Community-Based Care Transitions Program

1. Community-Based Care Transitions Program Care Connection for Aging Services Primaris

2. The Problem • 17% of Medicare beneficiaries are readmitted within 30 days of discharge • 64% receive no post-acute care between discharge and readmit • 76% of these readmits may be preventable • Avoidable hospital readmissions cost Medicare an estimated $12 billion annually • Coming steps with the CMS “Value Based Purchasing” initiative will include penalties for these preventive hospital readmissions

3. Solution • Develop a local Care Transition Coalition to provide leadership and partner in providing quality care transition services for Medicare beneficiaries

4. Purpose/Goals • To build and sustain a community coalition with a focus on improving transitions of care for Medicare beneficiaries • To encourage person-centered and person directed models of care • To collaborate and encourage efforts of organizations with shared vision

5. The CMS Community Care Transitions Program • Hospitals within a geographic region partner with a Community-Based Organization (CBO), in a collaborative initiative to reduce preventable 30 day hospital readmissions. • The focus is on Medicare “Fee for Service” patients. • The CBO and hospitals, along with area “downstream providers”, form a working “coalition”, to reduce readmissions and improve care continuity • The “coalition’s” partner hospitals identify their “high-risk” patients for unscheduled readmission, from among the Medicare FFS population

6. The CMS Community Care Transitions Program • The community calculates the anticipated volume of their eligible patients. • The “coalition” identifies a best intervention for reducing readmissions, from evidence-based models. • The CBO submits a application for program funding to CMS, on behalf of the community coalition. • If accepted, the CBO provides staff to deliver the agreed upon / CMS -accepted post-discharge intervention • CMS monitors the community’s performance in reducing readmissions .

7. First steps • Care Connection for Aging Services and Primaris met with all acute care hospitals in 13 county area. • The West Central Care Transition Coalition was formed. • The partner hospitals conducted a Root Cause Analysis of their 30 day readmissions to determine their individual “high-risk” Medicare population.

8. Root Cause Analysis • The five participating hospitals were instructed in conducting a Root Cause Analysis, to help in identifying a “target population” to receive the Care Transitions intervention. • Four of the five Coalition hospitals successfully completed an RCA. • RCAs were to evaluate readmission trends for Medicare Fee for Service patients, only (as defined in the CMS – CCTP Program guidelines).

9. RCA Focus • Identify patterns of readmissions specific to the community and hospital provider • Used to guide targeting criteria and intervention selection • Assist the Community Based Organization and participant hospitals in identifying their “high-risk” population and anticipated program volume • Assist the CBO and participant hospitals in defining a “screening methodology for these “high-risk” discharges

10. Key Components of the RCA Completion of an RCA could include any or all of the following components: • Medical Record review (including use of specific audit tools) • Analysis of admission and discharge data • Process assessment including patient/family interviews and direct observation • Focus groups with patients and providers

11. RCA Results Target population identified by the RCAs included the following most frequently identifed diagnoses: • AMI • Heart Failure • COPD • Pneumonia

12. Other RCA Findings • Hospitals identified opportunities for improvement in their pre-discharge process, including (examples); • Identification of pre-discharge risk factors • Patient/family pre-discharge education process effectiveness and lack of standardization • Specific medication –reconciliation issues • Inadequate understanding of need for timely primary care physician follow-up visits • Nutrition / dietary needs clarified and addressed

13. Other RCA Findings (continued) • Inadequate patient instruction on “red flag” signs / symptoms • Lack of, or inadequate, patient support system (i.e. available family, other possible care-givers) • Financial resources for recommended follow-up care • Delays / inconsistency in discharge instructions/ communication to home health, long term care providers • Lack of any (or inadequate) follow-up contact with patient post-discharge • Identification of potential transportation barriers, post-discharge

14. Evidence-based Transition Interventions • Coalition reviewed the Evidence-based Transition interventions • The Care Transition Intervention (CTI): (the Dr. Eric Coleman/Care Coach Model) was selected. • Staff will be trained in the model the summer of 2013

15. Next steps • The group did not apply for the CCTP funding in the last round. • It was decided to do a pilot project • Hospitals in pilot: Fitzgibbon Hospital (Marshall) and Golden Valley Memorial Hospital (Clinton)

16. Pilot – Qualified Patients • 60 years of age or older • Diagnosis of CHF, COPD, or PNEU • Discharged from hospital to home • Without adequate support • Reasonable expectation that after services stop that person will either be able to manage on their own or have other supports in place to remain living at home

17. Pilot – Care Transition Program • Care Transition Coordinator – will support patient’s recovery efforts during the 30 days immediately following discharge. • Additional Support Services Options: • Home delivered meals • Transportation • In-home services – a homemaker aide providing household assistance; including housekeeping, meal preparation, grocery shopping, prescription pickup, and/or personal care up to 2 hours a week for 30 days.

18. Role of Hospital • Identify qualified patients • Explain the Care Transitions Program and role of the care transition coordinator • Secure written consent to share information • Provide appropriate referral information • Notify Care Connection Transition Coordinator if patient readmitted to the hospital within 30 days

19. Role of Care Connection Transition Coordinator • Accept referrals of qualified patients • Establish contact with patient/caregiver within 24-26 hours • Review information with patient/caregiver • Set up documentation and tracking system • Follow up to verify services are being delivered as ordered and at discharge from program, close out services and make referrals for any unmet needs

20. Care Transition Coordinator Reviews • Personal Health Care Record • Verify the follow-up appointments have been scheduled • Medication reconciliation • Identify Red Flags to watch for • Verify if additional support services are required • Arrange for support services • Conduct future care planning, including making referrals such as care management or other services.

21. Care Connection for Aging Services Role • Provide Care Transitions Coordinator • Accept referrals of qualified patients • Compile data on pilot project

22. Data collection • Client name, address, etc. • Diagnosis, reason for hospitalization • Where did referral come from? • Tracking of all care transition coordinator contacts, services received and for how long • Were there any hospital readmissions or ER visits within 30 days – if so what for?

23. Data collection (cont.) • What happened after the care transition services stopped? What additional supports and services were needed? • Client satisfaction with care transition service package or other feedback • Any issues of non-compliance?

24. Tools Used in Program • Communication Tool • Referral form • Personal Health Record • Care Transitions: Information Counselor Protocols • Discharge Preparation Checklist

25. Pilot Results • Still in beginning phase