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HOSPITAL TRANSITION
PROGRAMChicago Southland Coalition for Transition of Care
(CSCTC)
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Community-based Care
Transition Program
Created by Section 3026 of the Affordable Care Act
Administered through the Center for Medicare andMedicaid Services (CMS)
Tests models for improving care transitions fromhospital to other settings
Reduces readmissions for high-risk Medicarebeneficiaries
Community-based organizations (CBOs) must haveformal relationships with acute care hospitals andother community providers
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Hospital Readmissions
20 to 25% of all Medicare and Medicaid patientsreturn to the hospital within 30 days of
discharge, costing $15 billion annually.
Hospitals within the upper quadrant with theseoccurrences will be penalized 1% of their
entire Medicare reimbursements if they do not
reduce their readmissions by at least 20% by
2013If the reductions do not occur by 2015, the
penalty increases to 3%
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Program Requirements
1. Identify community-specific root causes of readmissions
2. Define target population and strategies for identifying high-
risk patients
3. Specify care transition intervention that will impact rootcauses identified
4. Describe how care transition strategies will incorporate
culturally appropriate and effective approaches
5. Provide implementation plan with milestones6. Provide clear budget
7. Demonstrate prior experience
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Our Collaboration
Catholic Charities of the Archdiocese of Chicago (CBO)partnered with Metropolitan Family Services to provide
coaching services to four neighboring high readmission
hospitals:
- Ingalls Memorial Hospital- MetroSouth Medical Center
- Franciscan St. James Health
- Little Company of Mary Hospital and Health Care Center
Open Kitchens will provide post-discharge meals
Several out-patient/community pharmacies will provide
medication management services.
Independent Living Systems (ILS) will provide the PASS system
used for this model
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Mission and Vision
The mission of CSCTC is to reduce preventable
hospital readmissions as an opportunity to
improve quality of care and reduce costs in the
healthcare system.
The coalition is committed to reducing 30-day
readmission rates by 20% over three years, and to
develop community partnerships to eliminate
barriers to successful care transitions
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Community
The Chicago Southland Coalition for Transition of Care is
targeting 70 ZIP Codes in Southern Cook County, an area
that includes portions of Chicagos South side and its
surrounding suburban area.
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Implementation Plan
1. Hospitals provide list of eligible participants
2. Coaches initiate hospital visit and introduce PASS program
to patient
3. Medication reconciliation occurs by pharmacy prior todischarge
4. Coach initiates home visit within 48-72 hours after
discharge
5. Referral for home delivered meals, if necessary6. Post-discharge follow-up calls occur on the 2nd, 7th, 14th,
and 30th day after discharge
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Coaching
1. Conduct initial hospital visit and related
components
2. Conduct home (post-discharge) visit and related
components
3. Assist in care coordination follow-up calls
4. Provide client education during visits using care
transition components.
5. Maintain clients personal health record and
electronic client file.
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Typical Failures FollowingDischarge from the Hospital
Medication errors
No follow-up appointment
Follow-up appointment left
up to patient Lack of emergency plan with
number the patient should
call first
Confusing discharge
instructions
Lack of social support
Follow-up appointment too
long after hospitalization
Lack of transportation tokeep follow-up appointments
Multiple care providers
Lack of patient adherence to
self-care due to poor
understanding or confusion
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The Five PASS Pillars
1. Medication self-management
2. Nutrition management
3. Personal Health Record
4. Primary Care and Specialist Follow-Up
5. Red Flags/Signs & Symptoms
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Example of Red Flags
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