The P2 Collaborative staff is hard at work on the final evaluation for the Western New York Community Based Care Transitions Program. Here is a sneak peak at the information that will be made available in the final report.
Can you provide us with some background?
P2 Collaborative of Western New York had the opportunity to convene 10 hospitals, eight community- based organizations (CBOs) and numerous other partners across seven counties in Western New York to work to improve transitions of care. This effort was formalized through the Community-based Care Transitions Program (CCTP), a contract with the Centers for Medicare and Medicaid Services (CMS), which spanned from July 2012 to June 2014
Through “Care Transitions of Western New York,” Care Transitions Intervention™ (CTI) – trained coaches helped patients and their caregivers transition from hospital to home over a 30 day period.
The need for care transitions support in our community is great. The transition from hospital to home can be extremely overwhelming for patients and caregivers.
What are some problems or issues you were trying to solve?
A root cause analysis performed at all participating hospitals showed the need for the following transition of care reforms within hospitals to help patients avoid a readmission after discharge:
One example of a tactic used by the coaches was through the use of the Medication Discrepancy Tool (MDT). Many patients return home and experience confusion and misuse of prescriptions due to a lack of understanding. Our goal was to reduce the number of individuals that experience this through the use of the MDT by coaches to describe medication inconsistencies that are identified through interaction with the patient at the home visit. This tool is essential for the intervention as the coach is able to work with the patient to identify solutions to any discrepancy identified.
What were the challenges? How did you overcome them?
Some of the main challenges that occurred were:
These challenges were overcome by working to build relationships with hospitals and showing the need for the program to be successful. We were able to communicate to hospitals that several issues were occurring when patients left the hospital and returned home that could have easily been avoided if a coach had been available.
The P2 Collaborative worked with our partners at multiple points throughout the program to expand eligibility criteria in an attempt to meet the original goals. The Health Foundation also helped to strengthen the integrity of the CTI model used by our coaches by providing technical assistance throughout the contract period.
Lastly, one of the major challenges of this program was the ability to track program outcome data related to readmission rates. As a result, the P2 Collaborative worked with the Health Foundation for Western & Central New York to secure a partnership with IPRO, the New York State Quality Improvement Organization, to help the hospital and CBO partners assess a program’s return on investment (ROI). IPRO and the P2 Collaborative worked with four hospitals to carry out this analysis.
Describe the outcomes, values, results and impacts
Overall, the Care Transitions of Western New York coalition provided the Care Transitions Intervention to 845 individuals. On average, the coalition had a 45 percent acceptance rate and 66 percent of patients who began the intervention in the hospital received a home visit.
Over the two-year grant period, the P2 Collaborative was able to work closely with the CBO-hospital teams to grow the volume of patients served, despite several environmental factors that were out of the coalition’s control, including declining rates of Medicare FFS population, financial hardship on rural hospitals, and limited electronic medical record sophistication for screening support. During the last year of the program, the coalition was able to serve a significantly higher number of patients than the first year as a result of many efforts to improve the program’s implementation strategies.
The coalition was able to improve acceptance rates, improve patient volume, strengthen relationships with partners and increase awareness of internal and external stakeholders.
Was there an “a-ha” moment or lesson learned?
There may not necessarily be one singular “a-ha” moment, but speaking with families and patients that have gone through the program and have had positive experiences makes all the challenges and difficulties worthwhile.
What advice do you have for others facing similar problems?
For individuals leaving the hospital that are concerned about their recovery, they should ask their health care provider about CTI and receiving help from a coach. Readmission into hospitals isn’t something we need to accept when it is due to avoidable circumstances. There are options, but patients need to be made aware of them, and spreading the word is a great place to start.