Care Transitions program recognized again as top performer

Tuesday, May 19, 2015

Care Transitions
"I had so many bottles of medicine -- new ones and old ones -- it was a mess.  She helped me figure it all out and we made a list and all.  We got it down pat now."  Bill, Care Transitions patient, with his Transitions Coach

For the second time in two years, Council on Aging’s Care Transitions program has been recognized as a top performer nationally in reducing hospital readmissions among at-risk Medicare beneficiaries.

Representatives of the Lewin Group, a health care consulting firm engaged by the U.S. Centers for Medicare and Medicaid Services (CMS), will visit COA for the second time in June to learn more about the enhancements and improvements that have contributed to COA’s success. They will meet with COA staff and visit some of the program’s partner hospitals.

Care Transitions is a health coaching program that uses simple interventions to help patients avoid preventable readmissions to hospitals after discharge. This revolving door syndrome is all too common, costs Medicare billions of dollars every year, and is hard on patients and their families.

The purpose of the Lewin Group visit is to gather information about best practices in COA’s program that can be shared with other Community-based Care Transitions Program (CCTP) sites around the country. CCTP is a CMS initiative designed to improve care and control Medicare costs by reducing hospital readmission rates by 20 percent. COA’s program ranks among the top 10 CCTP sites nationally and has shown continual improvement over time.

According to a Lewin Group analysis of CMS’ most recent quarterly Monitoring Report and other data, COA’s program excels at:

  • enrolling eligible patients into the program (which is voluntary), and
  • reducing 30-day hospital readmission rates from the baseline to the most recent data period

“I am so proud of our team,” said Danielle Amrine, manager of COA’s Transitional Care department. "The keys to our success include engagement of our partner hospitals; the ability to generate performance data and holding ourselves accountable to it; innovation and staffing flexibility; and just plain hard work by all the health coaches."

The COA program was developed in 2012 by the Southwest Ohio Care Transitions Collaborative which includes, besides COA, the Health Collaborative, and nine partner hospitals: The Christ Hospital; Clinton Memorial Hospital; Mercy Health: The Jewish Hospital, Anderson Hospital, Clermont Hospital, Fairfield Hospital, West Hospital; University of Cincinnati Medical Center; and UC Health - West Chester Hospital.

The program uses the Care Transitions Intervention model developed at the University of Colorado by Eric Coleman, M.D. Over a 30-day period, the health coaches work with patients and their caregivers to help them:

  • Better understand and manage medications
  • Make a plan for follow up appointments with their primary care physician and specialists
  • Recognize and respond to the warning signs or red flags that could mean their condition is worsening
  • Create a Personal Health Record 
  • Connect to community resources that can help them maintain their health and independence (this last intervention was added to the model by COA)

From March 10, 2012 through March 31, 2015, COA enrolled more than 13,000 people into the program. Currently, nearly 70 percent of patients complete the 30-day program which includes a home visit within three days of hospital discharge and three follow-up phone calls from the coach. Typically, the patients have multiple chronic conditions that put them at risk for re-hospitalization.

A critical component of the intervention is to help patients reconcile existing medications with any new medications or dosage changes resulting from hospitalization.

For the period June 1, 2012 – October 30, 2014, the readmission rate to one of the nine partner hospitals among patients who participated in COA’s Care Transitions program was 10.48 percent. This rate is less than half the 2010 average national baseline 30-day readmission rate of 21.3 percent.