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  • readmissions – MediCaring.org
    equally valid ways to reduce readmissions Whether the hospital reduced hospitalizations in order to reduce readmissions is less important than being sure that we do not penalize hospitals for taking such steps Population based rates are closely aligned with the three part aim of the National Quality Strategy individual care population health and affordability not only because they are population based but also because they reflect the close relationship between care in the community and a hospital s apparent performance Thus a program can reduce burdens on beneficiaries and Medicare through significant reductions in the population based discharge and readmission rates but see much smaller reductions in the discharge based readmission rate In a companion blog to this piece Joanne Lynn presents evidence that this attenuation of changes in discharge based rates has happened repeatedly in community based readmissions programs We do not know at this point whether attenuation of changes translate into financial penalties but it seems very likely to increase a hospital s risk We also do yet fully understand what specific changes produce these decreases in the population based discharge rate but the most parsimonious explanation is that the causes are pretty much the causes of reduced readmissions Provide urgent care with support for keeping the patient in the community and you are likely to reduce all admissions not just readmissions Enroll more patients in medical homes and the benefits will not disappear 30 days after hospital discharge Improve nursing home communications with emergency rooms and the benefits will not be limited to patients within 30 days after hospital discharge What we can foresee is that hospitals already wary of readmissions reduction because it directly reduces revenue will become doubly wary if they conclude that reducing discharges may also cause or increase the MRRP penalty If CMS is penalizing hospitals and communities for succeeding at improving care and reducing costs the reaction may threaten a very successful set of initiatives The examples we report are for community based efforts to reduce readmissions Hospital level calculations are generally beyond our capability CMS can however easily determine whether all else being equal penalties are more likely or larger in areas where the population based hospital discharge rate is declining substantially than elsewhere That information is urgently needed What to do The purpose of the MRRP is to reduce the burden of readmissions on Medicare beneficiaries and the Medicare trust funds so the important indicator of progress is the number of readmissions not the percentage of discharged patients that are readmitted Healthcare quality measurement needs to catch up with the National Quality Strategy and add measures of the impact of care on the health of the population that will complement measures of the quality of individual episodes of care such as hospitalizations In the case of readmission measurement for the MRRP this need is substantially more urgent because there is good reason to fear that a hospital that engages with its community and does exactly what the MRRP hopes for is more liable to financial penalties under the current discharge based measure than it would be under a population based measure The first step is to assess the degree of urgency by examining national evidence on actual penalties If unreasonable penalties are at all frequent then the problem is far more urgent This will be complex because Epstein has already shown in cross sectional studies that population based hospitalization rates and readmission rates are positively correlated 2 At the same time it will be important to develop population based measures of readmissions and compare their impact on penalties with the impact of discharge based measures The obstacles are bureaucratic technical and political Bureaucratically the most important obstacle has been a widespread belief that the Patient Protection and Affordable Care Act requires calculating discharge based rates In fact the Act says only that penalties are to be determined from the ratio of observed to expected numbers of readmissions and is silent on how the expected number is to be calculated The other bureaucratic problem is less tractable Under current procedures the steps laid out for implementing a new measure both at CMS and at the National Quality Forum NQF would likely take several years The process should be expedited if the analysis of current penalties indicates that hospitals are being penalized for success in reducing admissions The technical challenges of creating a population based readmission measure for hospitals are substantial First the procedure must find a way to measure each hospital s population based hospitalization rate Second a method of risk adjustment must be developed and applied so that population based readmission rates for each hospital and community can be compared Although these methods are still evolving adjustments for factors such as neighborhood deprivation 3 are actually easier at the population level These are difficult tasks but a first step good enough to improve on the existing model should be possible within a year Politically hospitals will be concerned about accountability for the community hospitalization rate They will recognize that if hospitals in areas with low hospitalization rates are protected then hospitals in areas with high hospitalization rates will be more vulnerable Some have hoped that traditional risk adjustment could solve this problem because the most likely scenario is that average risk of readmission increases as the number of discharges decreases That prospect is not promising because the most assiduous work on risk adjustment has produced tools of only moderate power The prospects for solving this problem with improved risk adjustment are not promising 4 5 When you find yourself in a hole you should stop digging It seems prudent for NQF to suspend endorsement of the pending discharge based readmission measures and for CMS to delay implementing discharge based measures if NQF endorses them until CMS has studied and reported the extent to which readmission penalties punish hospitals that are actually reducing both admissions and readmissions and has laid out an approach to any problems found Finally the problem identified here underlines the importance of placing a population based foundation under at least some measures of health care system performance Footnotes References 1 Centers for Medicare and Medicaid Services Readmission reduction program Retrieved from http www cms gov Medicare Medicare Fee for Service Payment AcuteInpatientPPS Readmissions Reduction Program html 2 Epstein A M Jha A K Orav J E 2011 December 15 The relationship between hospital admission rates and rehospitalizations New England Journal of Medicine 365 24 3 Kind A J H Jencks S Brock J Yu M Bartels C Ehlenbach W Smith M 2014 December 2 Neighborhood socioeconomic disadvantage and 30 day rehospitalization a retrospective cohort study Annals of Internal Medicine 161 11 765 775 4 Yale New Haven Health Services Corporation Center for Outcomes Research Evaluation 2014 July 2014 measure updates and specifications Hospital wide all cause unplanned readmission version 3 0 Retrieved from https staging qualitynet org dcs BlobServer blobkey id blobnocache true blobwhere 1228774408425 blobheader multipart 2Foctet stream blobheadername1 Content Disposition blobheadervalue1 attachment 3Bfilename 3DRdmsn Msr Updts HWR 0714 pdf blobcol urldata blobtable MungoBlobs 5 Kansagara D Englander H Salanitro A Kagen D Theobald C Freeman M Kripalani S 2011 October 19 Risk prediction models for hospital readmission A systematic review Journal of the American Medical Association 306 15 1688 1698 The Evidence That the Readmissions Rate Readmissions Hospital Discharges Is Malfunctioning as a Performance Measure Posted by Les Morgan on December 8 2014 3 Responses Tagged with hospital readmissions Medicare public policy quality improvement readmissions rehospitalization Dec 08 2014 By Joanne Lynn M D Also see companion post by Stephen F Jencks M D M P H Care transitions improvement programs have been effective in helping the health care system both become more effective in serving people living with serious chronic conditions and reduce costs However the key metric used to measure performance is seriously malfunctioning in at least some hospitals and communities leading to penalties and adverse publicity for providers and communities that are actually performing well and continuing to improve performance In this post we provide supporting data and a companion blog article provides a thoughtful discussion of the conceptual issues underlying this troubling malfunction For our earlier blog post about this problem see http medicaring org 2014 08 26 malfunctioning metrics Very simply this problem arises because the metric used is some variant of readmissions within 30 days divided by discharges from a particular hospital within a particular period Thus the usual metric is something like 20 of Medicare fee for service FFS hospitalizations are followed by a readmission within 30 days This metric works well if the denominator namely the number of hospitalizations is not affected by the improvements that reduce the risk of readmission If the denominator declines along with the numerator the metric will not reflect the degree of improvement that was actually achieved The data below show that this happens in real situations We are here showing the data from San Diego County a very large county with about 250 000 Medicare FFS beneficiaries who had about 60 000 Medicare FFS admissions to hospitals per year and about 10 000 readmissions per year in 2010 when almost all of the hospitals and the county s Aging Independence Services functioning as the Community based Care Transitions Program partner agency Area Agency on Aging Aging and Disability Resource Center started working together to improve care transitions and reduce readmissions under the San Diego Care Transitions Program one of the Community based Care Transitions Programs initiated by Section 3026 of the Patient Protection and Affordable Care Act The application year was 2012 and the start up year was 2013 The table below shows an initial summary of their results provided through their Quality Improvement Organization Exhibit 1 San Diego County Relative Improvement by Metric 30 day Readmissions Readmissions of county Medicare FFS residents fell by 15 in 2013 compared with 2010 San Diego County reduced hospitalizations by 11 However when the numerator and denominator go down at nearly the same rate the fraction moves just 4 3 which falls far short of the 20 reduction goal that Medicare has set What follows are the quarterly data from San Diego The first graph Exhibit 2 shows the quarterly rate of admissions per 1 000 Medicare FFS beneficiaries in San Diego County We have adjusted these data for the effects of seasons on admissions since there are usually more admissions in the winter The shaded portion shows the control limits an area which represents the expected range of variation demonstrated in the first 3 years of the data 2010 2012 Data that fall outside of the range or that consistently run on one side of the midline indicate that something has changed in how the system is functioning Clearly admissions are falling Exhibit 2 San Diego Seasonally Adjusted Admissions The second graph Exhibit 3 shows the readmissions rate in the same framework quarterly rate of readmissions per 1 000 Medicare FFS beneficiaries in San Diego County adjusted for seasonality The control limits again show change Readmissions are falling Exhibit 3 Seasonally Adjusted Readmissions The third graph Exhibit 4 shows the metric in the conventional form readmissions divided by discharges The graph does eventually show a decline but only a modest one The fact that the denominator was falling attenuated the impact of the falling number of readmissions Exhibit 4 Seasonally Adjusted Percent Discharges with 30 day Readmissions for San Diego County by quarter The next three exhibits show the comparison of the San Diego measures with the national rates for the same metrics Exhibit 5 shows that San Diego County is dramatically less likely to have Medicare FFS beneficiaries in the hospital than the nation as a whole 56 per 1 000 per quarter in San Diego compared with 69 per 1 000 per quarter nationwide Exhibit 6 shows that San Diego is also much lower in readmissions than the national average 10 per 1 000 per quarter in San Diego compared with 12 per 1 000 per quarter nationwide In both cases the declining use is reasonably parallel between San Diego and the nation This would imply that improvement strategies are still being effective at this lower range and thus the lower range is not yet a limit on improvement opportunities Exhibit 7 shows that San Diego County s conventional metric of readmissions divided by discharges simply tracks the national average Clearly the metric is not functioning in a way that reliably separates good practices from wasteful ones That readmissions over discharges metric does not convey the fact that San Diego is much less likely to hospitalize and to rehospitalize Indeed 10 of the 14 San Diego hospitals eligible for penalties for high readmission rates are being penalized next year Since the calculations that go into determining the hospital penalty focus on particular diagnoses in three past years it is possible that these hospitals manage to do badly with those diagnoses in those years but it seems quite unlikely More plausibly the metric used is of the readmission divided by discharge form so the shrinking denominator will affect this calculation Exhibit 5 Seasonally Adjusted Quarterly Admissions National and San Diego County Exhibit 6 Seasonally Adjusted Quarterly Readmissions National and San Diego County Exhibit 7 Percentage of Quarterly Discharges Readmitted National and San Diego County Without access to and analysis of much more data one cannot know how widespread this problem is We do know that San Francisco had an admission rate of just 50 per 1 000 per quarter in 2013 and a readmission rate of just 8 per 1 000 per quarter which are rates much lower than San Diego Yet 8 of San Francisco s 10 eligible hospitals will be penalized for excessive readmissions in 2015 Furthermore we know that the initial Medicare foray into this work published in the Journal of the American Medical Association in January 2013 link http jama jamanetwork com article aspx articleid 1558278 resultClick 3 Association Between Quality Improvement for Care Transitions in Communities and Rehospitalizations Among Medicare Beneficiaries see Outcome Measures involved 14 smaller communities and that project had to change from using the discharge based metric to using the population based metric when it became clear that the shrinking denominator was making the project monitoring unreliable Hospitals other providers and communities that believe they may be adversely affected by the malfunctioning metrics should have access to the data needed to investigate and CMS should welcome reconsideration of those situations NQF should suspend endorsement of new readmission discharge metrics and re examing existing ones CMS has multiple contractors working on readmissions and some have substantial experience and skills in the technical details of these metrics CMS should quickly modify their contracts to require them to investigate the extent of this problem to identify steps to ameliorate adverse impacts of the current readmissions discharges metrics and to build the metrics that can guide care transitions work into the future Certainly the time has come to sort this out and develop metrics that reliably separate exemplary from persistently inefficient practices Want to know more Protecting Hospitals that Improve Population Health by Stephen F Jencks http medicaring org 2014 12 16 protecting hospitals Senior Alert A Swedish National Dashboard for Preventitive Care for the Elderly by Elizabeth Rolf http medicaring org 2014 12 22 senior alert A Dangerous Malfunction in the Measure of Readmission Reduction Posted by Les Morgan on August 26 2014 No Responses Tagged with Affordable Care Act CCTP CMS measurement metrics readmissions rehospitalization Aug 26 2014 By Joanne Lynn and Steve Jencks Work to reduce readmissions has started to yield remarkable improvements in integration of care for frail elderly people by prompting hospital personnel to talk with community based service providers by teaching patients and families how to manage conditions and navigate the health care system more easily and by paying more attention to trying to fill gaps in the community s services But the measure being used to track improvement is seriously misfiring in some settings and if CMS does not mitigate the adverse impacts they may become destructive to the momentum and the good that has been done This is much more than an issue of imperfect risk adjustment or inadequate identification of planned readmissions it is a punitive error that undermines program goals Since CMS mostly aims to assign responsibility for readmissions to the discharging hospital the key metric has been the risk of readmission for the average person discharged which is the number of readmissions divided by the number of live discharges Any time outcomes are monitored with a ratio one has to watch out for whether interventions that affect the numerator also affect the denominator Here that s happening enough to completely obliterate the usefulness of the metric at least in some circumstances Here s a quick hypothetical example At baseline a hospital has 1 000 Medicare fee for service FFS discharges per quarter with 200 of them back within 30 days Subsequently the hospital team and various community based providers work together and drop the readmissions to 160 per quarter Does the readmission rate go down to 16 under the metric No First they no longer have the 40 readmissions that are also admissions and in the denominator But more important the very things that are reducing the readmission rate also affect the likelihood of coming back in 45 days or 6 months or ever Patients are supported in learning to take care of themselves and to advocate for themselves in the care system they make good care plans including advance care plans and they encounter a more supportive care system in the community These things are still affecting the patient many months after the hospitalization Indeed as the care system learns how to support fragile people in the community better fewer patients will need to come to the hospital in the first place The result for our hypothetical hospital is that it ends up with 800 discharges

    Original URL path: http://medicaring.org/tag/readmissions/ (2016-04-30)
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  • rehospitalization – MediCaring.org
    adverse publicity for providers and communities that are actually performing well and continuing to improve performance In this post we provide supporting data and a companion blog article provides a thoughtful discussion of the conceptual issues underlying this troubling malfunction For our earlier blog post about this problem see http medicaring org 2014 08 26 malfunctioning metrics Very simply this problem arises because the metric used is some variant of readmissions within 30 days divided by discharges from a particular hospital within a particular period Thus the usual metric is something like 20 of Medicare fee for service FFS hospitalizations are followed by a readmission within 30 days This metric works well if the denominator namely the number of hospitalizations is not affected by the improvements that reduce the risk of readmission If the denominator declines along with the numerator the metric will not reflect the degree of improvement that was actually achieved The data below show that this happens in real situations We are here showing the data from San Diego County a very large county with about 250 000 Medicare FFS beneficiaries who had about 60 000 Medicare FFS admissions to hospitals per year and about 10 000 readmissions per year in 2010 when almost all of the hospitals and the county s Aging Independence Services functioning as the Community based Care Transitions Program partner agency Area Agency on Aging Aging and Disability Resource Center started working together to improve care transitions and reduce readmissions under the San Diego Care Transitions Program one of the Community based Care Transitions Programs initiated by Section 3026 of the Patient Protection and Affordable Care Act The application year was 2012 and the start up year was 2013 The table below shows an initial summary of their results provided through their Quality Improvement Organization Exhibit 1 San Diego County Relative Improvement by Metric 30 day Readmissions Readmissions of county Medicare FFS residents fell by 15 in 2013 compared with 2010 San Diego County reduced hospitalizations by 11 However when the numerator and denominator go down at nearly the same rate the fraction moves just 4 3 which falls far short of the 20 reduction goal that Medicare has set What follows are the quarterly data from San Diego The first graph Exhibit 2 shows the quarterly rate of admissions per 1 000 Medicare FFS beneficiaries in San Diego County We have adjusted these data for the effects of seasons on admissions since there are usually more admissions in the winter The shaded portion shows the control limits an area which represents the expected range of variation demonstrated in the first 3 years of the data 2010 2012 Data that fall outside of the range or that consistently run on one side of the midline indicate that something has changed in how the system is functioning Clearly admissions are falling Exhibit 2 San Diego Seasonally Adjusted Admissions The second graph Exhibit 3 shows the readmissions rate in the same framework quarterly rate of readmissions per 1 000 Medicare FFS beneficiaries in San Diego County adjusted for seasonality The control limits again show change Readmissions are falling Exhibit 3 Seasonally Adjusted Readmissions The third graph Exhibit 4 shows the metric in the conventional form readmissions divided by discharges The graph does eventually show a decline but only a modest one The fact that the denominator was falling attenuated the impact of the falling number of readmissions Exhibit 4 Seasonally Adjusted Percent Discharges with 30 day Readmissions for San Diego County by quarter The next three exhibits show the comparison of the San Diego measures with the national rates for the same metrics Exhibit 5 shows that San Diego County is dramatically less likely to have Medicare FFS beneficiaries in the hospital than the nation as a whole 56 per 1 000 per quarter in San Diego compared with 69 per 1 000 per quarter nationwide Exhibit 6 shows that San Diego is also much lower in readmissions than the national average 10 per 1 000 per quarter in San Diego compared with 12 per 1 000 per quarter nationwide In both cases the declining use is reasonably parallel between San Diego and the nation This would imply that improvement strategies are still being effective at this lower range and thus the lower range is not yet a limit on improvement opportunities Exhibit 7 shows that San Diego County s conventional metric of readmissions divided by discharges simply tracks the national average Clearly the metric is not functioning in a way that reliably separates good practices from wasteful ones That readmissions over discharges metric does not convey the fact that San Diego is much less likely to hospitalize and to rehospitalize Indeed 10 of the 14 San Diego hospitals eligible for penalties for high readmission rates are being penalized next year Since the calculations that go into determining the hospital penalty focus on particular diagnoses in three past years it is possible that these hospitals manage to do badly with those diagnoses in those years but it seems quite unlikely More plausibly the metric used is of the readmission divided by discharge form so the shrinking denominator will affect this calculation Exhibit 5 Seasonally Adjusted Quarterly Admissions National and San Diego County Exhibit 6 Seasonally Adjusted Quarterly Readmissions National and San Diego County Exhibit 7 Percentage of Quarterly Discharges Readmitted National and San Diego County Without access to and analysis of much more data one cannot know how widespread this problem is We do know that San Francisco had an admission rate of just 50 per 1 000 per quarter in 2013 and a readmission rate of just 8 per 1 000 per quarter which are rates much lower than San Diego Yet 8 of San Francisco s 10 eligible hospitals will be penalized for excessive readmissions in 2015 Furthermore we know that the initial Medicare foray into this work published in the Journal of the American Medical Association in January 2013 link http jama jamanetwork com article aspx articleid 1558278 resultClick 3 Association Between Quality Improvement for Care Transitions in Communities and Rehospitalizations Among Medicare Beneficiaries see Outcome Measures involved 14 smaller communities and that project had to change from using the discharge based metric to using the population based metric when it became clear that the shrinking denominator was making the project monitoring unreliable Hospitals other providers and communities that believe they may be adversely affected by the malfunctioning metrics should have access to the data needed to investigate and CMS should welcome reconsideration of those situations NQF should suspend endorsement of new readmission discharge metrics and re examing existing ones CMS has multiple contractors working on readmissions and some have substantial experience and skills in the technical details of these metrics CMS should quickly modify their contracts to require them to investigate the extent of this problem to identify steps to ameliorate adverse impacts of the current readmissions discharges metrics and to build the metrics that can guide care transitions work into the future Certainly the time has come to sort this out and develop metrics that reliably separate exemplary from persistently inefficient practices Want to know more Protecting Hospitals that Improve Population Health by Stephen F Jencks http medicaring org 2014 12 16 protecting hospitals Senior Alert A Swedish National Dashboard for Preventitive Care for the Elderly by Elizabeth Rolf http medicaring org 2014 12 22 senior alert A Dangerous Malfunction in the Measure of Readmission Reduction Posted by Les Morgan on August 26 2014 No Responses Tagged with Affordable Care Act CCTP CMS measurement metrics readmissions rehospitalization Aug 26 2014 By Joanne Lynn and Steve Jencks Work to reduce readmissions has started to yield remarkable improvements in integration of care for frail elderly people by prompting hospital personnel to talk with community based service providers by teaching patients and families how to manage conditions and navigate the health care system more easily and by paying more attention to trying to fill gaps in the community s services But the measure being used to track improvement is seriously misfiring in some settings and if CMS does not mitigate the adverse impacts they may become destructive to the momentum and the good that has been done This is much more than an issue of imperfect risk adjustment or inadequate identification of planned readmissions it is a punitive error that undermines program goals Since CMS mostly aims to assign responsibility for readmissions to the discharging hospital the key metric has been the risk of readmission for the average person discharged which is the number of readmissions divided by the number of live discharges Any time outcomes are monitored with a ratio one has to watch out for whether interventions that affect the numerator also affect the denominator Here that s happening enough to completely obliterate the usefulness of the metric at least in some circumstances Here s a quick hypothetical example At baseline a hospital has 1 000 Medicare fee for service FFS discharges per quarter with 200 of them back within 30 days Subsequently the hospital team and various community based providers work together and drop the readmissions to 160 per quarter Does the readmission rate go down to 16 under the metric No First they no longer have the 40 readmissions that are also admissions and in the denominator But more important the very things that are reducing the readmission rate also affect the likelihood of coming back in 45 days or 6 months or ever Patients are supported in learning to take care of themselves and to advocate for themselves in the care system they make good care plans including advance care plans and they encounter a more supportive care system in the community These things are still affecting the patient many months after the hospitalization Indeed as the care system learns how to support fragile people in the community better fewer patients will need to come to the hospital in the first place The result for our hypothetical hospital is that it ends up with 800 discharges per quarter and it has not budged its readmission rate Officially it has not improved even though the work done by the hospital by patients and families and by community based providers has improved care substantially and has saved millions of dollars for Medicare Yet using the current flawed metric the hospital is still likely to be penalized for having a high rate of readmissions This is not a new observation The first sizable pilot project that CMS sponsored involved 14 communities and the readmissions discharges metric functioned so poorly that the outcome measure was changed during the project to a population based measure readmissions per 1 000 Medicare FFS beneficiaries in the geographic community See http jama jamanetwork com article aspx articleid 1558278 That measure works to track changes in the experience of those living in a community but it does not help in assigning credit or blame to particular providers unless there is only one provider in the area It is intrinsically community anchored The rub is that while good care of frail chronically ill persons is at heart a community endeavor Medicare has few tools to incentivize or penalize communities Furthermore it is not clear what the right rate of readmissions should be Very little work has been published on how well the various metrics perform in various circumstances though NQF has a score of new ones under consideration See http www qualityforum org ProjectDescription aspx projectID 73619 The hospital penalty measure has a very complicated risk adjustment but should the population based measure also be risk adjusted perhaps at least for the population age structure and whether the person is in Medicare due to disability or age The problem here is more urgent than other controversies regarding the Medicare readmission measure such as higher readmission rates in disadvantaged populations and whether communities with low total hospital utilization should be expected to have higher readmission rates In the case of measuring change the measurement flaw directly punishes hospitals and communities for doing what the Affordable Care Act and the Medicare Readmissions Reduction Program otherwise encourage them to do reduce preventable hospitalizations What should a responsible system manager like Medicare do Below are some suggestions In the short term Quickly sort out how to exclude certain contexts perhaps as part of risk adjustment e g whether CMS is authorized to limit application of the readmissions discharges metric through regulation or whether the issue has to go back to Congress For safety net hospitals don t penalize hospitals primarily serving poor beneficiaries For reducing admissions see which of these approaches works best or combine them Hospitals with declining admissions and the same bed size when the decline is at roughly the same rate or more than declining readmissions Hospitals with 50 of their Medicare FFS utilization in counties with admission rates in the lowest quartile in the nation Allow hospitals in a particular geographic area to propose accountability for a population jointly or singly so long as they together supply more than for example 70 of the hospital use for that population Then measure their success on a population basis readmissions 1 000 relevant people living in the area quarter and admissions 1 000 quarter In the longer term Develop useful metrics for continuity and quality of care especially for Reliability patient family sense of trustworthiness preparation and Patient family driven care plans evaluated for quality with feedback Develop useful metrics for the global costs of care including private and Medicaid costs for longer terms of illness not depending upon hospitalization as the trigger and including long term services and supports What Can You Do Now If you agree let s talk about how to make improvements to the metric with the National Quality Forum CMS hospitals and other interested organizations and colleagues Feel free to add comments and suggestions here too Let s build a commitment to evolving toward measures that really reflect optimal care rather than staying with the under performing and often misleading ones we have Want to know more Update as of January 26 2015 Initial CMS Evaluations of Readmissions Have Serious Flaws http medicaring org 2015 01 26 evaluation flaws Jencks et al s New England Journal of Medicine article on readmission statistics http www nejm org doi full 10 1056 NEJMsa0803563 The Hospital Readmissions Reduction Program http www cms gov Medicare Medicare Fee for Service Payment AcuteInpatientPPS Readmissions Reduction Program html The Community based Care Transitions Program http innovation cms gov initiatives CCTP CCTP Success Will We Know It When We See It Posted by Janice Lynch Schuster on July 3 2013 No Responses Tagged with care transitions CCTP CMS Coleman Model community based frail elders hospital readmissions Medicare quality improvement rehospitalization Section 3026 Jul 03 2013 By Carol Castillon Defining success in work that focuses on people who are very sick can be a challenge The usual metrics just aren t always applicable With that in mind how will we know success in our community based care transitions work CCTP Like everyone else involved in this endeavor San Diego faces the challenge of reaching a 20 reduction in Medicare fee for service readmissions We are avidly monitoring our progress But is that really success To some extent of course it is and it would be fabulous to get there If and when we do though I think there would still be a void Perhaps I m naïve or perhaps I have what we lovingly call a social worker s heart but my definition of success is something a little different The only way to convey this is by telling the story of patient X A day after admitting patient X to a partnering hospital our Inpatient Transition Coach assessed the patient for meeting our high risk criteria That same day the patient was assigned to the Care Transitions Intervention CTI coach The coach saw the patient and enrolled him into CTI as well as into our Care Enhancement program which could address the need for social services Throughout the hospital stay the partnering hospital provided the patient with assistance in communicating his needs to his healthcare team From this interaction the team learned that the patient could not afford his medication co pays Based on hospital regulatory charity guidelines we were able to have that fee waived After 3 days in the hospital the patient was discharged and the CCTP clock began to tick When the patient opened his apartment door our coach found herself in an all too familiar situation She found that the apartment had been hit by what looked like a tornado involving the patient s medications The patient filled with nervousness and relief at seeing the coach who is a nurse blurted I need to call 911 I need to get to the ER Every CTI coach fears hearing this Staying calm our coach assessed the patient and found that he had been suffering from a headache since the day of discharge The patient did not have any pain medications or transportation to obtain such medications Using her charismatic charm the coach was able to coach the patient to call his physician and discuss these symptoms She then helped him to identify some key issues that were quite evident with his medications The visit lasted for about 2 hours but even with that much time the coach could not complete the four pillars of the CTI model Instead she worked with the patient to set follow up medical appointment with his physician and connected him with some of our Care Enhancement services Through Care Enhancement we were able to provide a taxi prescription to get the patient to his doctor s office The Care Enhancement social worker then worked miracles The social worker connected the patient with a home health program which the patient had declined at discharge She assisted the patient in obtaining transportation through our Metropolitan Transit System Access which assists people with disabilities The long term needs assessment found that the patient had shown symptoms of depression and so the social worker addressed this problem with the patient and physician The patient was connected with in home counseling aide and attendance through the VA and housing In terms of housing she helped the patient to move from his second floor apartment floor and limited his ability to go out the patient uses a scooter to a living environment better suited to his needs Now that s success Because of our team s work and focus the patient doing better This was a direct result of our collective interventions Patient x has ongoing support from a team that is committed to improving the lives of each and every patient we meet Right now we are at 80 days post discharge and no readmission Carol Castillon works for Aging Independence services and manages the CCTP work in San Diego County key words CTI Coleman model care transitions San Diego County CMS readmissions quality improvement care enhancement The Feedback Circle San Diego CCTP Listens to All Perspectives to Improve Care Transitions Posted by Janice Lynch Schuster on June 21 2013 No Responses Tagged with care transitions CCTP CMS coalition building community partnerships discharge planning hospital readmissions Medicare quality improvement rehospitalization San Diego Section 3026 Jun 21 2013 By Carol Castillon By developing a feedback loop so that community based organizations and hospitals can communicate more effectively about shared patients San Diego s Community based Care Transitions Project CCTP has opened a door for improving patient health improvement Over the past few months I have witnessed first hand the development of this crucial piece of the program In the San Diego CCTP anchored by Aging Independence Services a community based organization we offer two CCTP approved interventions the Care Transitions Intervention CTI and Care Enhancement Our partnership includes four health systems and 13 hospital campuses When I think of hospitals and medicine I think of answers Individuals seek attention from hospitals and physicians for answers as to why they are ill or why their bodies are not reacting as they should Clinicians and other professional caregivers witness health problems within the clinical environment or only hear about them from a patient or caregiver For those individuals who are in a high crisis mode accuracy can become a problem And often as soon as a patient is admitted to the hospital he or she patient expresses the desire to go home and in order to get home they will say or agree to just about anything clinicians recommend I know this from my own experience as someone who believes quite sincerely that there s no place like home At the same time patients and their loved ones often are unprepared for the functional decline that is often associated with a hospital admission often not fully appreciating how depleted they are until they actually get home To respond to this CCTP has engineered a merging of the hospital and home perspectives My organization AIS is a real partner in this process we have had the opportunity to collaborate closely with each hospital One of our approaches has been to participate in bi weekly internal meetings or huddles We use these meetings to debrief one another about patients smooth work flow processes review data to ensure that we are on target to meet performance targets present success stories and conduct a root cause analysis whenever a patient is readmitted These meetings are truly multidisciplinary and include all members of the partnership assigned to a particular hospital As we go around the table and discuss our pre and post discharge interventions we have found that our feedback circle is gaining a presence of its own The feedback circle enables us to bridge the clinical to home environment in ways we have not experienced before We are able to immediately feed information back to hospitals about successes accomplishments and challenges In some cases the feedback circle has even enabled hospitals to change internal processes The home assessments conducted by our CTI Coaches and Care Enhancement Social Workers are beginning to be incorporated into the patient s hospital medical records and even into primary care physician s records We ve had physicians contact our coaches to commend the CCTP team on a job well done One particular physician was amazed in how much a patient had changed and even commented You guys have done more for this patient with your interventions than I could ever do Such feedback is almost music to our ears Carol Castillon works with AIS to manage the San Diego CCTP key words CCTP care transitions evaluation feedback loops quality improvement community partnerships San Diego Solving a Puzzle Invoicing for Patient Encounters with the San Diego CCTP Posted by Janice Lynch Schuster on May 29 2013 No Responses Tagged with care transitions CCTP community based discharge planning frail elders hospital readmissions Medicare rehospitalization San Diego County May 29 2013 By Deborah Marquette It was the classic conundrum how do you fit a square peg into a round hole The County of San Diego is widely known for doing things a little differently and our model for providing community based care transitions project CCTP services is no different The San Diego Care Transitions Partnership SDCTP CCTP model includes the Care Transitions Intervention CTI However in addition to CTI the SDCTP model includes a variety of interventions that are completed prior to discharge e g High Risk Health Care Coach Inpatient Navigator Bridges and Pharmacy The model also includes additional post discharge interventions such as CTI Care Enhancement and non CTI follow up phone calls These additional interventions posed our first challenge for invoicing We quickly realized that the List Bill design CMS method for billing Medicare for CCTP wouldn t meet our internal needs for gathering monitoring and tracking invoice and intervention data For some of our interventions there is no clear mapping between our intervention and the List Bill s Care Transition Services For others the List Bill was too ambiguous For example if we select Telephone follow up as the Patient Encounter how will we know whether that patient received CTI or our non CTI follow up phone call intervention Hmm thoughtful pause we needed to find a way to meet the List Bill requirements while capturing the data in a way that would be meaningful for us as well That s how our Manual Invoicing Process was born I ll be completely honest this invoicing baby is less than attractive Alright it s downright ugly Picture this an Excel worksheet 41 columns long With no margins and at a scale of 75 the worksheet still prints out on six 6 legal size pages And that s just to capture the data we need for managing and tracking our List Bills It doesn t include the additional 32 columns that we use for capturing other data elements such as Reason for Non Enrollment or Reason for Withdrawal Now factor in the fact that at full capacity we ll be maintaining these data for 13 hospitals and roughly 21 000 patients year What fun the manual process will be then Like I said it isn t pretty But it does work and it seems to work well We may even be sad to see the manual process go not likely when it s replaced by our web based invoicing and data collection system ALEX I ll share more about ALEX in a later post The format of the List Bill led to our second invoicing challenge Considering our size there s no way we can manage all of our List Bills by entering them one by one using the List Bill template Aside from increasing the risk for data entry errors entering all of the List Bills manually would be a more than full time job for several people Since that isn t an option it was back to the drawing board Here we had some help Reaching out to our Project Officer and other CCTP sites we asked if anyone had successfully submitted a List Bill in a format other than the List Bill template Our call was answered by the Southwestern Ohio CCTP They had figured out the Excel formulas needed to convert data into the format s that would meet Gentran s requirements Gentran is the online application for submitting List Bills to CMS With a little tweaking we ve tailored those formulas and added a few of our own to convert the information collected on our Manual Invoicing worksheet With just a little copy and paste action of data and formulas we re now able to create a List Bill for all of our patients in 10 15 minutes It doesn t matter if we have 1 or 1 000 the timeframe is the same Around here we call that a success Ms Marquette is the Principal Administrative Analyst for the San Diego Care Transitions Partnership This is part of our regular series on San Diego s experiences launching its CCTP work Key words CCTP CMS Medicare care transitions quality improvement hospital readmissions frail elders San Diego County Southeast Michigan CCTP Tests New Approaches to Reduce Readmissions Posted by Janice Lynch Schuster on April 23 2013 No Responses Tagged with care transitions CCTP coalition building Coleman Model community based discharge planning eldercare hospital readmissions Naylor Model rehospitalization Apr 23 2013 by Benjamin Kuder Every Community based Care Transitions Program CCTP in the country of which there are now 102 funded by the U S Centers for Medicare and Medicaid CMS aims to balance targeted evidence based interventions to patient needs CCTP teams know that every avoidable readmission has a story behind it The Area Agency on Aging 1 B AAA 1 B seeks to meet care transitions needs for elders in two of their counties Oakland and Macomb with an innovative multilayer strategy CMS directed communities applying to participate in the CCTP to conduct a root cause analysis so that they could build a CCTP that meets community needs The AAA 1 B found that it could deliver the highest priority services by dividing the population based on five clinical needs 1 Care Transitions Intervention CTI Coaching Following the self activation model developed by Dr Eric Coleman this strategy empowers participants with coaching that helps them find the strategies that enable the patient to take charge of recovery and achieve personal goals Through increased health literacy and greater confidence individuals with chronic conditions are better able to make decisions about their care and recovery and insist that clinicians provide appropriate help 2 CTI Coaching with Behavioral Intervention Many patients experience mental health issues such as depression anxiety and serious mental illnesses which contribute to frequent readmissions In this strategy a behavioral health coach works with patients to provide support and mitigate some of the problems that can hinder recovery 3 CTI Coaching with In Home Services This strategy provides coaching and referrals to in home services such as meal delivery or transportation to the doctor which help reduce risk of readmission 4 Coaching with Multiple Interventions Hospice Coaches connect with patients who have little family support and who do not want home care or hospice and try to reconnect them with supportive services and initiate longer term care planning 5 Skilled Nursing Facility SNF Transitions Coaching Skilled nursing facilities in the area had especially high readmission rates so this strategy provides coaching for better transitions from the hospital to the SNF and from SNF to home Coaches meet with participants and their caregivers before hospital discharge again shortly after nursing home admission and then shortly before discharge from the SNF In addition the coach also discusses differences between the nursing home and hospital how to pursue personal goals and how to find help to achieve these goals at the nursing home The coach also works with the participant and caregiver to complete the personal health record modified for the SNF and encourages them to participate in the care plan meeting The coach also engages hospital and nursing facility partners to increase communication and improve shared processes Tailoring these strategies to the five distinctive categories of patients allows AAA 1 B to provide high value transitions coaching to virtually everyone Many of the coaches say people have been dealing with chronic conditions so long and no one has asked them their opinion on their plan of care says Barbra Link director of care transitions for AAA 1 B Coaches help them to get tools to self activate That s the most powerful thing That s the foundation of the program Participants in the program must be referred from AAA 1 B s partner hospitals have traditional Medicare and either have one of the targeted conditions chronic obstructive pulmonary disease heart attack pneumonia or congestive heart failure or any condition with a readmission within the last 90 days The AAA 1 B Care Transitions Coach assigns each beneficiary to a category using a risk assessment completed by the hospital s care management team The program also allows Strategy 1 Coaches to refer the participant to a Specialty Coach Strategy 2 Strategy 4 and Strategy 5 when appropriate All coaches provide Strategy 1 and Strategy 3 Coaching but may consult with Specialty Coaches whenever needed The AAA 1 B project is about 10 months into its initial two years with the possibility of renewal for the following three years All five strategies are operating and 650 beneficiaries have enrolled Although the first strategy has the highest volume of people 67 percent the other strategies are proving to be just as important for elders who need more support The CCTP team quickly recognized that project leaders and staff must watch for problems that call for different remedies For example when AAA 1 B leaders observed that many of the program s vulnerable elders did not understand their nutrition needs they reached out to a nutritionist at a partner hospital to develop simple accessible one page flyers for patients regarding nutrition One flyer explained how to cut back on dietary sodium and how to calculate sodium intake from a nutrition facts label Through close interactions with the patients coaches were able to identify and respond to specific nutritional problems that would not have otherwise been apparent In its CCTP AAA 1 B has a coalition with three local hospitals that had some of the highest readmissions rates in the state Creating these coalitions while ultimately quite beneficial did present some initial challenges Before implementing the program AAA 1 B leaders had to help all stakeholders understand the benefits of the program Once this had been done referrals from the hospitals took a major upswing According to Barbra Link We found that each hospital is unique and lots of relationship building was required Once we established greater trust and better understood the system things seemed to go well The future of this program involves moving toward a larger community based coalition with more community organizations Link explains We are trying to move into becoming a learning network Our focus will be information exchange and growing as a coalition Now that the program is up and running we can work on this over the next year AAA 1 B also collaborates with other CCTP organizations nationwide Through regional and national phone calls and virtual learning sessions they share best practices and solve problems together In this way AAA 1 B is spreading its innovative multilayer approach to reducing hospital readmissions and empowering patients This article originally ran on the Altarum Institute Health Policy Forum on April 18 2013 key words care transitions CCTP community based Area Agency on Aging Hear Dr Joanne Lynn Discuss Care Transitions Posted by Janice Lynch Schuster on April 2 2013 No Responses Tagged with care transitions CCTP coalition building discharge planning eldercare frail elders hospital readmissions Medicare patient activation rehospitalization Apr 02 2013 A Thursday webinar cosponsored by Illuminage com will feature Dr Joanne Lynn discussing care transitions Each year thousands of older patients are discharged from the hospital only to be later re admitted Avoiding preventable rehospitalizations has become a major cost savings goal for our health care system IlluminAge in partnership with the National Council on Aging has scheduled an online briefing to examine how older patients can play a larger role in the effort to reduce the frequency of hospital readmissions You are invited to join the webinar on Thursday April 4 beginning at 1 30 p m Eastern time Improving Care Transitions Engaging Older Patients on the Issue of Preventing Rehospitalization Joining us as presenter will be Joanne Lynn M D chair of the Center on Elder Care and Advanced Illness at the Altarum Institute Dr Lynn a geriatrician quality improvement advisor and policy advocate is a member of the Institute of Medicine and the National Academy of Social Insurance a fellow of the American Geriatrics Society and The Hastings Center and a master of the American College of Physicians The webinar aims to provide a fresh perspective on the increasingly important challenge of reducing hospital re admissions including The importance of educating and empowering older patients and caregivers The role senior care and aging service professionals can play in providing needed support services and other resources to older persons returning home following a hospital stay Resources you may find helpful in your own community practice or organization The April 4 webinar is free with registration on a first come first served basis To register follow this link https www1 gotomeeting com register 581843281 Key words Joanne Lynn care transitions quality improvement patient activation Reaching Rural Residents Improving Care Transitions in Western New York State Posted by Janice Lynch Schuster on August 23 2012 No Responses Tagged with care transitions CCTP coalition building community based frail elders hospital readmissions rehospitalization Section 3026 Aug 23 2012 The P

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  • Section 3026 – MediCaring.org
    TCM originally developed by Dr Mary Naylor While TCM relies on advance practice nurses working with patients and caregivers COSA s new CCTP is a modified version as it includes hospital based registered nurses and social workers The social workers who are affiliated with COSA work closely with the RNs to deliver patient education and arrange referrals for follow up services In the AoA pilot program an advanced practice nurse enrolled patients based on screening criteria that included patients over the age of 65 who were because of their diagnosis at risk for an avoidable readmission The hospital had a COSA assessor who offered patients a level of care assessment at bed side for potential enrollment into COSA programs Once assessed patients were assigned to a COSA care manager who followed them in the community The advance practice nurse followed patients for up to 60 days while the COSA care manager could follow them for much longer In the modified Centers for Medicare and Medicaid Services CMS CCTP program a registered nurse will screen hospital admissions for patients who are 60 years old and older with Medicare Fee for Service with both Parts A and B all cause hospital admissions and meet any of several criteria such as at risk for readmission poly pharmacy lack of informal supports living alone lack of follow up with a primary care physician PCP in a previous hospital discharge or hospital readmissions within the previous 180 days Once the nurse has identified an eligible patient the nurse will meet with him or her at the bedside to discuss enrolling in the program Patients who agree to participate will receive a visit from the project s social worker Together the nurse and social worker will provide the patient with user friendly transfer and discharge forms and teach the patient how to use AHRQ s Taking Care of Myself That booklet which is customized to the patient s needs includes information about medications diagnosis nutrition and activity follow up appointments and so on Patients will be encouraged to take the booklet with them to follow up appointments and to have physicians update it as needed The CCTP nurse is scheduled to make two home visits to the patient as the first visit will be with in 72 hours of the hospital discharge and another at week 4 before the completion of the program The COSA CCTP social worker will meet with patients weekly and also follow up by phone The nurse and social worker will follow the patient for 30 days The COSA social worker will work with the patient according to his or her needs and preferences If the patient would like the social worker will accompany him or her to the first post discharge PCP visit If additional COSA services are needed the patient can be assessed at bedside or in the community by a COSA Assessor and then assigned to a COSA Care Manager who would follow the patient much longer if needed In addition social workers have over sized business cards that will feature their photographs and contact information The cards give social workers a face patients can share the cards with family members at home so that they can see who will be visiting the patient For patients who have people in and out of the home daily the card is a visual reminder about the social worker The CCTP is an initiative of the Partnership for Patients a nationwide public private partnership launched in April 2011 that aims to cut preventable errors in hospitals by 40 percent and reduce preventable hospital readmissions by 20 percent over a three year period CCTP s goals are to reduce hospital readmissions test sustainable funding streams for care transitions services maintain or improve quality of care and document measurable savings to the Medicare program The CCTP project which received funding late this spring is ready to hit the ground running Two hospitals will launch the work on August 6 and three others will join in by October According to the COSA CCTP Project Director Terry Levine the project s success hinges on the relationships among COSA and all the participating hospitals In planning it he said it was important to communicate with the hospitals and to let them know that the CCTP work is not meant to replace their discharge planning but to supplement it Over the course of the next two years the project aims to enroll 4 282 patients with hopes that successful work will lead to subsequent years of funding For more information about the project contact Mr Terry Levine the COSA CCTP Project Director at email protected key words CCTP CMS Naylor model care transitions SAGE Bridging the Divide between Acute Medical Care and Social Services in Northeast Ohio Posted by Janice Lynch Schuster on July 23 2012 No Responses Tagged with care transitions CCTP coalition building community based discharge planning eldercare frail elders hospital readmissions rehospitalization Section 3026 Jul 23 2012 By Dr Kyle Allen and Susan Hazelett The Summa Health System Area Agency on Aging 10B Geriatric Evaluation Project SAGE is a collaboration between an integrated health system and the local Area Agency on Aging which was begun in 1995 SAGE provided the organizational structure to develop the resources and processes needed to effectively integrate geriatric medical services and community based long term care services Such integration is essential to bridging gaps between acute medical care and community based care enabling medical and social services providers to reach frail older adults living in the community with multiple chronic conditions and to improve their quality of life The SAGE project which operates in the Akron Ohio metropolitan area has managed to do just that Results of the 17 year collaborative indicate that consumers health care systems health care providers and payers have all benefited from the focus on integrating service delivery In the early 1990s Summa Health System SHS an integrated not for profit health delivery system had launched several projects aimed at improving care for frail elders Summa comprises six community teaching hospitals with more than 2000 beds as well as its own health plan skilled home care hospice and a foundation Summa s insurance plan has 150 000 covered lives including a Medicare Advantage Plan of 23 000 One of the projects being tested at Summa was the ACE Acute Care for Elders model a model of hospital care delivery aimed at improving the functional status and clinical outcomes for hospitalized older adults Recognizing that this model did not have the necessary patient connection in the outpatient setting Summa realized it would need to expand its reach to elderly patients across the continuum of care To this end it created the Center for Senior Health CSH an outpatient consultative service that supports primary care providers by offering an interdisciplinary comprehensive geriatric assessment high risk assessment a geriatrics resource center a clinical teaching center inpatient geriatric consultation and outpatient consultation followup The CSH attempts to treat and reach the whole patient by addressing acute and chronic medical needs psychosocial needs and family concerns Despite the range of services provided the CSH continued to be limited in its scope because it did not have access to patients in their homes nor could it provide long term case management As a result it began to rely increasingly on community based long term care agencies for this kind of information and management At about the same time the Area Agency on Aging 10B Inc AAA found itself managing a growing number of consumers with functional decline geriatric syndromes and multiple chronic illnesses The AAA which serves more than 20 000 elders in Northeast Ohio recognized that it needed to be better integrated with the acute medical sector if it were to achieve its goal of delaying and preventing nursing home admissions Leaders from Summa Health and the AAA recognized the challenges and deficits each one faced in providing continuity of care to patients consumers and began meeting to discuss how they could build a new integrated model of care They realized that they shared a common goal and vision to improve care for frail elders and launched SAGE which provided the organizational structure needed to effectively integrate their services SAGE had no grants or funding just a spirit of collaboration and cooperation and a common desire to do more than just business as usual A SAGE task force was created comprised of staff from both organizations including physicians nurses and social workers as well as senior leaders to promote communication provide feedback and create initiatives that linked the two The group met monthly for two years and now meets quarterly Among its early objectives were the development of protocols to screen and identify at risk older adults to establish mechanisms for information sharing and resources to identify gaps and duplication in service delivery to locate a AAA case manager at the CSH to educate staff from both organizations to collect data and information and to identify and address barriers to implementation Eventually SAGE created an RN care manager assessor program in which placed an AAA assessor in the acute care hospital The assessor works closely with the ACE team to identify hospitalized patients who can benefit from community based programs as well as patients who are eligible for PASSPORT the state s Medicaid waiver program This was a new initiative for the AAA which had traditionally conducted these assessments post discharge in the patient s home That assessment now occurs before the patient is even discharged from the hospital thus helping to determine needs for community based services and facilitating the process for eligibility and approval for Medicaid long term care benefits This is beneficial because patients will typically receive Medicare covered services for skilled needs but long term care needs are not addressed as well and the Medicare skilled benefits are provided for only a limited time usually 30 days Without the other supports this vulnerable population is at risk for poor health care access emergency department visits and hospital readmission The AAA then assumes case management for the consumer and offers periodic geriatric follow up This program has facilitated improved capacity management for complex patients in the acute care hospital It improved AAA communication with primary care and hospital staff reducing repeat hospitalizations ED visits and nursing home placements It improved outcomes for complex patients and decreased discharges from PASSPORT to nursing homes During the pilot period referrals to and enrollments in the PASSPORT program doubled The AAA was also successful in replicating this model at other hospital systems in the Northeastern Ohio AAA service area A more recent positive outcome related to this collaboration work was the awarding for AAA 10b Inc one of the first seven Community Based Care Transitions projects from CMS CMMI as part of the The Community based Care Transitions Program CCTP created by Section 3026 of the Patient Protection and Affordable Care Act In developing SAGE several barriers had to be overcome primarily those affecting leadership of the program development of an effective multidisciplinary workgroup and resources in terms of staff time The program can be adapted by other communities around the country offering their acute medical system and community based programs a way to align their services and collaborate in ways that better address the needs of frail older adults Key words community collaboration SAGE Project ACE Units CCTP 3026 pilot programs CMS Offers Tips and Pitfalls for CCTP Applications Posted by Janice Lynch Schuster on July 12 2012 No Responses Tagged with care transitions CCTP CMS hospital readmissions Medicare QIO Section 3026 Jul 12 2012 In today s CMS phone call and webinar CMS officials offered tips and pitfalls that applicants for CCTP funding should keep in mind You can find those by scrolling through the slides from today s webinar And Medicaring will post more information early next week detailing what we heard in the call and what we learned Note one correction to the slides Do NOT use the 9600 average cost of readmission as the baseline for calculating your blended rate It is only to be used to project savings everything you wanted to know to apply to the cctpfinal slides Key words CCTP CMS Section 3026 root cause analysis tips applications Learn How to Apply to the Community based Care Transitions Program Posted by Janice Lynch Schuster on July 10 2012 No Responses Tagged with care transitions CCTP CMS community based community based care transitions program Section 3026 Jul 10 2012 On Thursday July 12 2012 from 12 00pm 1 30pm ET the Centers for Medicare Medicaid Services CMS will host a webinar on Everything You Wanted to Know to Apply to the Community based Care Transitions Program CCTP by September 3 2012 Learn more about program requirements preferences and other keys to success from CMS Innovation Center staff and communities currently participating in the CCTP program Topics that might be discussed include defining eligible community based organizations conducting a root cause analysis calculating a blended rate selecting an intervention and more The final CCTP review panel for 2012 will convene on September 20 2012 Applications must be received by September 3rd to be considered for this review Future panels may be announced as funding permits WHAT Community based Care Transitions Program Webinar WHEN Thursday July 12 2012 12 00pm 1 30pm ET WHERE Register at the following link https event on24 com eventRegistration EventLobbyServlet target registration jsp eventid 493029 sessionid 1 key C0880AB50429D8C938027FAB47465002 sourcepage register To join by telephone call 866 216 6835 and enter code 507295 For those unable to participate on Thursday the entire program will be archived for later viewing on the CMS Innovations website which you can access here http www innovations cms gov initiatives Partnership for Patients CCTP partners html Key words CCTP Section 3026 CMS Innovations Center Partnership for Patients care transitions Tips for CCTP Applicants on Writing Successful Applications Posted by Janice Lynch Schuster on May 29 2012 No Responses Tagged with application process blended rate calculation care transitions CMS Section 3026 May 29 2012 A recently released SCAN Foundation white paper summarizes a daylong conference aimed at helping organizations to understand and complete applications for the Centers for Medicare and Medicaid CMS Community based Care Transitions Program CCTP The report features advice and guidance provided during a March 2012 program sponsored by the Southern California Patient Safety Collaborative the event included experts from the Hospital Association of Southern California Health Services Advisory Group of California Collaborative Healthcare Strategies Collaborative Consulting and recent CCTP applicants Part of the program focused on how to navigate the CCTP application process and the report summarizes that process and offers tips on how to address common concerns and challenges Panelists identified four key themes that organizations need to address in the application process including Conducting a root cause analysis and developing a program strategy Developing a budget calculating the blended rate Hiring a grant writer Building relationships The report explains the purpose of the root cause analysis which is to identify gaps in care new target populations cultural and linguistic barriers communication challenges and many other barriers to a smooth post hospital transition that are specific to the community and target population The report describes how some recent applicants have used the root cause analysis to develop programs one for instance found that medication reconciliation was a major issue and developed a program that targeted medication management very soon after discharge In terms of developing the program strategy panelists urged applicants to use a simplified care transitions model and not make their intervention too complicated They also urged applicants to conduct small pilot projects implementing evidence based models a critical step in demonstrating past success with care transitions work In addition the report provides very detailed information on how to develop and present the project s budget along with other financial tips including how to calculate the blended rate Here panelists suggested that applicants develop two budgets one that includes the entire cost of the intervention and one that is designed for the CCTP opportunity and addresses only direct service costs The report notes that to date funded organizations have received from 250 to 500 per eligible patient and adds CCTP is not a money making venture but could significantly help improve the quality of life for participants and supplement in house costs to pay for improved care transitions Calculating the blended rate has proven to be a challenge for many organizations The report offers very specific information on calculating it as well as how to calculate the target population number In short as applicants develop their budgets the report recommends that applicants consider the following questions What is in it for CMS How is it going to save them money and keep people out of the hospital and improve the Triple Aim What does this project mean for CMS Some organizations have hired professional grant writers to help them develop their applications such a person can help organizations to put their ideas into language appropriate for CMS ask questions that help to clarify the program and ask questions that help to develop the budget In addition to working with professional grantwriters organizations should also consider having their applications reviewed and critiqued by external partners or others with no stake in the application Finally the report notes CMS strong preference for applications that indicate the involvement of multiple hospitals in their community led by an eligible CBO As groups build such relationships they should consider all community organizations that influence and affect patient lives with particular attention to gaps in care identified by the root cause analysis and groups that might fill them The full report by writer Patrice Wagonhurst can be downloaded from the SCAN Foundation website at http www thescanfoundation org sites scan lmp03 lucidus net files P Wagonhust Community Based Care Transitions 4 24 12 pdf Key words CCTP Section

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  • webinar – MediCaring.org
    Banner Health webinar learning session Care Transitions 101 Dr Joanne Lynn on the Basics Posted by Janice Lynch Schuster on April 15 2013 No Responses Tagged with care transitions Illuminage Joanne Lynn NCOA quality improvement webinar Apr 15 2013 Dr Joanne Lynn recently led a webinar focused on care transitions what they are why they matter and how to improve them The session sponosred by Illuminage and the National Council on Aging streamed live on April 4 The recording is now streaming online and can be viewed here http illuminage com webinars improving care transitions htm In addition to Dr Lynn s ideas and insights the session featured a Q A segment Take a few minutes and see what you can learn Speak Up Detroit Roundtable To Focus on Aging Caregiving and End of Life Posted by Janice Lynch Schuster on May 6 2012 No Responses Tagged with aging community based end of life family caregivers palliative care public policy webinar May 06 2012 On June 5 2012 Altarum Institute will sponsor a roundtable Speak Up Infuential Women Give Voice to the Challenges of Eldercare Moderated by Eleanor Clift the panel will include physicians Muriel Gillick Cheryl Woodson and Joanne Lynn along with policymaker and caregiver advocate Lynn Alexander The session to be held in the Detroit studios of Detroit Public Television will be recorded and will form the basis of an hour long documentary The program runs for a full day with the roundtable discussion in the morning and breakout discussion groups in the afternoon Those not able to journey to Michigan for the event are invited to join the streaming webcast For details on how to sign up watch the following video and follow the links at the end This video includes outtakes from an April 13 Roundtable held in Washington DC and features several of the authors slated for the June program http www youtube com watch v nBaYNFHT07A Key words Altarum Institute policy roundtable Eleanor Clift Muriel Gillick Lynn Alexander Joanne Lynn end of life caregiving aging writing Webinar on a Community Based Approach to Reducing Hospital Readmissions Posted by Les Morgan on May 10 2011 No Responses Tagged with community based evidence based hospital readmissions quality improvement webinar May 10 2011 You can view a recorded version of the webinar on The Community Based Approach to Reducing Hospital Readmissions Resources that took place on May 6 2011 You also can download the presentation slides for the webinar and supporting materials from the Commonwealth Fund website The webinar featured the following experts in care transitions Anne Marie Audet M D M Sc moderator vice president Quality Improvement and Efficiency The Commonwealth Fund Eric Coleman M D M P H director Care Transitions Program and professor of medicine at the University of Colorado Health Sciences Center Garry MacKenzie M D medical director of cardiology services at McKay Dee Hospital Center in Ogden Utah Janice Fitzgerald R N director of quality and medical management at Baystate Medical Center

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  • Agitator’s Guide to Elder Care – MediCaring.org
    it should attend to the full package of services including Older Americans Act Medicaid and Medicare As with private schools people would generally buy in for at least a year relying on the services tied to a defined geographic area Require that elder care service be available around the clock with records of each elderly person s plan of care and with the ability to respond to the home or nursing home within a few hours Provide stipends health care insurance respite time assessment and training and engagement for family caregivers who provide substantial support to frail elders Generate population based data regarding costs and performance for communities Make sure that meaningful use criteria in electronic health records enable and require documentation of the likely course of the illness a person centered plan of services an advance care plan and a time for feedback and revision Put material about the disease its likely course and the main elements of the care plan on www mymedicare gov and in personal health records Support decent pay and benefits for direct care workers such as home health aides How to Get Underway Go to a candidate forum or debate in the current political campaigns and raise your voice about elder care and caregiver support Share an experience and describe how the system might have made it better easier or more effective Get an elder care improvement initiative on the policy agenda of the professional consumer disease based and volunteer groups to which you belong Tell your stories write responses to blogs post your story on websites talk with civic leaders and tie the challenging experiences to specific aspects of policy and practice Visit medicaring org and share your insights on the blog The Center for Elder Care and Advanced Illness is led by Dr Joanne Lynn To learn more about the ongoing work of the center please email email protected or phone 202 776 5100 Altarum Institute Center for Elder Care and Advanced Illness Vision To help the United States achieve social arrangements that ensure that when we must live with serious chronic illnesses associated with advancing age we can count on living meaningfully and comfortably at a sustainable cost to our families and society 2 Responses to Agitator s Guide to Elder Care Elder Home Care Services says August 8 2013 at 1 13 am I love your post on Elder care This is very sensitive topic this type of posts aware people to Help elder and also work for their care Reply Ellen Corindia says March 31 2015 at 9 03 am This site is an excellent source of information Elder care reform is a long overdue issue throughout our country In a culture that overvalues youthful appearances and prefers not to consider end of life I am hopeful that people will smarten up and do some forward thinking Reply Leave a Reply to Elder Home Care Services Cancel reply Your Comment You may use these HTML tags and attributes a

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  • Agitator’s Guide to Elder Care – MediCaring.org
    and it should attend to the full package of services including Older Americans Act Medicaid and Medicare As with private schools people would generally buy in for at least a year relying on the services tied to a defined geographic area Require that elder care service be available around the clock with records of each elderly person s plan of care and with the ability to respond to the home or nursing home within a few hours Provide stipends health care insurance respite time assessment and training and engagement for family caregivers who provide substantial support to frail elders Generate population based data regarding costs and performance for communities Make sure that meaningful use criteria in electronic health records enable and require documentation of the likely course of the illness a person centered plan of services an advance care plan and a time for feedback and revision Put material about the disease its likely course and the main elements of the care plan on www mymedicare gov and in personal health records Support decent pay and benefits for direct care workers such as home health aides How to Get Underway Go to a candidate forum or debate in the current political campaigns and raise your voice about elder care and caregiver support Share an experience and describe how the system might have made it better easier or more effective Get an elder care improvement initiative on the policy agenda of the professional consumer disease based and volunteer groups to which you belong Tell your stories write responses to blogs post your story on websites talk with civic leaders and tie the challenging experiences to specific aspects of policy and practice Visit medicaring org and share your insights on the blog The Center for Elder Care and Advanced Illness is led by Dr Joanne Lynn To learn more about the ongoing work of the center please email email protected or phone 202 776 5100 Altarum Institute Center for Elder Care and Advanced Illness Vision To help the United States achieve social arrangements that ensure that when we must live with serious chronic illnesses associated with advancing age we can count on living meaningfully and comfortably at a sustainable cost to our families and society 2 Responses to Agitator s Guide to Elder Care Elder Home Care Services says August 8 2013 at 1 13 am I love your post on Elder care This is very sensitive topic this type of posts aware people to Help elder and also work for their care Reply Ellen Corindia says March 31 2015 at 9 03 am This site is an excellent source of information Elder care reform is a long overdue issue throughout our country In a culture that overvalues youthful appearances and prefers not to consider end of life I am hopeful that people will smarten up and do some forward thinking Reply Leave a Reply to Ellen Corindia Cancel reply Your Comment You may use these HTML tags and attributes a href

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  • About Us – MediCaring.org
    in PDF format For more information please email us at email protected Center for Elder Care Advanced Illness Altarum Institute 2000 M Street NW Suite 400 Washington DC 20036 Creative Commons License Unless otherwise noted all content on medicaring org is available for your use under the Creative Commons Attribution NonCommercial 3 0 license http creativecommons org licenses by nc 3 0 Visitors to this website agree to grant a non exclusive irrevocable royalty free license to the rest of the world for their submissions to medicaring org under the Creative Commons Attribution NonCommercial 3 0 License http creativecommons org licenses by nc 3 0 One Response to About Us Sharon Cheng says September 1 2011 at 7 57 am I have been working with several hospitals to apply for the CCTP and really appreciate the resources and conversations you have provided on your website Have you heard anything about the first couple of waves of applications which were submitted This forum might be a good place to discuss any info or feedback to improve everyone s understanding of what CMS is looking for Again thanks for your help Sharon Reply Leave a Reply to Sharon Cheng Cancel reply Your Comment You may use these HTML tags and attributes a href title abbr title acronym title b blockquote cite cite code del datetime em i q cite s strike strong Name required E mail required URI MediCaring is a service of the Center for Elder Care and Advanced Illness at Altarum Institute Follow Us To receive our email newsletter send a request to email protected Tweets by medicaring Care Transitions News Ringling Bros circus elephants set for final act Sunday USA TODAY April 29 2016 PMH announces Annette Schnabel as president CEO Bureau County Republican April 29 2016 College baseball

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