and sustain coalitions for this work, and how to measure progress. It is also full of real-life examples from other teams around the country. Build on their ideas and efforts as you develop your own. Be sure to check back often, as we plan to write frequently on issues surrounding care transitions, and on efforts to improve them. Or email us at [email protected]. We look forward to hearing from you.


Keywords: Care transitions, Section 3026, CCTP programs, avoidable hospitalizations, reduced readmissions

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