Posts Tagged ‘coaching’

QIO Advice for Improving Care Transitions: Dig Deep Into Local Data

June 6th, 2013 by Cheryl Miller

There is no cookbook or recipe for improving care transitions.

Instead, the first step for any healthcare organization and community-based healthcare provider is to conduct a root cause analysis of readmission data, which can vary from community to community, says Alicia Goroski, MPH, senior project director for care transitions for the Colorado Foundation for Medical Care (CFMC), the Medicare Quality Improvement Organization (QIO) for Colorado. Once established, the appropriate intervention can be selected, and quality improvement methods then used to monitor, assess, and improve the implementation of those interventions.

Goroski shared these lessons and more from 14 communities that participated in the CMS Care Transition Demonstration Project (CCTP), and detailed how the program is being rolled out in 400 communities and to over 12 million Medicare beneficiaries across the country during a recent HIN webinar, Patient Engagement and Provider Collaborations Across the Healthcare Continuum to Improve Care Transitions. CFMC coordinates the work of state-based QIOs, which are contracted by the CMS and designed to work with hospitals and community providers to improve care transitions and reduce readmissions.

According to a study in the Journal of the American Medical Association (JAMA), hospital admissions and readmissions among Medicare beneficiaries declined nearly twice as much in communities where QIOs coordinated care transition programs that engaged the whole community. Some of the programs, focused on patients, providers or both groups not only lowered key Medicare readmission rates but also reduced participants’ overall admission stats.

The key is to dig into the data locally, she says, because there is no one size fits all intervention.

In Harlingen, Texas, it was discovered that over half of the 30-day readmissions coming back in their community were from skilled nursing facilities (SNFs). So they implemented the Interact intervention. They convened all the nursing homes and created a coalition dedicated to reducing the numbers. Within the 18-month intervention period, the 30-day readmission rate for nursing homes in that Harlingen community went from about 46 percent down to 19 percent.

On the flip side, in Goroski’s home community in Denver, nearly three fourths of readmissions were occurring among beneficiaries who had been discharged home with no home health services. Instead of implementing the Interact intervention, which wouldn’t have addressed the driver of readmissions, they hired three full-time coaches for those patients who were being discharged directly home.

The CTI was also useful for medication reconciliation, Goroski continues, pointing to the three main drivers of readmissions: patient and family engagement, a lack of standard and known processes, both within and across care settings, and health information exchange.

Medication reconciliation crosses all those areas, Goroski says, and up to half of all readmissions can be attributed to medication errors, whether the problem stems from a lack of reconciliation at discharge to a lack of follow-up calls once home. Care transition coaching is helpful, in terms of coaching the beneficiary on any medication discrepancies, advising their provider and then using the correlative technology. What differentiates the coach, usually a nurse, from a medical provider is that instead of making the follow-up phone call for the patient, the coach shows them how. This intervention, usually lasting one month, has been very successful, Goroski says.

But ultimately, it takes a village to effectively improve care transitions, Goroski says. Hospitals need to work with hospitals, nursing homes, home health agencies, hospice organizations, dialysis facilities and outpatient physicians to close care gaps.