Transitioning to Better Quality Care in Kansas City

04 Nov 2013

Twenty percent of more than 2.6 million seniors with Medicare are readmitted to the hospital within 30 days. Created by the Affordable Care Act, community-based care transitions programs (CCTPs) aim to fix this problem by working with local hospitals and health care and service providers to improve care transitions for high-risk Medicare patients when they move from hospital stays to their home or other care settings.

The Greater Kansas City’s area Aligning Forces for Quality Alliance, led by The Kansas City Quality Improvement Consortium (KCQIC), was named as the first Missouri/Kansas organization to receive recognition as a CCTP by the Centers for Medicare & Medicaid (CMS). KCQIC, along with the additional CCTP participants, provides care transition services to nearly 700,000 patients in 40 states.

"This is a great opportunity for KCQIC to continue its care transitions work with hospitals and local nursing facilities," said Dr. Steve Salanski, co-chair of the KCQIC board. "We look forward to forming new relationships with physicians in the Greater Kansas City area through our partner hospitals and testing new methods for improving the quality of care delivered in our community."

Partnering with the Visiting Nurses Association, Area Agency on Aging, and 15 hospitals, the program is focused on reducing hospital readmissions, enhancing patient experience, improving quality of care, and documenting measurable savings to the Medicare program. Currently, readmissions from Medicare patients cost more than $26 billion dollars every year. The program in the Kansas City area serves more than 10,000 patients and will bring an annual savings to Medicare of more than $1 million.

Each participating hospital has CCTP coaches to help lead transition efforts. KCQIC provided training for the coaches, who contact the patient at least five times in 30 days, which includes a hospital visit, home visit, and phone calls. Overland Park Medical Center is testing the “Lead Coach” method. This model imbeds a coach at the hospital full time to integrate transitions of care service into patient care. Patients at Overland Park will be served by a team of coaches who will support patients’ recovery when they transition home. The CCTP helps improve the quality of life for patients by teaching them to manage their chronic health conditions. Patients who participated in the program said:

“My husband, with this last hospital visit, became eligible for the new transitional care program.  What a delightful source of information. Your coach, Denise Turner, visited our home last Monday. The information that Denise provided us was so educational and enlightening. She looked at my husband’s medications and patiently explained what each one is used for and what the medication actually does.  In explaining the working of the heart, she even drew a picture. Keep up the good work.”

"I wanted to let you know how much I appreciate your new program from KCQIC. The coach help me realize two things: 1) Enabled me to realize I needed someone to help me out. 2) Helped me find a counselor. She was not only concerned about my husband but recognized my emotional needs as a caregiver. Jenna made a phenomenal difference. It was great to see all of us working together!”

The CCTP runs through 2015. Monthly data reports will track the effectiveness of CCTP services and highlight the level of cooperation among health care providers in the Kansas City region.

“The backbone of the program will be cooperation of service providers in the community, since the participation and engagement of many stakeholders who share in the care of the area’s patients is essential,” said Catherine Davis, Project Director of the AF4Q Kansas City Alliance. “The CCTP seeks to encourage the community to come together to improve quality, reduce costs, and improve patient experience.”