Tag: rehospitalization

Through a Glass Darkly: The Community-Based Care Transitions Program Evaluation

Photographs of Joanne Lynn and Sarah Slocum

By Joanne Lynn and Sarah Slocum “All models are wrong, but some are useful”. – George Box In late November, the Centers for Medicare and Medicaid Services (CMS) released an extensive evaluation of the Community-based Care Transitions Program (CCTP). (https://downloads.cms.gov/files/cmmi/cctp-final-eval-rpt.pdf) While the report has some useful points, the primary metrics used to measure performance –

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The Evidence That the Readmissions Rate (Readmissions/Hospital Discharges) Is Malfunctioning as a Performance Measure

Dr. Joanne Lynn Portrait

By Joanne Lynn M.D. [Also see companion post by Stephen F. Jencks, M.D., M.P.H.] Care transitions improvement programs have been effective in helping the health care system both become more effective in serving people living with serious chronic conditions and reduce costs. However, the key metric used to measure performance is seriously malfunctioning in at

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Reaching Rural Residents: Improving Care Transitions in Western New York State

The P2 Collaborative of Western New York [name was changed to Population Health Collaborative in 2017] represents a different spin on the Community-based Care Transitions Program (CCTP) model. It is unique in its focus on a very rural area of Western New York, and is unusual in that it is one of a few  community-based

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SAGE: Bridging the Divide between Acute Medical Care and Social Services in Northeast Ohio

By Dr. Kyle Allen and Susan Hazelett The Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project(SAGE) is a collaboration between an integrated health system and the local Area Agency on Aging which was begun in 1995. SAGE  provided the organizational structure to develop the resources and processes needed to effectively integrate geriatric medical services

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Early Days: Chicago-Based CCTP Program Describes The Work To Date

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

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Dr. Joanne Lynn on the Need for Rapid Follow-up Post Discharge

Patients just discharged from the hospital urgently need rapid follow-up in the community. Dr. Joanne Lynn describes the care coordination needed among patients, community providers, hospitals, and other settings, and what’s needed to make it work. Key words: rapid follow-up, care transitions, discharge planning, quality improvement, rehospitalization

Southwest Ohio Care Transitions Collaborative Talks to Medicaring about CCTP Award

The Southwest Ohio Care Transitions Collaborative, one of 7 sites chosen by the Centers for Medicare and Medicaid for the first cohort of 3026 funding, had lots going for it as it pulled together a broad-based community health coalition and implemented strategies to reduce avoidable readmissions for older adults. The program brought to its application

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Dr. Joanne Lynn Highlights Project RED to Improve Discharge Planning

Dr. Joanne Lynn describes Project RED (Re-Engineered Discharge), a program developed by Dr. Brian Jack and his colleagues at Boston University. It is designed to help hospitals to re-engineer their discharge processes, and offers some free online materials and guidance, as well as IT-enabled patient transition aids. You can read more about the details of

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Learning from Reviewing Readmissions: Tools You Can Use

A colleague asked an important question: Which tools are best for reviewing causes of readmissions? Two examples, from Georgia and New Jersey, are attached to this posting. Georgia’s form requires starting from a patient/family interview review, and does not pull much from the record of the hospitalization. New Jersey’s form starts from the other direction

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Better Care Transitions: Starting Points for Clinicians

As a frontline hospital or nursing home professional, you may be feeling increasingly frustrated with the lack of support, community follow-up and caregiver training for your vulnerable patients and residents. Despite your hard work these complicating factors are likely to send your patient or resident back to the hospital. Your administrators may have suggested to

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