From hospital to home

NILES – A local agency is working with health care and community partners in the hopes of helping some 10,000 seniors to reduce hospital readmission rates.

The Area Agency on Aging 11 recently received the thumbs up from federal authorities to begin providing care transition services for up to 10,000 eligible Medicare beneficiaries.

The agreement with Centers for Medicare & Medicaid Services uses the Community-based Care Transition Program, or CCTP, a five-year program created by the Affordable Care Act. The program tests ways to improve care transitions from the hospital to other settings and reduce avoidable readmissions for high-risk Medicare beneficiaries.

A pilot project conducted over the summer of 2011 reduced avoidable readmission rates significantly. That test project for PASSPORT consumers with cases of renal failure, pneumonia and congestive heart failure reduced readmission rates from about 20 percent to about 13 percent, according to the agency.

In the three counties targeted for the project, the cost to Medicare for average readmission within 30 days of discharge from a health care facility is about $9,600 per patient, or approximately $1.7 million in all over the study period. CMS is projecting significant savings through this program by reducing those avoidable readmission costs.

“This program is one of the largest initiatives for AAA11 since the PASSPORT home and community based program began,” said Joseph Rossi, chief executive officer. “Care Transitions not only empowers older adults to take control of their health but also has the potential of significant savings to Medicare.”

Agency care transition coaches are located in seven hospitals in Columbiana, Mahoning and Trumbull counties. The program is free for patients about to be discharged. Coaches teach patients self-management skills to ensure the patient’s health needs are met during the transition from hospital to home or other care settings. Goals include improving quality of care, reducing readmissions for high-risk beneficiaries and documenting measurable savings to the Medicare program.

AAA11 invested nearly $50,000 in training 42 staff members in the Coleman Care Transitions Intervention coaching model prior to receiving the CMS award.

AAA11 formed a collaborative in November 2011 that included four health systems representing seven hospitals, including East Liverpool City Hospital, Salem Community Hospital, St. Elizabeth Health Center, St. Elizabeth Boardman Health Center, Northside Medical Center, Trumbull Memorial Hospital and St. Joseph Health Center. Also included were a coalition of United Auto Worker retirees and the medical directors of the hospital systems, Youngstown State University and Allen’s PharmaServ.

The group’s focus was on educating patients to ensure they take responsibility for their own health.

It was determined that although most patients leaving the hospital believe they understood how to properly take their medications, more than half of readmitted patients had taken them incorrectly. Medication management and education is a key step to success. Communication is also key for patients who move between care facilities.

“This program works because we are empowering patients to take control of their health care instead of just doing it for them,” said Kim Varley, RN, care transition coordinator. “They have more buy-in to take control of their health and are given opportunities to consult on medication management and other questions that they may not have thought about when they were leaving the hospital.”