Southwest Ohio region number 2 in the country for reducing hospital readmissions

Thursday, November 19, 2015

Care Transitions
"She explained everything. I had different people coming to the house, but she gave me more knowledge than any of them."  Jewell, Care Transitions patient, with her Care Transitions Coach

Since 2012, Council on Aging and area hospitals have been working together to reduce readmission rates among Medicare patients through the Southwest Ohio Care Transitions Collaborative.  COA's Care Transitions program is one part of this effort and has been successful at reducing readmission rates among Medicare patients who participate in the program at one of the collaborative’s nine area hospitals.  

Recent data show this collaboration is paying off.  The combined efforts of Care Transitions, and other hospital-based programs designed to reduce readmissions, are having an impact on readmission rates among all Medicare patients – not just those who participate in Care Transitions.  According to data from the U.S. Centers for Medicare and Medicaid Services (CMS), for the quarter ending January 2015, the overall readmission rate for Medicare patients at the nine area hospitals in the Southwest Ohio Care Transitions Collaborative dropped 16.8 percent, from a baseline of 21.9 percent to 18.2 percent. During the same time period, the readmission rate for patients who participated in the Care Transitions program at the same hospitals was 15.5 percent.

“I am so proud of our Care Transitions team and hospital partners for being champions of this initiative,” said Danielle Amrine, COA’s manager of transitional care programs. “We’ve all taken ownership in helping patients achieve better health and better outcomes. The data is promising and shows that our combined efforts are worthwhile.”

COA's Care Transitions program is part of CMS’ Community-based Care Transitions Program (CCTP). The program was created through the Affordable Care Act and is 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 (out of 46 total sites) and has shown continual improvement over time. The 16.8 percent quarterly reduction is the closest our region has come to the 20 percent goal since the collaborative formed in 2012.  Just three Care Transitions sites nationally (including southwest Ohio) logged readmission rate declines of greater than 15 percent during the quarter. At nearly 17 percent, the southwest Ohio region has the second greatest quarterly decline in readmission rates among the 46 participating CCTP sites.

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 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 October 31, 2015, COA enrolled more than 17,000 people into the Care Transitions 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.

COA's Care Transitions program has been recognized several times as a top performer in reducing hospital readmissions and emergency department visits. Earlier this year, representatives of the Lewin Group, a health care consulting firm engaged by CMS, visited COA for the second time to learn more about the enhancements and improvements that have contributed to COA’s success. The purpose of the visits was to gather information about best practices in COA’s program that could be shared with other CCTP sites around the country.