Aug 082011

A colleague asked an important question: Which tools are best for reviewing causes of readmissions? Two examples, from Georgia and New Jersey, are attached to this posting. Georgia’s form requires starting from a patient/family interview review, and does not pull much from the record of the hospitalization. New Jersey’s form starts from the other direction – all pulled from charts, with just the contact information that enables an interview if someone undertakes it.  Each has targeted a certain set of issues — clear plan, medications, teach-back, advance directives, social problems, and so on.  Although the two forms overlap on many targets, on others they do not.

NJ_Readmission Chart Review tool

NEW_GA ReadmissionWorksheet

The Institute for Healthcare Improvement (IHI) has developed another useful form, which can be found on page 88 at this URL:  It “feels” more succinct, because it is set up to do 5 readmissions at a time and to focus upon themes.  But it also requires a more insightful reviewer, one who has thought about what it is that makes for rapid readmissions and what might work to make transitions bette

One way to get started is to simply review just a few charts of people who were readmitted to the hospital with which you are most familiar, and see what you most wanted to learn. You might start with the IHI form and then try filling out the other two to see what additional elements you might consider. Call a few patients or families, or, if that is not appropriate, call the main attending physician in the community. Try to gain some insight from the perspectives of people involved.
Keep track of the time it takes to do this review.  If you can get someone to pull the charts, the work to this point will take about two or three hours. Of the time involved, what seemed most productive and what was most illuminating?

Then put together your own form, starting with whichever one is most suited and adding or deleting the elements to end up with the ones that you found to be most useful.  Test that form on another two or three records, perhaps asking a colleague to do those (to learn what instructions are needed and whether another perspective identifies other things that are very important to include.
My prediction would be that you’ll find some remarkable stories–people in fragile condition whose community doctors did not really know they were out of the hospital or doctors who were unfamiliar with the patient’s situation and medications; people who could not afford the treatment prescribed; and people who simply greatly misunderstood what they were to do. (I recall the patient who told me about having to eat fresh vegetables for his heart – whereupon he opened a fresh can of peas every day!) Those stories will greatly help you galvanize the will to move ahead.  And you’ll have a process and form that you can persuade the quality improvement team at each hospital to do: Perhaps at large hospitals, five each week for four weeks and at small hospitals, five in the month.  Within a month, you’d have enough data and stories to build the endeavor, and continuing to collect the data provides rapid feedback about progress. Pick a lead intervention or two and get it tested and underway!

You are likely to find a certain sense of chaos– that there is a lot of “catch as catch can” processing with thorough unreliability on all sides. If this is the case, your coalition might well work on standardizing the process simply so that it is reliable.  You may find that the issues affecting the frail elders are different from those affecting younger populations– more complexity and fragility in the elders and more lack of access or barriers arising from mental illness in the younger.  Whatever you find, this is the “root cause analysis” that you’ll need to decide priorities and to apply for CCTP funds.

Key words: root cause analysis, reviewing readmissions, discharge record review, quality improvement tools, CCTP funding

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:  You might contact your Area Agency on Aging (for a national list, visit: 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 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 222011

Community coalitions can be an effective way to engage diverse stakeholders in achieving common goals. Establishing such coalitions to address problems in care transitions is likely to be an essential tool for ensuring that such transitions become routinely good. Shortcomings in transitions today reflect larger, systemic problems that can best be addressed by community organizations working together. Indeed, no single organization will be able to resolve the broader issues, or work on its own to improve care transitions. It will truly take a village to make transitions safe, effective, and routine.

Many organizations around the country are looking to build coalitions that focus on care transitions. For many, similar experiences building community connections will enable them to establish and lead such coalitions. But many others will need guidance and support for learning the basics of coalition building, and for understanding issues specific to care transitions.

The Center for Eldercare and Advanced Illness posted a workbook, “It Takes a Village,” that offers  community leaders ideas and pointers for how to get started – and how to get going. It can be read in its entirety on the website at:

The guide provides an overview of coalition building, ranging from recruiting partners to resolving governance. It describes what to consider when setting priorities for the work. Much of the text is devoted to issues of measurement – how will coalitions know that their work is improving patient care and experience? The guide explains how to usemeasurement to advance the coalition’s goals, how to find good data sources, and how to decide on what to measure. It provides very specific information on fixing care transitions, including how to fix the hospital discharge process and how to target rehospitalizations. Because care transitions have a major effect on very sick and vulnerable patients and families, the guide also includes ideas for how coalitions can coordinate their efforts with palliative care programs and services.

Community coalitions have proven effective at addressing diverse public health issues, from improving maternal and child health to creating healthier environments. Coalitions are defined by their focus on a particular issue, by their willingness to collaborate, and by their ability to bring a range of resources and perspectives to problem-solving. The guide offers a starting point – we hope you find it compelling and useful.

We’d like to hear about your experiences – what works for you and what doesn’t, where are your successes and what have been your challenges. Please join the dialogue by offering comments here, or emailing us at [email protected]. We look forward to hearing from you!


Key Words: care transitions, rehospitalization, readmission, quality improvement, coalition building, data sources, measurement

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

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:

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

May 172011

Many improvement teams have real problems with measuring their progress – some never get around to measuring, and some never do anything else!  This presentation was set for the communities funded under the Beacon initiatives that are working to bring information exchange to care transitions, but you’ll find the pointers applicable to any intervention that your community might try.

You can download a PowerPoint presentation by clicking the following link:

caretransitionsmeasuresprimer (PowerPoint presentation)

Keywords: Beacon communities, care transitions, reasonable skeptic test, ten units of energy test, sure audience test, rehospitalization, best practices, Medicare, good care plans, near misses, targeting, nursing home residents, mentally ill, delirious, frail elderly, homeless, ESRD,  “revolving door” patients, case reviews, Care Transitions Measure, avoidable readmission, HCAHPS, discharge planning, denominator problems, numerator problems