Excellence in Population Health

Abstract

Purpose/Objective: The Community-based Care Transitions Program (CCTP) defined a broad spectrum of interventions and services for elderly patients at high risk of hospital readmission. The purposes for a CCTP as developed by the Centers for Medicare & Medicaid Services are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high-risk beneficiaries, and to document measurable savings. The goals for this CCTP initiative were as follows: achievement of a 20% reduction in the 30-day all-cause readmission rate across all partner hospitals compared with baseline; reduction in the 30-day all-cause readmission rate among the high-risk cohort served; and achievement of the target volumes for full enrollment. Primary Practice Settings: The partnership included acute care institutions and community-based care organizations that have been involved with care transition programs for years and have a long history of working collaboratively to provide services to a largely low-income, underserved, and ethnically and racially diverse target population. Findings/Conclusions: The program successfully transitioned to full operation within the first year of inception. To date, the partnership of the acute hospital setting and the community-based organizations has reached and provided services to nearly 8,000 total individuals, surpassing our target enrollment goal. To date, the readmission rate has decreased to 12.5%, which is an 11% decline since inception of the program. Implications for Case Management Practice: The collaboration of health care providers, social workers, nurse practitioners, physicians, community pharmacists, and the visiting nurses is integral to a successful transition from hospital to home. Home visits by the transition facilitators allowed for the coordination of a multitude of services in the community, including those previously available to patients in the past that have rarely been accessed. Including a pharmacist on the team provided teaching regarding medication adherence, medication management, and pharmacy services, which added to interventions to decrease future hospitalizations.

Hospital Partnerships for Population Health: A Systematic Review of the Literature

“…Table 2 summarizes the 11 articles that included partnerships focused on improving care coordination/transitions. Eight of these studies used case study designs to provide descriptions of partnerships with diverse organizations to support coordination of care for high-risk populations (e.g., Medicare, Medicaid; Baxter et al, 2018; Berkowitz et al, 2016; Everett et al, 2014; Hsiao et al, 2018; Malseptic et al, 2018; Sandberg et al, 2014; Sherry et al, 2016; Warren et al, 2019). Findings suggested that multisector partnerships are helpful in removing barriers to engagement with patients and connecting them to needed clinical, behavioral, and community-based services (Baxter et al, 2018; Berkowitz et al, 2016; Everett et al, 2014; Hsiao et al, 2018; Malseptic et al, 2018; Sandberg et al, 2014; Warren et al, 2019).…”

“…Eight of these studies used case study designs to provide descriptions of partnerships with diverse organizations to support coordination of care for high-risk populations (e.g., Medicare, Medicaid; Baxter et al, 2018; Berkowitz et al, 2016; Everett et al, 2014; Hsiao et al, 2018; Malseptic et al, 2018; Sandberg et al, 2014; Sherry et al, 2016; Warren et al, 2019). Findings suggested that multisector partnerships are helpful in removing barriers to engagement with patients and connecting them to needed clinical, behavioral, and community-based services (Baxter et al, 2018; Berkowitz et al, 2016; Everett et al, 2014; Hsiao et al, 2018; Malseptic et al, 2018; Sandberg et al, 2014; Warren et al, 2019). Additional key takeaways documented across these studies included a need for better integration of providers across the continuum of care (Berkowitz et al, 2016; Everett et al, 2014; Hsiao et al, 2018; Malseptic et al, 2018; Sherry et al, 2016) and the use of available data and information technology to support better information sharing and design interventions tailored to communities of interest (Berkowitz et al, 2016; Hsiao et al, 2018; Malseptic et al, 2018; Sherry et al, 2016).…”

Transitions of care for older adults discharged home from the emergency department: an inductive thematic content analysis of patient comments

“…Orchestrating cooperation among health workers increases patient satisfaction [ 50 ] and reduces length of hospital stay [ 51 ]. If we can ensure that older adult patients are satisfied with their care, we may reap the rewards of fewer avoidable visits to the ED [ 52 ]. The benefits of a successful care transition are not limited to individual patients as they impact on communities and caregivers.…”

Transitional Care from Hospital to Cardiac Rehabilitation During COVID-19: The Perspectives of Older Adults and Their Healthcare Providers

“…2 Older adults with cardiovascular disease benefit greatly from cardiac rehabilitation 3 ; however, transitions from one health care setting to another can result in patient vulnerability, often aggravated by lack of coordination among healthcare providers and unclear discharge instructions. 4…”

“…2 Older adults with cardiovascular disease benefit greatly from cardiac rehabilitation 3 ; however, transitions from one health care setting to another can result in patient vulnerability, often aggravated by lack of coordination among healthcare providers and unclear discharge instructions. 4 Transitional care is a set of actions that ensure the coordination and continuity of healthcare as individuals transfer between different locations or levels of care. 5 Care transitions can be very challenging because they encompass the integration and coordination of care across different health care sectors and providers that are involved in the patient's circle of care.…”