LeadingAge Magazine · July/August 2013 • Volume 03 • Number 04

Care Transitions Programs Thrive Due to Proactive Providers

June 23, 2013 | by Debra Wood, R.N.

LeadingAge-member providers that are participating in CMS’ Community-based Care Transitions Program use coaching, education and skill-building to help smooth seniors’ transitions between hospitals, rehab care and home.

Care transitions between settings often are fraught with problems—patients unsure about what medications to take or when to call their primary care providers—leading to about 20 percent of Medicare patients returning to the hospital within 30 days. Hospitals are working to address the patient education and the discharge process, but the Centers for Medicare & Medicaid Services’ Community-based Care Transitions Program (CCTP), created by the Affordable Care Act, takes a different approach. Six LeadingAge members are among the 102 organizations to receive funding.

“We think this is a great project, one that helps people stay at home,” says David Beck, president and CEO of Brewster Place in Topeka, KS. “We are helping patients make that transition from hospital to home successful.”

The CCTP encourages community members to come together to improve quality, reduce costs and improve the patient experience. The five-year program, started in 2011, is part of Partnership for Patients, a nationwide public-private partnership that aims to reduce hospital readmissions by 20 percent, among other quality- and safety-improvement goals.

“It’s a terrible thing that people come back to the hospital so frequently and are readmitted when they could halt progression of their disease at home with simple measures,” says Millie Gamble, R.N., director of the Bridge to Home program at the Isabella Geriatric Center in New York.

All participants in the CCTP have partnered with acute-care hospitals and established formal relationships with other providers along the continuum of care. The awardees receive two-year agreements, which may be extended based on performance. CMS sought organizations experienced in providing care transition services and following an evidence-based model.

“We saw this as a phenomenal opportunity to create a bridge between the social service network and the health care network,” says Laura Prohov, vice president of community services at CJE SeniorLife in Chicago, IL. “We have to look at older adults from a holistic perspective.”

While several evidence-based transitions models exist, all six of the LeadingAge organizations implemented programs based on Eric Coleman’s Care Transitions model, which includes four pillars: a personal health record; medication reconciliation; prompt follow-up with a physician; and education about the disease process, warning signs of an exacerbation and how to respond. Transition coaches help the patient and family caregivers make the adjustments to self-care at home. Some entities have modified the model to better serve their populations.

A couple of the LeadingAge organizations, including Brewster Place, have incorporated technology into their programs, but the prime focus remains a health coach connecting with the patient while still in the hospital and then making a home visit and telephone follow-up calls during the first 30 days the person is home.

Brewster Place received its CMS award for its Capital Care Transitions Coalition earlier this year but had been providing care transition services for residents in its continuing care retirement community and saw the value in it, says Eileen McGivern, project director and director of wellness and Brewster at Home.

Brewster at Home’s technology-based remote health monitoring (based on the BeClose system) includes a medication reminder and an automatic personal emergency-response system. Family caregivers can log onto the Internet-based program and check on their loved ones’ patterns of activity and medication usage.

Capital Care Transitions identified, through a comprehensive root-cause analysis, patients at high risk for rehospitalization at the participating hospitals. Patients with congestive heart failure (CHF), pneumonia, acute myocardial infarction (AMI), diabetes, chronic obstructive pulmonary disease (COPD), and those who have undergone coronary artery bypass graft surgery and have a medication change are eligible for the program.

A home visit occurs within 24 to 48 hours after discharge. McGivern describes the coach’s role as transferring skills and teaching the patient how to advocate for himself and communicate effectively with the physician. Coaches reinforce education received in the hospital, red flags and appropriate actions to take for exacerbations.

Brewster Place has hired retired nurses, social workers and people with other backgrounds as coaches. They help the patient set goals, which often are not the same as a medical professional would choose.

Sometimes it’s hard for the nurse to let go of the natural urge to do things for the patient, McGivern says. Yet, the role requires teaching patients to advocate for themselves, not acting on their behalf.

Brewster Place obtained grant funding to apply for the CMS program, which has brought together multiple community organizations, collaborating in new ways, McGivern says.

CJE SeniorLife offers a range of services across the continuum, with a commitment to helping people maintain their independence for as long as possible, says Sue Newman, project director of the Care Transitions Collaborative.

The program initially targeted patients with conditions that Medicare has focused on for reductions of readmissions—CHF, pneumonia, AMI and COPD—and then added diagnoses, with approval from CMS, to include others that were of concern to the hospitals. CJE also has expanded the program to people discharged to long-term care facilities and receiving palliative care.

The collaborative began in March 2012, and has seen improvement in readmission rates. It recently doubled its staff to serve more patients.

At CJE, registered nurses serve as coaches. They meet the patient in the hospital and follow them for 30 days, doing a home visit and making three follow-up telephone calls. Coaches and nurses are matched by language if needed.

The nurse conducts several standardized assessments and refers those determined to be at risk to care management for additional support or resources. They help the patients fill out the personal health record and reconcile their medications.

Nurses do not make calls on behalf of the patient, but rather stay with the patient as he or she contacts the provider or pharmacist. The goal is to get the patient or family member to take ownership of the process and learn what to do. However, if the nurse walks into an emergency situation, she will step out of the coach role and call for assistance.

“The nurses provide skilled clinical eyes at no expense to be the patient’s advocate to help them stay at home,” Newman explains. “It was hard for the nurses to learn not to be hands on, but they understand the value of what they are trying to accomplish with these patients.”

The Eddy Visiting Nurse Association in Troy, N.Y., has partnered with five area hospitals and the Office for the Aging in four counties on its CMS transition program. It began care transitions services in 2010 as a grant-funded pilot.

“Because the outcomes were so good, and we saw a decrease in the readmission rate for high-risk diseases, we applied for the CMS funding,” says Patrick Archambeault, director of clinical specialties at Eddy VNA. That federal money allowed the Eddy VNA to add staff and hospitals to the program. The readmission rate has been cut nearly in half, bringing it down to 11 percent.

The Eddy also uses registered nurse coaches, who evaluate hospital patients for participation in the program and then make a home visit within 72 hours. They will provide tools, such as a scale or incentive spirometer if appropriate, and a pill box to help organize medications.

“We wanted a clinical person looking at the meds, who could call the physician right away if there are discrepancies,” Archambeault says. He adds that the average patient goes home on 12 medications, and nurses find medication discrepancies of four per discharge on average.

Three weekly telephone calls follow, with additional teaching and encouragement to keep medical appointments.

“Once we build their confidence, they don’t want to go to the hospital,” Archambeault says. “It’s a benefit to the patient.”

The Bridge to Home program at the Isabella Geriatric Center began on May 1 and serves patients with CHF, AMI, pneumonia, COPD, diabetes and end-stage kidney disease living in 22 New York zip codes.

A nurse based at the hospital meets with patients, explains the program and surveys them to learn their level of interest in self-management of the disease. A social worker follows through with the home visit and coaching process.

Bridge to Home uses a green, yellow, red system to help patients learn when their condition is under control and when to contact their provider or emergency medical services.

“We help them avoid the red zone,” Gamble explains. “We role play how to call the physician.”

The social worker also will assist the patient to connect with community services and free home-delivered meals.

The Area Agency on Aging (AAA) 1-B in Southfield, Mich., began its Southeast Michigan Community-based Care Transitions Coalition program in April 2012. The program serves patients with COPD, CHF, pneumonia, AMI and those with any condition who have been readmitted within the previous 90 days.

“We are seeing a good downward trend in readmission rates,” says Barbra Link, director of care transitions at AAA 1-B. “Participants appreciate our helping them live with their conditions.”

The program follows the Coleman model but supplements, as needed, with a behavioral health coach, community services, emergency response systems, available support coordinators in the office, intensive case management, funding for the coach to purchase food or other immediately needed items, and a skilled-nursing facility intervention. Most of the coaches are social workers, but they also come from other backgrounds. Certain coaches only work with patients needing specific strategies. Coaches carry iPhones and laptop computers for documentation.

Link enjoys the initiative’s cooperation with the hospitals and other providers and the opportunities for regional and national collaboration and idea exchange with other providers participating in the CCTP.

“We’ve enhanced our relationships, and I’ve seen a lot of growth with our partners,” Link says. “Everyone is in this together to figure out what is the best way to help the participants stay out of the hospital. It’s heartening.”

Sun Health’s Care Transitions Program in Surprise, AZ, began in November 2011 to fulfill an unmet need in the community; it became a CMS-funded program in June 2013. It first served patients with CHF, AMI and pneumonia but has expanded to nearly all chronic disease diagnoses. Sun Health modified the Coleman model to include connecting patients with community resources, and uses nurses as coaches.

“We have an opportunity to link patients with services they didn’t even know existed,” says Jennifer Drago, vice president of Sun Health.

A licensed practical nurse meets the patient in the hospital and calls patients as a follow-up to a registered nurse home visit. The RN teaches, reviews medications and completes a patient assessment, including an evaluation of the person’s fall risk and a mini-depression screening. Depending on the person’s health literacy and urgency, the nurse may instruct the patient in how to find the answer or if critical, the nurse will call the physician, with the patient on the line, for resolution.

Additionally, Sun Health may keep patients slightly longer than 30 days, but nurses also will discuss, with patients and family, additional services or a need for a higher level of care or hospice.

“While the program started with readmissions in mind, if we do our job and educate patients and give them skills, we will not just keep them out of the hospital but give them a better quality of life,” Drago concludes.

The CCTP section of the CMS.gov website offers a list of the 102 partner organizations participating in the Community-based Care Transitions Program (CCTP). Site summaries are available for each program.