COA among first sites selected for federal Care Transitions contract

Friday, November 18, 2011

New program helps reduce avoidable hospitalizations among seniors

Council on Aging and hospital group are among nation`s first recipients to win major federal funding designed to help seniors and reduce Medicare costs

Council on Aging of Southwestern Ohio, in partnership with the Greater Cincinnati Health Council and several area hospitals and health care organizations, is one of the nation`s first recipients of a major federal contract designed to reduce hospital admissions among seniors.

On Nov. 18, the federal Center for Medicare and Medicaid Services (CMS) announced its first seven site selections for the Community-based Care Transitions project of the Partnership for Patients initiative. partnership-for-patients

Council on Aging is the leading partner in the newly formed Southwest Ohio Community Care Transitions Collaborative which will carry out the contract with CMS. The focus will be on coaching hospitalized seniors on how to get home, stay healthy, and avoid return visits to the hospital.

The collaborative estimates that the program will serve nearly 5,400 seniors per year and bring an annual net savings to Medicare of more than $1 million dollars. Savings are achieved through reductions in hospital readmissions.

Through this award, CMS has recognized the important role Council on Aging plays as an Area Agency on Aging in helping older adults transition smoothly among different care settings. In seeking remedies for the nation`s fragmented health care system, CMS required that funding applicants be or include community-based organizations, such as Area Agencies on Aging, that contribute to better healthcare outcomes for older adults.

As part of the Patient Protection and Affordable Care Act (2010 health care reform law), CMS is awarding the contracts, via competition, to identify the programs and partnerships around the country that have demonstrated effectiveness at reducing harm to older hospital patients, returning them home as quickly as possible, and preventing avoidable and costly readmissions to the hospital.

Health coaching helps seniors manage chronic conditions and remain independent
The funding will allow the collaborative to expand a successful program Council on Aging has started at University Hospital and The Christ Hospital. Based on the proven Care Transitions Intervention developed by Dr. Eric Coleman of the University of Colorado Health Sciences Center, , the program uses coaching, health information technology, help with medications, and chronic disease management to help hospitalized seniors get home and stay home.

"Our mission is to help older adults remain independent in their homes and Care Transitions gives us a new way to accomplish that,` said Council on Aging CEO Suzanne Burke. "We have effectively managed the long-term care needs for seniors in our community for forty years and have developed a coordinated infrastructure that successfully serves seniors in our community. We`ve had success in our initial care transitions efforts in Cincinnati and look forward to being able to help additional seniors as they transition from various care settings. We are thrilled that CMS is recognizing our aging network as a valuable partner in improving healthcare outcomes."

Hospital readmissions are very costly and can be avoided
According to CMS, Medicare beneficiaries who are discharged from hospitals are increasingly being readmitted for avoidable conditions within 30 to 90 days. Much of this is due to a fragmented health care system which does not adequately support patients during the vulnerable time when they are transitioning from the hospital to other settings, such as nursing homes, rehabilitation facilities and their own homes. The cost to Medicare for hospital readmissions is estimated at $15 billion a year, $12 billion of which is for cases considered preventable.

Hospitals are under increasing pressure to reduce the number of patients who come back 30 days after discharge. The federal Medicare program can now withhold a portion of payments to hospitals that have high readmission rates for patients with certain conditions such as heart failure and pneumonia. The 30-day hospital readmission rate in southwestern Ohio ranges up to 29 percent for these conditions in some hospitals.

"This contract enables us to expand on our work to build a stronger health care community," said Nancy Strassel, Senior Vice President of the Greater Cincinnati Health Council. "We will bring to the Care Transitions Collaborative our connections in the health care community, and expertise in quality improvement, patient safety, access to care, and data services. Through this partnership, we will make a difference for those patients who are at risk for returning to the hospital prematurely."

Care Transitions program works
According to a report of the Coleman Care Transitions Intervention, patients who participated in the program were significantly less likely to be readmitted to the hospital, and the benefits were sustained for five months after the end of the one-month intervention. Anticipated cost savings over 12 months is $295,594 for a typical Transitions Coach TM panel of 350 chronically ill adults with an initial hospitalization. Patients who received this program were also more likely to achieve their personal goals for managing symptoms and regaining function.

Preliminary results of Council on Aging`s pilot program at University Hospital, showed participants had a lower-than-average hospital readmission rate and most patients were discharged to their homes or other community setting (such as assisted living) rather than to skilled nursing facility. Of those who went to a nursing facility for rehabilitation, most had a short stay and then returned home or to a community setting.

"We have been successful because we have been careful to implement every facet of the Coleman Care Transitions protocols and have also ensured that eligible patients can access community services through Council on Aging`s in-home care programs," Burke said. 

Southwest Ohio Community Care Transitions Collaborative
To apply for the CMS funding, Council on Aging worked with the Greater Cincinnati Health Council to form a collaborative with five hospitals and several other health care organizations. The hospitals include: Clinton Memorial Hospital, The Jewish Hospital, Mercy Hospital Fairfield, The Christ Hospital, and UC Health University Hospital. The other partners include: HealthBridge (health information technology and exchange), Health Care Access Now (coordinate patient access to physicians), Hamilton County Mental Health and Recovery Services Board, and the Health Collaborative.

The funding will allow the collaborative to expand Care Transitions to all Medicare patients hospitalized at the participating hospitals and diagnosed with heart failure, heart attack, pneumonia, or multiple chronic conditions.

How the program works
A variety of methods are used to coordinate care after hospital discharge and to encourage patients to manage their chronic conditions. While in the hospital, participants receive Personal Health Records, where they can record their medical information and health care instructions. Council on Aging Care Transitions specialists -- also known as coaches -- help patients follow up with their personal physicians (who often aren`t aware that their patients are in the hospital), and with medical specialists.

The model also includes a visit to the patient at home or in a nursing facility within three days of hospital discharge, three phone calls at regular intervals post-discharge, and help reconciling existing medications with new ones. The partner organizations help connect patients to community resources and eligible patients will be referred to Council on Aging`s in-home care programs.

CMS will measure funding recipients on their ability to reduce hospital readmissions, improve patient satisfaction, and generate savings to Medicare.