Page header will display here

Across the state hospitals are uniting with community-based organizations to form tight, integrated clusters of care with the goal of reducing hospital readmissions.

Focusing on high-risk Medicare patients recently discharged from hospitals, and funded through Section 3026 of the Affordable Care Act, these Community-based Care Transition Programs (CCTPs) are successfully cutting avoidable readmissions. There are 102 CCTPs funded nationwide and four in Massachusetts, funded by the Centers for Medicare and Medicaid Services (CMS).

While the Massachusetts programs - in Berkshire County, Merrimack Valley, the Worcester/Framingham area, and Mystic Valley Basin - are free to construct their own care transition program, they all share some core elements: a partnership between Aging Service Access Points (ASAPs) and local hospitals, the formation of caregiving teams involving Nurse Practitioners and other "care transition coordinators" or "coaches"  working within the hospital and patients' homes, and close tracking of results to report back to CMS.

(The Massachusetts ASAPs are a network of 27 non-profit agencies, operating in defined geographic areas, with authority from the Massachusetts Executive Office of Elder Affairs to provide a broad array of services to help consumers remain successfully in their homes. They offer information and referrals for senior services, including home care services and housing options. Many ASAPs have expanded their service offering to also include care transition services.)

The coordinated care between hospital-based case managers, home care-transition specialists, post-acute providers, the patient's primary care physician and, in many cases, the patient's family, among others, ensures that appointments are kept, medicines are ordered and taken, and the pitfalls that result in readmissions are avoided.

"It's a very collaborative process," says Patricia Eddy, R.N., director of Clinical Services at Elder Services of Berkshire County, one of the 27 Massachusetts ASAPs. "We have a very close relationship with Berkshire Health Systems, so we have non-medical people working with medical personnel, all united to benefit patients."

The Berkshire model was created in December 2012 and first focused on patients discharged from Berkshire Medical Center's (BMC) Heart Failure Clinic. But the Berkshire CCTP program eventually branched out to include any Medicare patient being discharged from BMC, who is at risk of being readmitted.

Karen Benzie, R.N., BMC's V.P. of Integrated Care and Home Health, says an R.N. within the hospital receives daily reports on all Medicare patients being discharged and then "risk stratifies" them to identify those most likely to be readmitted.  The R.N., often accompanied by coaches from Elder Services of Berkshire County, then interviews the patient in the hospital, assessing how much follow up care is needed and the patient's existing support structure.

Once a patient is identified as being able to benefit from the CCTP program, Elder Services' Pat Eddy says, "We follow them home to bridge the gap between hospital and home. We try to get in the home with them within the first two days."

CMS pays a per-patient amount that funds the CCPT's care team.  If avoidable readmissions are reduced, Medicare saves money and hospitals' CMS penalties for readmissions will decrease. Nationwide, CMS is evaluating the progress of CCTPs to consider the sustainability of care transition programs that effectively integrate hospitals with community-based organizations such as ASAPs.

Using Coleman and Naylor Models

Elder Services and BMC use a combination of the two best-known care transition programs - the Coleman Care Transitions Intervention and the Naylor Transitional Care Model.  The Coleman model consists of one hospital visit and one home visit, with follow-up telephone calls by a coach (either a nurse, social worker, or other caregiver), all focusing on care fundamentals such as: going through the patient's medications and helping them manage their use; ensuring that an appointment with the patient's primary care doctor is scheduled within seven days; and ensuring the patient has means to get to that appointment.

Coleman coaches also walk through "red flags" with patients, families and caregivers - that is, the warning signs that the patient is getting sick and susceptible to going back into the hospital. For a patient with congestive heart failure, for example, a red flag could be the sudden weight gain of two pounds or more, signaling retention of water and decreased pulmonary function.  A Coleman coach from Elder Services may also be able to help a patient get other, non-medical services, such as Meals on Wheels or the transportation to and from a doctor's office that can be critical to a patient's ability to follow through with their care plan.

Berkshire Medical Center delivers the Naylor side of the care transition, which is when a Nurse Practitioner (NP) provides a more intense medical care for patients who are at high risk for post-discharge complications.

"We deal with complex patients with co-morbidities and maybe even dementia," says BMC's Benzie. "Even though many of these patients have family, the spouse may have disabilities or the family may live far away.  So we end up helping the family as much as the patient."

She says a key role for the Nurse Practitioner is to accompany the patient to his or her primary care physician for the first follow up appointment. The NP has already reconciled all of the medications so the PCP can quickly assess the prescription list without spending too much time on that aspect of care.

Pat Tremblay, MS, R.N. administrative director of Berkshire VNA, says that when the nurse practitioner arrives at the patient home, usually within 72 hours of discharge, patients are often reluctant to receive the care they agreed to in the hospital. That is, patients will tell a hospital case manager that they're receptive to home visits, or a visit from meals on wheels, but once in the comfort of their home, patients may feel they don't really need help.

"The nurse practitioner alleviates that disconnect," Tremblay says. "The more exposure we can get with the patient the better. A lot of our nurses have very close relationships with their patients and that helps them with goal setting. So we ask, 'What do you want out of this?' For some it's getting through an upcoming holiday, or being able to keep healthy enough so they can see their grandchildren."

Tremblay says once the goal is set, the nurse can say, "Ok, this is what you have to do to get there. This is why you need to track your medications closely or weigh yourself."

Difficult Conversations

But oftentimes, no matter the goal, nurses have to conduct more serious conversations - about end-of-life care.

Benzie says that while "the real goal is to do whatever is necessary to meet the patient's goal, at time we have to explain if that goal is not realistic."

"In a very short time frame we have very intimate conversations with the patient, their families, and their doctor," Tremblay says. "We do advance life planning in a conducive environment - the home - talking to patients about MOLST forms [Medical Orders for Life-Sustaining Treatment] or end-of life care. What we're doing during these conversations in the home setting is supplementing the information patients have received from their primary care physicians; we're responding to questions that patients or their families may have. The location of these difficult conversations and the time we can devote to them is key - so that's one thing that makes this program so different."

While the four CCTP care transition teams across the state are demonstrating the efficacy of care transition interventions, including low-cost supports by ASAPs, there are many other readmission-fighting programs also occurring. Massachusetts hospitals are taking advantage of lessons learned from - among other intensive programs - the Re-Engineered Discharge (RED) Toolkit from AHRQ; the STAAR Initiative (STate Action on Avoidable Rehospitalizations); and the and the statewide implementation of Medical Orders for Life-Sustaining Treatment (MOLST).

Currently, the Massachusetts Hospital Association (MHA) is serving as a Hospital Engagement Network (HEN) as part of the Centers for Medicare and Medicaid Services (CMS) Partnership for Patients (PfP) Campaign.  Over the past two years most Massachusetts hospitals have been enrolled in HEN and are participating in this national quality improvement initiative to reduce readmissions by 20% by implementing evidence based interventions.

"Many hospital readmissions are the result of events that occur outside of a hospital's walls," says Pat Noga, R.N., PhD, MHA V.P. for Clinical Affairs. "It's easy to list readmission numbers and associated costs, but it's much harder to do the hard work of educating patients and the other parts of the care continuum - in effect, changing cultures inside and outside of the hospital - to reduce readmissions and help prevent patients from returning to the hospital within 30 days.  It's tough to accomplish but hospitals are committed to the challenge."