Partnership for Patients Office Hours Community- Based Care Transitions Program 101 Featuring VNA Health Group representing the Central New Jersey Care Transitions Program Co-Hosted by NJHEN and HQSI CCTP 101 Marie Perillo, RN, BSN, Director of Care Coordination Kimberly Mora, RN, BSN, Care Coordination Manager Victoria Peck, RN, MSN, Care Coordination Coach What is Transitional Care? The movement of a patient from one setting of care (hospital, sub-acute care, ambulatory care, primary & specialty practice, long-term care, home health, etc.) to another. Source: Centers for Medicare and Medicaid Services, 2013. What is Transitional Care? • The American Geriatrics Society: Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient's goals, preferences, and clinical status. Source: Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):556-557. What is Transitional Care? What does Transitional Care mean? Transitional Care is a time-limited service Transitional Care is not case management. Transitional Care Models Transitional Care Models include: Eric Coleman’s Care Transitions Model Mary Naylor’s Transitional Care Model The Bridge Model BOOST Project RED What’s different about CCTP? The Community-Based Care Transitions Program (CCTP) • Funded by Center for Medicare & Medicaid Innovation • Part of Partnership for Patients national patient safety initiative • 3 part aim of CCTP is to: Improve the care of patients by reducing preventable readmissions Improve population health Decrease costs of care delivery About CNJCTP The Central New Jersey Care Transitions Program is the first Demonstration Project in the state of NJ to receive funding from CMS CNJCTP was awarded a 2-year contract that will be extended on an annual basis for 3 additional years based on performance. CCTP requires participation in Learning Collaborative Webinars and continuing training and education of Coaches Goals of CNJCTP • CNJCTP will serve 4,000 patients yearly, in 6 Partner Hospitals across the program: CentraState Medical Center Raritan Bay Medical Center Robert Wood Johnson University Hospital Robert Wood Johns University Hospital at Rahway Saint Peter’s University Hospital Trinitas Regional Medical Center Our Home Care and AAA Partners CNJCTP services are provided by • Four Home Health Care Agencies     Community VNA VNA Health Group Holy Redeemer Home Care Robert Wood Johnson (RWJ) Visiting Nurses • Four Area Agencies on Aging  Monmouth County Division on Aging, Disabilities and Veterans Services  Middlesex County Office of Aging and Disabled Services  Union County Division on Aging  Jewish Family Service of Central Jersey Goals of CNJCTP Reduce 30-day all-cause readmission rates by 20%. Reduce emergency room utilization for high-risk Medicare beneficiaries. Improve patient care, improve population health, and decrease costs in the healthcare delivery system. Goals of CNJCTP • CNJCTP improves the quality of health care delivery by: • Improving communication across providers • Coordinating care across settings • Coaching patients in disease-specific interventions • Identifying socioeconomic barriers. Eligibility Screening / Risk Assessment Patients are eligible if: At least 65 years old Have Medicare Fee for Service (not managed Medicare) Not been enrolled in the CNJCTP program in last 180 days Are a FULL admission (no ED or OBS patients) Not in Hospice program Have a qualifying diagnosis About CNJCTP Diagnoses criteria include: Acute Myocardial Infarct Heart & Vascular Surgery Heart Failure Cerebrovascular Disease Pneumonia Chronic Obstructive Pulmonary Disease Atrial Fibrillation CNJCTP Workflow • Coaches screen patients utilizing eligibility criteria and risk assessment. Coaches also receive referrals by collaborating with the Case Management team. • Eligible patients are approached for coaching services by Care Coordination Coach (CCC). • Once a patient accepts services the coach conducts an in-hospital visit. This is required by CMS. CNJCTP Workflow • Care Coordination Coach (CCC) visits patient within 24-72 hours after transition from hospital to home or SAR/SNF. (Patients who transition to sub acute facilities receive an additional visit in the home). • If the patient is receiving home care services, the CCC alerts homecare nurse that patient is enrolled in CNJCTP. • Once the first transition visit is made, the CCC creates a care plan for follow up phone support. CNJCTP Workflow • If a need is identified, a referral for a social work visit or an additional RN visit can be planned at this time. • Patients enrolled in CNJCTP are followed for a 30 day period. • CCC may refer patient to homecare, Area Office on Aging, or other services for continuing care needs. About CNJCTP 30-day episode led by a Transitions Coach 1 hospital visit 1 transitional home and/or SNF/SAR visit Telephone monitoring weekly during episode Note: may include additional visits, eg: social worker visit(s) or additional RN visit, as needed The Intervention Focus Dr. Eric Coleman’s Four Pillars of the Care Transitions Model: Medication SelfManagement Patient Health Record Physician Follow-Up Red Flags/Disease Management Source: Care Transitions Intervention®, Eric A. Coleman, MD, MPH. Retrieved from http://www.caretransitions.org/four_pillars.asp The Good News There is NO paperwork for Physicians NO order necessary FREE for Medicare FFS patients This program does NOT replace homecare – CNJCTP services are complimentary and supplemental to any homecare that you may have already ordered. • Patients do NOT have to be homebound in order to receive CNJCTP services. • • • • CCTP 101 Our CCTP project serves to foster self efficacy….. According to Albert Bandura, selfefficacy is "the belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations." Questions? Partnership for Patients Goal By the end of 2014, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20 % compared to 2010. Save the Date Transitions in Care Learning Session May 8, 2014 NJHA Conference Center Princeton