Care Transitions Gain Ground

07 May 2014
Patients in Western New York hospitals are having less fraught transitions from the hospital to home thanks to a community initiative. Under the leadership of the P2 Collaborative, 10 hospitals and eight community-based organizations have banded together to reduce avoidable hospital readmissions. Contracted by the Centers for Medicare and Medicaid Services through the Community-based Care Transitions Program (CCTP), the coalition provides coaching services to Medicare Fee-for-Service patients who are at risk for readmission to the hospital after an acute care episode. Patients are eligible for CCTP only if they are insured under Medicare Fee-for-Service.
The goal of the Western NY CCTP is to strengthen the self-management skills of patients moving from the hospital to home while providing support by a trained coach and increasing referrals to community programs and resources. The goal of the program is to reduce readmissions by 20 percent over two years. Ultimately, the intended outcome is a significant cost savings to both Medicare and the community while affording patients the best possible experience.
Core components of the coaching model include medication self-management, creating a patient-centered record, primary care and/or specialist follow up after hospital discharge, and helping the patient to understand “red flags” about their condition.
During the first year of the program, the Care Transitions of Western New York coalition provided coaching services to more than 280 Medicare Fee-for-Service beneficiaries across seven participating counties (Allegany, Cattaraugus, Chautauqua, Genesee, Niagara, Orleans, and Wyoming). At only nine months into year two, the coalition already has exceeded year one’s numbers, having served more than 420 patients to date.
Initially, the launch of the CCTP program was problematic. Shrinking hospital financial resources and ever-increasing demands on hospital staff time limited the time and attention it received. The number of eligible patients declined as more patients chose Medicare Advantage plans over Medicare Fee-for-Service. A continuous difficulty has been the problem of patient volume. “The economies of scale just aren’t there without the volume,” said Megan MacDavey, manager of care transitions for P2.
Dana Corwin RN, nurse coordinator with Chautauqua County Office for the Aging, described the initial difficulties her agency faced in offering CCTP to local hospitals. “We had some communication and some relationship, but it really was kind of a tough sell to the hospitals. They were afraid that we were going to interfere with their discharge plans.” The Office for the Aging had to introduce itself anew and explain its perspective as a single point of entry for long-term services for older adults. Even then, the hospitals flagged some appropriate cases for the program— but not all the cases. “It was a very slow ramp up,” said Corwin.
Once an area hospital had a change in its administration, the Chautauqua County Office for the Aging re-approached the hospital and was approved to have a case manager join rounds three times per week on a nursing unit, and twice a week on primary care disposition
rounds. Once the case manager joined rounds, brainstorming about client care and discharge plans became all the easier with hospital staff. “Once that started, referrals to the program doubled!” said Corwin. “Now the staff are really seeing a value.”
“The coach joining rounds is pretty unique. The coach represents a lot of services given by the office of aging and also can serve as a resource for patients that aren’t eligible for CCTP by referring to other services, such as meals on wheels,” said MacDavey.
Other small changes have increased CCTP’s uptake. “It’s simple things, like multidisciplinary staff discussing the program each time when visiting the patient, if they are eligible, and explaining the benefits,” said Joan Breese, RN, CCM director of case management with Upper Allegheny Health System. Other hospitals have found success by requiring eligible patients to opt out, rather than securing permission to opt in.
As the coalition, hospitals, and care managers work together to grow the program, more and more patients in Western New York will thrive after an acute hospital episode.