CJE SeniorLife, a community-based organization that serves some 18,000 older adults annually, is among the first cohort of recipients for Section 3026 or Community-Based Care Transition Program (CCTP) funding from the Centers for Medicare and Medicaid. One of seven early awardees, CJE will anchor a project that includes three large hospitals in Northern Chicago, as well as long-term services and supports organizations that serve frail older adults.
Medicaring talked to Heather O’Donnell, JD, LLM, CPA, then CJE’s Director of Planning for Healthcare Reform. She said that the process that led to funding has been underway for more than a year, and began when the group first began to consider opportunities that were arising as a result of health care reform, and how it might further its effort to bridge gaps between social services and medical care.
CJE, which had already been involved in care transitions improvement efforts, began to reach out to hospitals in its community, approaching them to find out whether they would be interested in partnering for the CCTP opportunity. Ultimately, three hospitals were selected: Northwestern Memorial Hospital (a major academic medical center), Provena-Resurrection Saint Joseph Hospital, and Provena-Resurrection Saint Francis Hospital. The team also includes Telligen, the Illinois Quality Improvement Organization and local Care Coordination Units. These state-run units, housed in communities throughout Illinois, address the needs of older adults who have complex, ongoing health care needs. Patients who have diagnoses of pneumonia, congestive heart failure, or AMI are targeted, as well as those who have complex conditions or take multiple medications.
The intervention is based on Eric Coleman’s model, which focuses on coaching patients and families to improve self-management skills for chronic conditions and medication management. The 30-day intervention aims to help people access home and community-based services and features a follow-up home visit by a transitional care nurse within 72 hours of discharge. These nurses, who have participated in the Care Transitions Intervention training program, help patients and families to set 30-day post-discharge goals, and to make and keep followup appointments. In addition, CJE received foundation funding which is enabling it to include a social work intervention; very high risk patients are identified and receive followup with a social worker for six months post-discharge.
“We had to adapt the Coleman protocols,” says O’Donnell. “We felt that for some patients, those with chronic conditions and psychosocial problems, thirty-days of followup were insufficient. We found that about 10 percent of the patients in our program would need more support services. That part of our program is not covered by CMS but is funded with private foundation funds.”
O’Donnell says that pulling the project together has taken a great deal of collaboration with the participating hospitals—from the on-the-ground work of finding the right contact people to developing specific strategies for the intervention. “But we felt that this was a good fit with what the hospitals were already doing,” she said. “It is very exciting work, getting every provider in the community to think about the quality of care from the standpoint of preventing an unnecessary readmission.”
Asked whether there had been any problems in bridging the divide between social services agencies and hospitals, O’Donnell said there had not. “This isn’t about us versus them. This is about everybody pulling together and undertaking a new initiative that’s good for everybody—good for the hospital, the nursing home, the patient. It’s a new approach.”
CJE meets regularly with its partners at each participating hospital, although the three are some miles apart and there is no reason to try to pull them all into one meeting. Orchestrating such a meeting, O’Donnell said, would be quite difficult, given how busy people are, and how hard it is to accomplish specific tasks when so many people are involved. “We’ve found it’s more effective to address each hospital and their concerns and our strategies individually.” CJE is, however, convening quarterly meetings of participating nursing homes, at which it hopes participants will talk about their successes, challenges, and processes. CJE is also mindful of the role to be played through partnerships with its local AAA (Area Agency on Aging), which is in the midst of applying for separate CCTP funding. It is also keeping the Department of Health Care and Family Services apprised of its work.
The process of actually launching the program took several months of work with CMS to address questions and concerns and finalize a contract. The application, submitted in August, received final approval in November. The first wave of projects will begin in one hospital on March 1, with other hospitals launching in April and May; ultimately, the project anticipates serving some 2,700 people each year. As O’Donnell notes, “It is a significant undertaking, and there are lots of details to be sorted out.”
She also noted that the relatively quick launch can be attributed in part to ongoing planning for implementation, addressing in advance issues that were likely to come up as the project rolled out. “We had these conversations internally and with hospitals before the application was even approved.”
Key words: care transitions, Section 3026, CCTP, CMS, Coleman model, CJE