Care Transitions - NW Denver Community

Supporting Providers in Improving Transitional Care

The Centers for Medicare and Medicaid (CMS) Care Transitions Theme aims to improve care coordination across the continuum of care. Colorado Foundation for Medical Care (CFMC) will work with a community of providers in the Northwest Denver metro area (our ‘target community’) to reduce unnecessary hospital readmissions, improve information transfer between providers and increase patient satisfaction. We will focus on implementing improvements that address medication management, post-discharge follow-up and patient-centered plans of care, improving information transfer between provider to provider and provider to patient based on data discovery of the drivers for readmission in the target community.

NW Denver Community

The target community includes two major hospitals and many nursing homes, home health agencies, primary care providers, hospice and other medical outpatient and inpatient medical settings.

We are currently inviting all interested care settings in the community to be involved in this important initiative.

The target community has established a “steering committee” that consists of leadership-level community providers from a variety of medical settings, large employer, end-of-life facilitator, patient/caregiver and a Medicaid representative all of whom have agreed to participate for the next three years (2008-2011). The steering committee will review data and determine the most appropriate care transition interventions that will best serve the community patient population. The steering committee is dedicated to drive the project through the next three years and build capacity to sustain the project past the deadline of CMS funding.

Click here for NW Denver CARE Transitions Fact Sheet

Interventions Focus

Hospital/community “system-wide” interventions to improve processes at a whole system level. Interventions might include redesigning discharge protocol system-wide, adopting information technology solutions, or creating a new protocol for transfer of patients to a SNF.
Interventions that impact readmission for specific diseases or conditions such as AMI, CHF, pneumonia. Interventions might include CHF disease management programs, or the Care Transitions Intervention.
Interventions that address specific reasons for admission in this community. Interventions might include creation of services that impact the readmission rate simply because patients have no other alternative, such as end of life/palliative care services.

Measures

CMS, CFMC and the target community steering committee are dedicated to achieve measurable outcomes of this project. The community steering committee are reviewing data quarterly, or as data is available, to ensure success of the projects activities.

Hospital Measures	% of patients 65+ who rate hospital performance meeting HCAHPS performance standard for medication management (questions 16 & 17).
Hospital Measures	% of patients 65+ who rate hospital performance meeting HCAHPS performance standard for discharge planning (questions 19 & 20)
Community Measures	% of patients discharged and readmitted within 30 days who are seen by a physician between discharge and readmission.
	% of patient care transitions (FFS Medicare), in the target community, for which implemented and measured interventions show improvement.
	% of patients from the target community re-hospitalized within 30 days of discharge from an acute care hospital.
	30-day all-cause risk standardized readmission rates following HF, AMI and PNE hospitalizations.
	% of patient transitions within the target community for which a CARE instrument was used.

Interested Providers and Community Stakeholders

Interested target community providers and stakeholders (community organizations, patients/caregivers, patient advocates, etc) should contact Diane Evans, QI Coach, at DEvans@cfmc.org or 720-277-1630.

Providers outside of the target community are more than welcome to contact the project manager for information on how to build a Care Transitions project in their community.

Care Transitions Intervention Resources

The Colorado Foundation for Medical Care (CFMC), the Medicare quality improvement organization for Colorado, prepared this material under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS Policy.