Care Transitions looks ahead

Wednesday, April 13, 2016

Danielle Amrine
 Danielle Amrine, COA's Manager of Transitional Care

Danielle Amrine, COA’s Manager of Transitional Care, has been selected to serve on the faculty for the national Community Care Transitions Project (CCTP). This major initiative was designed by the U.S. Centers for Medicare and Medicaid Services (CMS) to save Medicare funds and improve patient care by reducing hospital re-admissions.

The initiative, which started in 2012 and is now in its final year, has included a learning component in which leaders from the highest-performing teams share what they have learned in planning and implementing their care transitions programs.

Amrine also served on the CCTP faculty for the learning sessions in 2015.

CCTP sites, including southwestern Ohio, are now working on strategies to sustain their programs once the CMS contracts end. The program involves a health coaching intervention for newly-discharged hospital patients on Medicare. The interventions empower patients to better manage their own health in order to reduce readmissions to hospitals and visits to emergency departments. It also streamlines access to long-term services and supports.

COA’s Care Transitions Medical Adherence program is among the top performers in the nation. The 30-day hospital readmission rate among patients who complete the program is 14.9 percent compared with the national baseline rate of 21.9 percent. The rate at which patients go to the emergency department within 30 days of hospital discharge is 9.7 percent among COA’s care transitions patients, compared with 14.6 percent nationally.

From February 2012 through July 2015, COA’s program has resulted in net savings to Medicare of $5.5 million. This is based on an average readmission cost to Medicare of $13,800 per person.

“I am very proud of what we have accomplished,” Amrine said. “We have learned so much and have driven ourselves to reach the goals. Now, as the CMS contract comes to an end, we look to our partners to work with us to sustain the program.”