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Care Transitions

Resources

What's New:

Visit this page often to learn about upcoming calls and view information from recent presentations.

SAS Code for Zip Code Overlap

Colorado

Transitional Care Weekly Learning Sessions

July 24, 2008: Cheri Lattimer - Coordinating Transition As The Collaborative Team: Patient, Caregiver & Provider
Handout
Taped Call
July 17, 2008: Vanessa Flint, MPH, MBA - Discharge Planning Checklist
Handout
Taped Call
July 10, 2008: W. Kline Bolton, M.D., FASN and Alvin H. Moss, MD - End-Stage Renal Disease
Handout
Taped Call
June 26, 2008: Mary Fermazin, MD, MPA - Improving Care Transitions, Measuring Progress
Handout
Taped Call
June 19, 2008: David Goodman, MD MS - Defining Populations and Providers for Measuring Health Care
Handout
Taped Call
June 12, 2008: Lori A. Gerhard, CASP, NHA - AAA’s and ADRC’s Role in Care Transitions
Handout
Taped Call
June 5, 2008: Lori Nichols, Marc Pierson, MD - Explore the Shared Care Plan PHMS; Implementation in Your Community; How Does HealthVault Fit In?
Handout
Taped Call
May 29, 2008: Michael P. Silver, MPH - Causes of Avoidable Hospitalization in Home Health Preliminary Results from a Field Study
Handout
Taped Call
May 22, 2008: Maulik S. Joshi, Dr.P.H. - Local Action for National Transformation and Harold D. Miller - Reducing Hospital Admissions by Transforming Chronic Care
Handout 1 | Handout 2
Taped Call
May 15, 2008: Judith Tobin, PT, MBA - CARE (Continuity Assessment Record & Evaluation) Overview
Handout
Taped Call
May 8, 2008: Stephen F. Jencks, MD, MPH - Rehospitalization: The Scope of the Problem
Taped Call
May 1, 2008: Marc Pierson, MD, Bill Mahoney, PhD, Lori Nichols - Transitional Care Whatcom County Perspectives
Handout
Taped Call
April 24, 2008:Gail A. Nielson, BSHCA - Creating an Ideal Transition Home for Patients with Heart Failure
Handout
Taped Call
April 17, 2008: Patricia Sodomka, FACHE - Sharing the Patient- and Family-Centered Care Experience at the Medical College of Georgia
Handout
Taped Call
April 10, 2008: Brian Jack, MD, Testing the Re-Engineered Discharge
Handout
Taped Call
April 3, 2008: Jennifer L. Wolff, MHS, PhD, Family Involvement in Transitional Care Among Medicare Beneficiaries
Handout
Taped Call
March 27, 2008: VALUE Project Final Results (CO and NM)
Handout
Taped Call
March 20, 2008: VALUE Project Final Results (CA and NJ)
Handout 1 | Handout 2
Taped Call
March 13, 2008: Chad Boult, MD, MPH, MBA, The Guided Care “Medical Home” for High-Risk Beneficiaries
Handout
Taped Call
March 6, 2008: Joseph G. Ouslander, MD, Improving Nursing Home Care by Reducing Avoidable Acute Care Hospitalizations and Mary Jane Koren, MD, MPH, Safely Preventing Hospitalization of NH Residents
Handout 1 | Handout 2
Taped Call
February 28, 2008:Nan Holland, PGP Demonstration Project - Factors Influencing Performance Year 1 Quality & Efficiency Results
Handout
Taped Call
February 21, 2008: Richard D. Brumley, MD, Palliative Care Across the Continuum Kaiser Permanente
Handout
Taped Call
February 14, 2008: Re-Designing Health Care for Quality: The Case for Investing in System-wide Quality Improvement, Continued
Handouts are the same as the previous call
Taped Call
February 7, 2008: Bonnie Brossart, Chief Executive Officer, Health Quality Council in Saskatchewan, Canada - Re-Designing Health Care for Quality: The Case for Investing in System-wide Quality Improvement
Handout 1 | Handout 2 | Handout 3
Taped Call
January 31, 2008: Dr. Jane Brock (CFMC) and Mark Gottlieb, PhD (NMMRA) - Developing Metrics for VALUE
Handout 1 | Handout 2 | Handout 3
Taped Call
January 24, 2008: Donald E. Casey Jr., MD, MPH, MBA, FACP - Findings from the CHP "HF GAP" initiative and Atlantic Health's Approach to Palliative Care
Handout 1 | Handout 2 | Handout 3 | Handout 4
Taped Call
January 17, 2008: Donald M. Berwick, MD, MPP, FRCP - Eating Soup with a Fork
Handout
Taped Call
January 10, 2008: Joseph Lau - “Non-pharmacological Peri Discharge Interventions and Outcomes in Heart Failure (HF)"
Handout
Taped Call
January 3, 2008: Thomas Edes, MD, MS - VA Home Based Primary Care
Presentation
Handout 1 | Handout 2
Taped Call
December 20, 2007: Eric Coleman MD, MPH - Care Transitions Intervention
Handout
Taped Call
December 13, 2007: Shannon Brownlee - "Overtreated"
Handout
Taped Call
December 6, 2007: Mary Naylor PhD, RN - Transitional Care Model
Handout 1 | Handout 2
Taped Call
Article about Brownlee's book, "Overtreated," in The New York Times

Upcoming Calls (subject to change)

June 19, 2008: David C. Goodman, MD, MS
June 26, 2008: Mary Fermazin, MD - Care Transitions Measures
July 3, 2008: NO CALL THIS WEEK DUE TO HOLIDAY
July 10, 2008: Alvin H. Moss, MD - ESRD
July 17, 2008: Vanessa Flint - Discharge Planning Checklist
July 24, 2008: Cheri Lattimer - National Transitions of Care Coalition

Other Calls

January 9, 2008: Inpatient CoP Call
Care Transitions featuring Dr. Jane Brock of CFMC
Handout
Taped Call

Recent Presentations

AHQA 2008

VALUE Project Final Results

QualityNET 2007

The Project

The Transitions of Care Program is an 18-month special study funded by the Centers for Medicare & Medicaid Services led by the Colorado Foundation for Medical Care (CFMC). The purpose of the study is to apply a well-proven intervention that reduces 14-and 30-day hospital readmission rates. Through this pilot study we are working with three diverse communities, each consisting of at least one hospital, one skilled nursing facility, one home health agency, and one outpatient physician office within Colorado. In addition to workflow analysis and cross-site visitation, we worked with our subcontractors, the University of Colorado at Denver and Health Sciences Center to train each community in the Care Transitions Intervention (CTI). Each community has approached the problem of hospital re-admission rates and implementation of the CTI slightly differently. Outlined below is the current status of each community.

Please check back often for the latest update!

Community 1

Unaffiliated group of four agencies (1 hospital, 1 skilled nursing facility, 1 home health agency, 1 outpatient physician office)
Implementing a modification of the CTI
Based in the outpatient physician office
Utilizing existing resources, no dedicated transition coaching staff has been hired
Physicians and mid-levels (i.e., physician assistants and nurse practitioners) have privileges of seeing patients in each of the four settings already
Transition process for patients is ‘visualized’ by patients wearing a silicon wristband with the name and phone number of the outpatient physician office printed on the inside of the band
Baseline scores of the 3-item Care Transitions Measure have been collected
A cohort of ‘frequent flyer’ patients have been identified and are being tracked whether the CTI has been administered by the outpatient physician office
Personal Health Records are being distributed to appropriately identified patients at the hospital, home health agency, and outpatient physician office
Workflow observations and process mapping have been finalized in each of the originally participating agencies

Community 2

Partially affiliated group of 7 agencies (1 hospital, 3 skilled nursing facilities, 1 home health agency, 1 outpatient physician office, 1 managed care organization)
Implementing the CTI as originally designed to be most effective
Based out of the home health agency and the managed care organization
Two transition coaches have been hired
Coaches are visiting patients in the hospital, in the skilled nursing facilities, and at the patient’s home
Baseline scores of the 15-item Care Transition Measure are being collected at present
Patients that have been hospitalized twice within the past two months are being identified as appropriate to receive the CTI
The CTI is in full swing
Workflow observations and process mapping have been finalized in each of the originally participating agencies

Community 3

Unaffiliated group of multiple agencies
Training of the CTI has occurred
Communitywide meeting convened with community stakeholders and leaders including: two hospitals, multiple skilled nursing facilities, multiple home health agencies, and multiple outpatient physician offices as well as the regional health information organization, department of human services, chamber of commerce, private and non-profit businesses, county commissioners, and local congressman.
Stakeholders have formed several taskforces to work on improving care coordination and transitional care for patients throughout the entire community. Specifically, each setting is working closely with others to standardize operations (e.g., hospitals and skilled nursing facilities) and the hospitals are critically examining records for those patients that have been re-hospitalized during the third quarter of 2007.
The CTI is not being implemented at this time
Workflow observations and process mapping have been finalized in each of the originally participating agencies

Useful links:

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.