A comprehensive new report provides nine hospital recidivism success stories about inter-agency collaboration projects in nine different regions. We found two that include home health care agencies using advanced technology as their projects’ center pins. This week, a home care agency, hospital and senior clinic in Denver worked together to reduce 30-day readmissions from 20% to 13% and 60-day readmissions by 50% compared to uncoached patients. Here is how they did it.
Strategic use of modern technologies and a willingness to update agency policies can help lower a home care provider’s rehospitalization rates. This is the conclusion of a new report, “Homeward Bound: Nine Patient-Centered Program Cut Readmissions,” published by the California HealthCare Foundation.
Though coming from a California-based organization, the report offers nine examples drawn from hospitalization reduction efforts across the country. HCTR received permission from CHCF to bring readers two of the report’s nine stories with direct relevance to home care. This week, we go to Denver. Next week, New York City.
Colorado Foundation for Medical Care (CFMC) is the Medicare Quality Improvement Organization (QIO) for Colorado. It convened representatives from three North Denver providers — St. Anthony’s Central Hospital, clinicians from its Senior Clinic, and Centura Home Health Agency — for a CMS demonstration project that ended in December 2008.
The senior clinic, which is based at St. Anthony’s Hospital and cares for frail elderly people, is part of an IPA, managed by the medical services management company, Physician Health Partners. The target population for the North Denver pilot was all of the Senior Clinics hospitalized patients with Medicare coverage, both fee for service and managed care.
The roll-out and planning process for the pilot took about six months, and the care transitions intervention itself lasted another six months.CFMC recruited St. Anthony’s Hospital as its closest partner, and together they recruited Centura Home Health Agency. CFMC provided the setting where the team could collaborate on planning and implementing the Coleman Care Transitions Intervention. The team included the head hospitalist, SNFists,* geriatricians, discharge planners, IT support and medical services management company representatives.
Dr. Jane Brock, chief medical officer for CFMC, said the Colorado QIO played a critical role in “structuring the implementation framework” and providing technical assistance. She believes that in a fragmented healthcare environment, someone — preferably a neutral entity — needs to play this role, to help disparate providers come together to build community and develop workable approaches to care transitions.
The North Denver participants were enthusiastic about the chance to problem-solve together, she reported. “The most productive thing we did was to create a time and place for providers to come and talk to each other about what they know. We had the idea, provided a little bit of facilitation and coffee, and they really did the work.”
The team members met regularly to work on common processes for streamlining and standardizing communication, information-sharing and transfer of medical responsibility. They focused initially on process mapping to improve and standardize the discharge process. To reinforce this collaboration, CFMC facilitated site-exchange visits between hospital emergency department nurses and nursing homes, and home visits for discharge planners.
In keeping with the Coleman Care Transitions Intervention (CTI), the North Denver partners collaborated to create and fund two nurse transition coach positions to carry out the intervention — a nurse case manager from the hospital, and a nurse from the home health agency (funded by the hospital system).
Preparing the patient for a post-hospital outpatient appointment is one of the four pillars of the CTI model. However, North Denver Geriatrician Dr. Thomas Cain noted the critical PCP hand-off can be “lost in the CTI model” without a way for hospital providers to coordinate with the outpatient physician.
To address this, the project brought providers together to develop reliable processes and communications strategies for safe transfer of medical responsibility, including prompt transfer of needed information. They agreed to use text messaging from the hospital to notify the PCP of a patient’s discharge. Dr. Cain observed that texting is less disruptive than a telephone call but more visible than a fax or e-mail. As of June 2009, a few hospitalists and outpatient physicians were testing the approach. To ensure that patients can see their physicians within a day or two of discharge, St. Anthony’s Senior Clinic builds time for same-day appointments into its schedule.
Within six months, this pilot project made a measurable difference in readmission rates. Thirty days after discharge, 13% of coached patients had been readmitted, compared with 20% of uncoached patients. Even more striking, at 60 days, coached patients were half as likely to be readmitted as the uncoached ones.
Looking Ahead
The success of the North Denver project led CMS in August 2008 to launch a three-year “Care Transitions Theme,” across 14 QIOs, which are responsible for bringing multiple local providers together to work on improving care transitions — much as CFMC did for the North Denver pilot. CMS selected CFMC as the QIO support contractor (QIOSC) for the 14 states. Thirteen, including North Denver, chose to use the Coleman Care Transitions Intervention model.
A second hospital has joined the North Denver project. Its steering committee includes providers from several settings, a large employer, an and-of-life facilitator and a Medicaid representative.†
The new project is open to all Medicare fee-for-service beneficiaries in specified zip codes who meet project criteria. The group hopes to prioritize patients with both a chronic disease requiring daily self-management (primarily heart failure, COPD, or diabetes) and a mental health diagnosis such as depression. Coordinators chose this target group because while local readmission rates for heart failure patients are lower than average due to effective post-hospital care, local data show that persons with both a mental health diagnosis and a serious chronic disease have significantly higher readmission rates.
The expectation is that coaching will have a large impact for such patients, giving them needed support for the tasks involved in maintaining their health after discharge. The project is testing the training of social work interns and community leaders, most of them seniors, as transition coaches.
The expanded implementation will begin with targeting patients on telemetry units within each hospital. The group believes that localizing the intervention to a specific unit will help set a standard protocol for involving coaches in discharge planning that can be more easily expanded as participants become familiar and comfortable with the intervention.
*SNFists serve a role in a skilled nursing facility comparable to that of hospitalists in a hospital.
†Colorado Foundation for Medical Care, Care Transitions — NW Denver Community, www.cfmc.org/providers/providers_pcc.htm.
