the community-based care transitions program (cctp)
TRANSCRIPT
The Metro Care Transitions Program (CCTP)
OUR GOAL
Build patient/caregiver confidence.
Engage patients to take a more active role in self-management of chronic health conditions.
Foster independence and well-being of Care Transitions participants.
Improve quality of care.
Reduce avoidable hospital readmissions for high risk participants.
Reduce healthcare system costs associated with hospital readmissions
OUR HISTORY
First patient enrolled in the program on April 16th, 2013.
Over 3400 patients served in the last 2 ½ years.
Performing person-centered Coleman Transitions Intervention plus wrap-around services to Medicare Fee For Service Beneficiaries from April 2014-September 2015 under a contract with the Center for Medicare Services (CMS)
OUR COLLABORATION
The Metro Care Transitions Collaborative is a joint effort of four Area Agencies on Aging (AAA), three medical systems and six hospitals.
The AAA’s include: Clackamas County Social Services Community Action Team of Columbia County, Multnomah Disability, Aging and Veteran’s Services and Washing County Disability, Aging and Veteran’s Services.
The Medical systems include: Legacy Health System Hospitals (Legacy Emanuel, Good Samaritan, Meridian Park and Mt. Hood), Oregon Health Sciences University (OHSU) and Portland Adventist Medical Center.
OUR SERVICE AREA
Additional service areas include: SW Washington (Vancouver, Kelso and Longview). The program currently has capacity to provide telephonic support and services to individuals living outside of the current program service area.
OUR TARGET POPULATION
We have served MEDICARE and/or MEDICAID Beneficiaries, including dual eligibles
Age 18 or older
CHRONIC HEALTH CONDITIONS, not including active substance abuse disorder and/or acute mental health condition(s). Also those with a second in-patient admission
Eligible Diagnoses List
COPD
Renal failure
Pneumonia
Diabetes
Orthopedic
Coronary artery disease
Coronary atherosclerosis
Ischemic heart disease
Aortic valve disease
Cardio myopathy
Unstable angina
Congestive heart failure
Acute myocardial infarction
Deep vein thrombosis
Cerebral vascular accident
Second in-patient hospitalization
OUR MODEL
Coleman Transition Intervention (CTI) Model
One home visit within 72 hours of discharge
Develop the participants Personal Health Record
Identify important personal goals
Make and keep doctors appointments
Manage participants medication(s)
Review warning signs and how to respond
Identify other community resources the participant or caregiver may need
Three follow-up phone calls within 30 days of discharge.
Review items covered at home visit
Follow up on additional needs
Plus Wrap-Around Services
Home-delivered meals
In-home assistance with personal care, activities of daily living, house-keeping, and more
Options Counseling
Connections to community services and resources, such as: behavioral health support services, Supplemental Nutrition Assistance benefits (SNAP/food stamps), family caregiver support services, transportation services, State Medicaid medical benefits, and many more.
Additional home-based screenings for depression, home safety, functional capacity, and medication risk are under development
OUR OUTCOMES
60% of patients accept services offered
Almost 90% complete the intervention, with one home visit and three follow up phone calls
Hospital re-admission rate within 30 days of discharge reduced by 58% for those who participate compared to those who decline services (data review of 270 patients between Dec. 2014 and Feb. 2015)
Decrease in overall hospital readmission rate amongst CCTP participants is greater than 50%
Fewer than 12% of CCTP participants re-admit to hospital
Return on Investment
The 2012 average cost per stay in Oregon hospitals was $15,200.
Adults aged 45-64 were the most costly to treat, followed by adults aged 65-84.
Chronic condition hospitalization cost an average of $6,000 than acute conditions.
Currently, in Oregon, approximately 25% of hospitalized patients re-admit within 30 days. Assuming that the Metro Care Transitions Program serves a monthly panel of 400 patients and reduces the re-admit rate by a little over half, the Metro Care Transitions Program will save approximately $1, 441,204 per month at a cost of $220,000 per month.
The approximate Return on Investment (ROI) is 6.5:1.
OUR PATHWAY TO POSITIVE OUTCOMES
Daily case finding among in-patient hospital census
Engage patient through in-room visit
in hospital
Initiate assessment regarding additional community service
needs
Schedule home visit prior to discharge
Warm hand-off to Community Coach
Community Coach completes home
visit with 72 hours of discharge
Community Coach continues
assessment and links to other services
Community Coach completes three follow up phone
calls over following several weeks
Close Care Transitions case
OUR FUTURE Expand services to additional populations
and payer sources
Expand to additional hospitals, primary care clinics and skilled rehabilitation facilities
Enhance Care Transitions services by incorporating additional home-based services, such as: medication risk and home-safety assessments, depression screening, screening for cognitive impairments, and functional-needs assessment
Develop collaborative partnerships with other transitional service providers
Maximize opportunities to build relationships with and make vital connections for CCTP participants
OUR TEAM – Hospital-Based Coaches
Angela Leonardo,
Legacy Emanuel and Good Samaritan
Colleen Davis,
Legacy Mt. Hood
Marcie Liesegang, Portland Adventist
Brianna Williamson,
Legacy Meridian
Park
Jennifer Rechel, OHSU
OUR TEAM – Community-Based Coaches
Kati Tilton Pat Carleton Laurie Alexander Amy Vlahos Bobbie Taylor Dina Miller
Heather Johnson Jennifer Starr Marissa Cysani Stephen O’Neal Juliann Davis Marge Tuomi
Bethany Chamberlin
Care Transitions Coordinator
(503) 988-8116
Angela Leonardo
Care Transitions Health Coach
(503) 988-2405