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The Community-Based Care Transitions Program, a provision of the newly enacted Patient Protection and Affordable Care Act (Section 3026 of HR 3590), provides $500 million to collaborative partnerships between hospitals and community-based organizations designed to meet the goal of implementing evidence-based care transitions services for Medicare beneficiaries at high risk for hospital readmission. The provision in the law grew out of a successful translation of the Care Transitions Intervention model into practice settings nationwide. The translation of the model was made possible by funding from the John A. Hartford Foundation, a national funder located in New York City. (The model itself was designed with funding from Hartford and the Robert Wood Johnson Foundation.) Fourteen states, under a Centers for Medicare and Medicaid Services (CMS) contract, have tested the model, and many have experienced significant reductions in hospital readmissions. Eric A. Coleman, a professor of medicine at the University of Colorado Denver, directs the broader Care Transitions Program and has led the model’s development and translation efforts. This intervention “helps smooth the transition from hospital to home,” explained Amy Berman, a program officer at the Hartford Foundation, in a 23 September 2009 post on the foundation’s blog, Health AGEnda . It works by encouraging older patients to take a more active role in their own care. The Community-Based Care Transitions Program is on schedule for implementation in early 2011. Eligible hospitals and community-based organizations that forge a partnership committed to implementing evidence-based care transitions services—such as the Care Transitions Intervention described above—may apply to the secretary of the Department of Health and Human Services (HHS) for funding. The program’s success will be assessed through an evaluation of hospital readmission rates for high-risk Medicare beneficiaries receiving services from the program over a five-year period.

August 16, 2019

Improving Care Transitions: A Key Component of Health Reform

The Community-Based Care Transitions Program, a provision of the newly enacted Patient Protection and Affordable Care Act (Section 3026 of HR 3590), provides $500 million to collaborative partnerships between hospitals and community-based organizations designed to meet the goal of implementing evidence-based care transitions services for Medicare beneficiaries at high risk […]
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The Community-Based Care Transitions Program, a provision of the newly enacted Patient Protection and Affordable Care Act (Section 3026 of HR 3590), provides $500 million to collaborative partnerships between hospitals and community-based organizations designed to meet the goal of implementing evidence-based care transitions services for Medicare beneficiaries at high risk for hospital readmission. The provision in the law grew out of a successful translation of the Care Transitions Intervention model into practice settings nationwide. The translation of the model was made possible by funding from the John A. Hartford Foundation, a national funder located in New York City. (The model itself was designed with funding from Hartford and the Robert Wood Johnson Foundation.) Fourteen states, under a Centers for Medicare and Medicaid Services (CMS) contract, have tested the model, and many have experienced significant reductions in hospital readmissions. Eric A. Coleman, a professor of medicine at the University of Colorado Denver, directs the broader Care Transitions Program and has led the model’s development and translation efforts. This intervention “helps smooth the transition from hospital to home,” explained Amy Berman, a program officer at the Hartford Foundation, in a 23 September 2009 post on the foundation’s blog, Health AGEnda . It works by encouraging older patients to take a more active role in their own care. The Community-Based Care Transitions Program is on schedule for implementation in early 2011. Eligible hospitals and community-based organizations that forge a partnership committed to implementing evidence-based care transitions services—such as the Care Transitions Intervention described above—may apply to the secretary of the Department of Health and Human Services (HHS) for funding. The program’s success will be assessed through an evaluation of hospital readmission rates for high-risk Medicare beneficiaries receiving services from the program over a five-year period.
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https://www.healthaffairs.org/do/10.1377/hblog20100429.004893/full/

August 14, 2019

The geriatric floating interdisciplinary transition team

J Am Geriatr Soc, 58;2:364–70 Authors: Arbaje, A. I., Maron, D. D., Yu, Q., Wendel, V. I., Tanner, E., Boult, C., Eubank, K. J., Durso, S. C. Older adults often receive suboptimal care during hospitalizations and transitions to postacute settings. Inpatient geriatric services have been shown to increase care quality […]
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J Am Geriatr Soc, 58;2:364–70 Authors: Arbaje, A. I., Maron, D. D., Yu, Q., Wendel, V. I., Tanner, E., Boult, C., Eubank, K. J., Durso, S. C. Older adults often receive suboptimal care during hospitalizations and transitions to postacute settings. Inpatient geriatric services have been shown to increase care quality but have not improved patient outcomes consistently. Acute Care for the Elderly units improve patient outcomes but are resource intensive. Transitional care has been shown to reduce hospital readmissions and healthcare costs. This article describes the Geriatric Floating Interdisciplinary Transition Team (Geri-FITT), a model that combines the strengths of inpatient geriatric evaluation and comanagement and transitional care models by creating an inpatient comanagement service that also delivers transitional care. The Geri-FITT model is designed to improve the hospital care of older adults and their transitions to postacute settings. In Geri-FITT, a geriatrician-geriatric nurse practitioner team assesses patients, comanages geriatric syndromes, provides staff education, encourages patient self-management, communicates with primary care providers, and follows up with patients soon after discharge. This pilot cohort study of Geri-FITT included hospitalized patients aged 70 and older on four general medicine services (two Geri-FITT, two usual care) at an academic medical center (N=717). The study assessed the effect of Geri-FITT on patients' care transition quality (Care Transitions Measure) and their satisfaction with hospital care (four questions). The results indicate that Geri-FITT is associated with slightly higher, though not statistically significantly so, quality care transitions and greater patient satisfaction with inpatient care. Geri-FITT may be a feasible approach to enhancing inpatient management and transitional care for older adults. Further study of its effect on these and other outcomes in other healthcare settings seems warranted.
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http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2009.02682.x/abstract

August 13, 2019

One Patient, Numerous Healthcare Providers, and Multiple Care Settings: Addressing the Concerns of Care Transitions Through Case Management

Tahan H. One Patient, Numerous Healthcare Providers, and Multiple Care Settings: Addressing the Concerns of Care Transitions Through Case Management. Professional Case Management. 2007;12(1): 37-46. http://journals.lww.com/professionalcasemanagementjournal/Abstract/2007/01000/One_Patient,_Numerous_Healthcare_Providers,_and.8.aspx. Accessed July 24, 2014. Abstract: Care transitions are a natural occurrence in our healthcare delivery system. During a single episode of illness, patients are […]
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Tahan H. One Patient, Numerous Healthcare Providers, and Multiple Care Settings: Addressing the Concerns of Care Transitions Through Case Management. Professional Case Management. 2007;12(1): 37-46. http://journals.lww.com/professionalcasemanagementjournal/Abstract/2007/01000/One_Patient,_Numerous_Healthcare_Providers,_and.8.aspx. Accessed July 24, 2014. Abstract: Care transitions are a natural occurrence in our healthcare delivery system. During a single episode of illness, patients are cared for in multiple care settings and by healthcare professionals of varied specialties and disciplines. Such dynamic events increase the risk of patients experiencing poor quality of care, especially as a result of medical errors and unsafe situations. Care coordination has been emphasized recently as a strategy for enhancing the effectiveness of care during such necessary transitions. This article describes the issue of care transitions and suggests how case management, through care coordination, can play an important role in ensuring safe and effective care transitions.
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http://journals.lww.com/professionalcasemanagementjournal/Abstract/2007/01000/One_Patient,_Numerous_Healthcare_Providers,_and.8.aspx

August 8, 2019

Project BOOST (Better Outcomes by Optimizing Safe Transitions) Mentored Implementation Program

Society of Hospital Medicine. Project BOOST (Better Outcomes by Optimizing Safe Transitions) Mentored Implementation Program. Http://www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/Overview.aspx. Updated 2014. Accessed July 25, 2014. The BOOSTing (Better Outcomes by Optimizing Safe Transitions) Care Transitions implementation toolkit provides a wealth of materials to help you optimize the discharge process at your institution. The […]
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Society of Hospital Medicine. Project BOOST (Better Outcomes by Optimizing Safe Transitions) Mentored Implementation Program. Http://www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/Overview.aspx. Updated 2014. Accessed July 25, 2014. The BOOSTing (Better Outcomes by Optimizing Safe Transitions) Care Transitions implementation toolkit provides a wealth of materials to help you optimize the discharge process at your institution. The tools and approach are based on principles of quality improvement (QI), evidence-based medicine, as well as personal and institutional experiences. Originally, the BOOST Implementation toolkit was developed in 2008 through support from the John A. Hartford Foundation and has been continued to be revised and improved over the years. In 2014, SHM developed a revised 2nd edition of the guide that incorporated the latest literature on transitions of care as well as the experiences of lessons learned from the Project BOOST mentoring program's mentors (faculty experts) and participating BOOST hospitals (more than 180 in US and Canada). The Guide is laid out in a user-friendly, step by step method with explicit instructions and worksheets to help new sites engage with Project BOOST, build effective QI teams, and improve the care of their patients as they transition out of the hospital.
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http://www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/Overview.aspx

August 8, 2019

Transitional Care Model

Transitional Care Model. Penn Nursing Science. Web Site. http://www.transitionalcare.info/home .2013. Accessed July 24, 2014. More than 10 million Medicare beneficiaries, approximately 20% of older Americans, are living with five or more chronic conditions. Effective care management of this population is often complicated by several other health and social risk factors. […]
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Transitional Care Model. Penn Nursing Science. Web Site. http://www.transitionalcare.info/home .2013. Accessed July 24, 2014. More than 10 million Medicare beneficiaries, approximately 20% of older Americans, are living with five or more chronic conditions. Effective care management of this population is often complicated by several other health and social risk factors. Unfortunately, multiple studies reveal that the health care needs of older adults are poorly managed, often with devastating human and economic consequences. The Transitional Care Model (TCM) is an evidence-based solution to these challenges. The TCM has consistently demonstrated improved quality and cost outcomes for high-risk, cognitively intact and impaired older adults when compared to standard care in: reductions in preventable hospital readmissions for both primary and co-existing health conditions; improvements in health outcomes; enhanced patient experience with care; and a reduction in total health care costs
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http://www.transitionalcare.info/

August 8, 2019

The Care Transitions Program

Coleman E. The Care Transitions Program®. Http://www.caretransitions.org/ Under the leadership of Dr. Eric Coleman, the aim of the Care Transitions Program® is to support patients and families; increase skills among healthcare providers; enhance the ability of health information technology to promote health information exchange across care settings; implement system level […]
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Coleman E. The Care Transitions Program®. Http://www.caretransitions.org/ Under the leadership of Dr. Eric Coleman, the aim of the Care Transitions Program® is to support patients and families; increase skills among healthcare providers; enhance the ability of health information technology to promote health information exchange across care settings; implement system level interventions to improve quality and safety; develop performance measures and public reporting mechanisms; and influence health policy at the national leve
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http://www.caretransitions.org/

August 8, 2019

NTOCC Medication Reconciliation Form Applicable Across All Continuum of Care Lines

Form assists in documenting patient’s understanding of Medication at time of admission or treatment, new medication added, medication list inclusive of continued and new medications
Form assists in documenting patient's understanding of Medication at time of admission or treatment, new medication added, medication list inclusive of continued and new medications
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August 8, 2019

Improving Transitions to Reduce Readmissions

Bisognano M, Boutwell A. Frontiers of Health Services Management. 25(3):3-10.2009. http://www.ihi.org/resources/Pages/Publications/ImprovingTransitionstoReduceReadmissions.aspx. Accessed 8/13/14. Delivering high quality healthcare requires crucial contributions from many parts of the care continuum. However, as healthcare becomes increasingly specialized, corrdination between providers and between settings is to often not conducted as a team effort.
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Bisognano M, Boutwell A. Frontiers of Health Services Management. 25(3):3-10.2009. http://www.ihi.org/resources/Pages/Publications/ImprovingTransitionstoReduceReadmissions.aspx. Accessed 8/13/14. Delivering high quality healthcare requires crucial contributions from many parts of the care continuum. However, as healthcare becomes increasingly specialized, corrdination between providers and between settings is to often not conducted as a team effort.
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http://www.ihi.org/knowledge/Pages/Publications/ImprovingTransitionstoReduceReadmissions.aspx

August 8, 2019

The Evaluation of the Medicare Coordinated Care Demonstration Findings for the First Two Years

Brown R, Peikes D, Chen A, et al. Mathematica Policy Research, Inc. The Evaluation of the Medicare Coordinated Care Demonstration: Findings for the First Two Years. http://www.mathematica-mpr.com/~/media/publications/PDFs/mccdfirsttwoyrs.pdf. Published March 21, 2007. Accessed December 11, 2014. This report synthesizes findings from the first 2 years of the demonstration programs operations, focusing […]
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Brown R, Peikes D, Chen A, et al. Mathematica Policy Research, Inc. The Evaluation of the Medicare Coordinated Care Demonstration: Findings for the First Two Years. http://www.mathematica-mpr.com/~/media/publications/PDFs/mccdfirsttwoyrs.pdf. Published March 21, 2007. Accessed December 11, 2014. This report synthesizes findings from the first 2 years of the demonstration programs operations, focusing on program impacts over the first year after enrollment for beneficiaries who enrolled during the first year, and over the first 25 months of operations for all enrollees. Findings presented include program-specific estimates of impacts on (1) survey-based measures of patients. health status, knowledge, behavior, satisfaction with their health care, quality of care, and quality of life; and (2) claims-based measures of patients. Medicare service use and expenditures, and the quality of care received. The report links differences across programs in these impacts to differences in the interventions and the target populations in order to draw inferences about .what works. and .for whom.. This synthesis of findings draws on an earlier report to Congress that described the types of programs and beneficiaries participating in the demonstrations, the interventions the programs have implemented, and how well patients and physicians like the programs (Brown et al. 2004). This report updates that information and adds analyses of Medicare service use and expenditures and a scoring methodology developed specifically for this evaluation to rate the quality of each program’s intervention on several dimensions. The findings in brief indicate that patients and physicians were generally very satisfied with the program, but few programs had statistically detectable effects on patients. behavior or use of Medicare services. Treating only statistically significant treatment-control differences as evidence of program effects, the results show: • Few effects on beneficiaries. overall satisfaction with care • An increase in the percentage of beneficiaries reporting they received health education • No clear effects on patients. adherence or self-care • Favorable effects for only two programs each on: the quality of preventive care, the number of preventable hospitalizations, and patients. well-being • A small but statistically significant reduction (about 2 percentage points) across all programs combined in the proportion of patients hospitalized during the year after enrollment • Reduced number of hospitalizations for only 1 of the 15 programs over the first 25 months of program operations • No reduction in expenditures for Medicare Part A and B services for any program
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http://www.mathematica-mpr.com/publications/pdfs/mccdfirsttwoyrs.pdf

August 7, 2019

Coordinating Care — A Perilous Journey through the Health Care System (Thomas Bodenheimer, M.D. N Engl J Med 2008; 358:1064-1071March 6, 2008)

In the United States, 125 million people are living with chronic illness, disability, or functional limitation.1 The nature of modern medicine requires that these patients receive assistance from a number of different care provi ders. Between 2000 and 2002, the typical Medicare beneficiary saw a median of two primary care […]
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In the United States, 125 million people are living with chronic illness, disability, or functional limitation.1 The nature of modern medicine requires that these patients receive assistance from a number of different care provi ders. Between 2000 and 2002, the typical Medicare beneficiary saw a median of two primary care physicians and five specialists each year, in addition to accessing diagnostic, pharmacy, and other services. Patients with several chronic conditions may visit up to 16 physicians in a year.2 Care among multiple providers must be coordinated to avoid wasteful duplication of diagnostic testing, perilous polypharmacy, and confusion about conflicting care plans.
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http://www.nejm.org/doi/full/10.1056/NEJMhpr0706165