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

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Mar 272012
 

From Dr. Joanne Lynn, Director, Center for Elder Care and Advanced Illness, Altarum Institute 

“Nothing about me without me!”  That’s the cry of the disability community and the AIDS community and so many others affected by health care dysfunctions.  But for the elderly, thus far, it has been acceptable for everyone else to shape the care system – the doctors, the drug companies, the Congress, the managed care companies, the care coordinators, and on and on. But where are the voices of the elderly?  When do we hear from the folks providing support and love for disabled elderly persons? 

We desperately need that voice.  Without it, we are prone to make decisions in the interests of the status quo or to prioritize myths and provider interests that don’t match what elderly people and their families most need.  The frail and ill elderly are only sometimes able to voice their own needs – but they mostly have family who love and support them, and those family caregivers can become the key to building an efficient and reliable set of supports and services.

Most of us are now or will be family caregivers – and now, most family caregivers are overwhelmed, unorganized, and voiceless.  We need to change that.  Family caregivers need to speak up on behalf of their elderly loved ones, and themselves, and push back on commonplace presumptions as to what matters most at this time of life.  But those of us who are not right now overwhelmed with care needs need to make it easier for family caregivers to have a voice!

That’s the point of our “Agitator’s Guide” (https://medicaring.org/action-guides/agitators-guide/). We’ve drafted up some specific things anyone can do—RIGHT NOW—to improve the lives of frail elders in your community.   We are looking for your advice.  Tell us what possibilities strike you as worthy.  Try one or two out, and let us know how it goes.  All of us aging persons need to weigh in on this and hit upon some acts that change the power of inertia – that is, “keeping doing what we’ve been doing” – which gets us nowhere. 

The time for speaking out is now – we risk being overwhelmed with the costs and challenges of elder care as the numbers double. We must make services appropriate, reliable, and efficient.  Let’s try out some avenues and see what works!

key words: eldercare, advocacy, quality improvement, patient engagement

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Dec 222011
 

by  Carol Levine

Carol Levine is director of the United Hospital Fund’s Families and Health Care Project, which coordinates the Next Step in Care campaign.

Family caregivers often say that they feel invisible in hospitals and other health care settings. I know what they mean from my own 17 years’ experience caring for my late husband. Even now, when I speak at a program on transitional care, I am usually the only one who talks about family caregivers’ critical roles and responsibilities.  This situation is changing but very slowly.  Transition protocols now sometimes mention the caregiver but only as the add-on to “patient,” as in “patient/caregiver.”

This modern chimera is as fantastical as the fire-breathing lioness/goat/snake of the Iliad. In reality the patient and caregiver are not mirror images of each other. Failing to acknowledge caregivers’ individual limitations and needs for information, training, and support is as misguided as ignoring their intimate knowledge of their ill family member or friend.

For 15 years the United Hospital Fund has been working to change provider practice and give caregivers accurate, pertinent, and accessible information to help them become true partners in care.

The Fund’s Next Step in Care campaign has three main components:

  • A website (www.nextstepincare.org), with 23 free downloadable guides for family caregivers available in English, Spanish, Chinese, and Russian. Other guides for health care providers help them work more effectively with family caregivers.
  • Outreach to community-based organizations to train staff to be able to use the Next Step in Care guides in their interactions with family caregivers.
  • The Transitions in Care-Quality Improvement Collaborative, now in its second round, which brings together teams from New York City hospitals, nursing home rehab programs, home care agencies, and hospices to work on processes that involve family caregivers in transition care planning and implementation.

The Next Step in Care guides are organized around four main categories:  (1) information for all caregivers, (2) hospital stays (including discharge planning), (3) rehabilitation services, and (4) home care. In the first category are guides, for example, on becoming a family caregiver, HIPAA and privacy regulations, emergency room visits, and hospice and palliative care, as well as a medication management guide and form.  In the hospital stay category are a guide to help caregivers do a self-assessment of needs and concerns, a guide to discharge planning options, and a discharge checklist.  The rehab and home care sections include guides that introduce these services and tell the caregiver about likely roles and responsibilities, as well as financial aspects.

These resources can be used in conjunction with or independent of any formal transition program.  They provide a basis for identifying and acknowledging family caregivers as the missing link between hospitals or rehab programs and community services.

Key words:  family caregivers, care transitions, toolkits, quality improvement, caregiver information, caregiver support

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Dec 052011
 

Patients just discharged from the hospital urgently need rapid follow-up in the community. Dr. Joanne Lynn describes the care coordination needed among patients, community providers, hospitals, and other settings, and what’s needed to make it work.

Key words: rapid follow-up, care transitions, discharge planning, quality improvement, rehospitalization

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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

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Nov 282011
 

Hospice and palliative care can play a major role in improving care transitions for patients who have serious chronic conditions. Dr. Joanne Lynn explains how the hospice/palliative care model can improve patient care, offering 24/7 support, excellent symptom management, and wraparound services. People will need to realize what they’re up against, and turn to these important resources.

Key Words: care transitions, palliative care, hospice quality improvement

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Nov 142011
 

Under the 10th Statement of Work, QIOs nationwide will be launching exciting new programs to improve care transitions. This three-year endeavor builds on promising working undertaken by QIOs in 14 states. Dr. Joanne Lynn explains what’s coming and how to get involved.

Key words: care transitions, QIOs, 10th SOW, 10th Statement of Work, quality improvement

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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

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Oct 032011
 

In today’s installment of the video series on improving care transitions, Dr. Joanne Lynn describes three crticial elements for ensuring smoother transitions. These are standardizing the process (in part by mapping what you do now and understanding how the current system works–or does not); activating and mobilizing patients and caregivers to take charge of the transition, to know what is going on, what to expect and how to recognize when things are falling apart; and ensuring good information flow among all settings and with patients and caregivers.

 

 

Key Words: Care transitions, quality improvement, process standardization, patient activation, information flow

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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.

https://innovations.ahrq.gov/videos

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

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