HMS Care Transitions Series: Learning Opportunities

Several Health and Human Services (HHS) agencies offer training and development to help providers learn how to improve the safety and effectiveness of care transitions. Below are some of the opportunities available.

For more information on care transitions, click here.

HMS Care Transitions Series: Plans For Communities

There are several programs available the help community providers with established working relationships move toward better integration across care settings.  Below are some of the programs which provide various combinations of technical assistance, financial support and learning opportunities.

Community-Based Care Transitions Program (CCTP), Affordable Care Act Section 3026: Tests models for improving care transitions from hospital to other settings and reducing readmissions for high risk Medicare beneficiaries. Community-based organizations (CBOs) will use care transition services to effectively manage transitions and report process and outcome measures on their results.

Medical Homes: The primary care and patient-centered medical home is a promising model for transforming the organization and delivery of primary care.  Key features of medical homes include team-based care, a robust care coordination and care management capacity, patient-centered care with strong support for self-management of health, an emphasis on access and relationships, the use of clinical data to proactively plan care and manage populations, and a systems-based approach to quality and safety.

Accountable Care Organizations: Accountable Care Organizations (ACOs) are groups of health care providers who accept joint responsibility for the cost and quality of care outcomes for a specified population of patients. They provide organizational infrastructure and a team of providers in order to improve coordination of care. Creating the relationships and infrastructure across providers and care settings and instituting evidence-based care transition and readmission reduction programs will be essential to successful Medical Homes and ACOs.

Health Homes: Health homes coordinate primary, acute, behavioral health and long-term care services and supports using designated health home providers. Services include care management, care coordination, health promotion and comprehensive transitional care from inpatient to other settings.

Visit the Center for Medicare & Medicaid Innovation for more information on community resources and check out the HMS Care Transitions blog series for more information on care transitions.


HMS Care Transitions Series: State Programs

There are several programs that offer financial support for performance measurement-related activities and technical assistance for state Medicaid and Children’s Health Insurance Program (CHIP) agencies seeking to improve the safety and effectiveness of care transitions and reduce readmissions. Examples of programs include:

State Demonstrations to Integrate Care for Dual-Eligible Individuals Design Contracts: 15 states have been selected to design new approaches to better coordinate care for dual-eligible individuals. The selected states will have up to 12 months to work with stakeholders to develop a detailed demonstration model describing how the state would structure and implement an intervention that aligns the full range of Medicare and Medicaid primary care, acute care, behavioral health, and long-term supports and services. States successfully completing their design contract may be eligible to receive support to implement their demonstration models, pending federal approval and funding availability.

Who is participating: California, Colorado, Connecticut, Massachusetts, Michigan, Minnesota, New York, North Carolina, Oklahoma, Oregon, South Carolina, Tennessee, Vermont, Washington and Wisconsin were selected to receive design contracts as part of this effort.

Resources and technical assistance provided: The Center for Medicare & Medicaid Services (CMS) will provide funding and technical assistance to the selected states to develop person-centered approaches to coordinate care across primary, acute, behavioral health, and long-term supports and services for dual-eligible individuals. CMS is also making technical assistance available to all states interested in improving services for dual-eligible individuals.

Time of start and duration of the program design period: April 2011-April 2012; implementation will occur in 2012 and beyond.

Medicaid Community Services and Long Term Supports/ Medicaid Grant Programs: In partnership with states, consumers and advocates, providers, and other stakeholders, CMS is working to create a sustainable, person-driven long-term support system in which people with disabilities and chronic conditions have choice, control and access to a full array of quality services to assure optimal outcomes, such as independence, health and quality of life.

Next week, HMS continues our Care Transitions blog series with a look at community plans, learning opportunities and the elements of a successful care transitions program.

HMS Care Transitions Series: Federal Programs

Several complementary public sector initiatives with a focus on improving care transitions are available to communities and health care systems. Below are some of the federal government programs providing various combinations of technical assistance, financial support and learning opportunities.

Federal Programs  

  • Quality Improvement Organization (QIO): In most states, the Centers for Medicare & Medicaid Services (CMS) contracts with a QIO to implement improvements in the quality of care in all settings. Information on QIO’s is available here.
  • Administration on Aging (AoA): AoAs assist individuals making decisions about long-term care. This work includes innovative interventions to facilitate the hospital discharge process and help residents of nursing facilities return to the community.

Up next: HMS continues our Care Transitions blog series with a look at the state programs in place to improve the safety and effectiveness of care transitions.

HMS Care Transitions Series: Getting Started

HMS Healthcare Management SolutionsThe Care Transitions Quality Improvement Organization Support Center (QIOSC) and Administration on Aging (AoA) web pages on the Patient Protection & Affordable Care Act (PPACA) and Aging & Disability Resource Centers Evidence-Based Care Transitions Program include toolkits that provide information and tools that help guide providers and communities to develop the relationships and build the infrastructure needed to improve the safety and effectiveness of individuals transitioning from one setting to another and reduce the occurrence of unnecessary, preventable hospital readmissions.

Below is information about and contacts for Medicaid programs that improve care transitions from the Center for Medicare and Medicaid Services (CMS).

  • The QIOSC website: The toolkit describes community participants, the role the local QIOs can play, strategies for community recruitment and engagement, root cause analysis and ways to measure success.
  • The Administration on Aging Care Transitions Toolkit : Developed for states, Area Agencies on Aging (AAAs), Aging and Disability Resource Centers (ADRCs) and other local service providers within the Aging Network, the Administration on Aging Care Transitions Toolkit is targeted to organizations interested in learning how to prepare for a future role in care transition programs.  The resources describe items to think about when getting started and can assist in formalizing efforts for future funding and program opportunities.
  • Medicaid Programs related to care transitions and community services can be found on the CMS website by clicking here.  For preliminary guidance on the implementation of health homes for enrollees with chronic conditions, click here.
  • Community Activities: Developing effective approaches to improved care transitions requires community engagement, root cause analysis and measurement of care transition processes. The QIOSC and AoA websites provide information on the following:
    • Strategies for community recruitment and engagement.
    • Root cause analysis.
    • Processes and outcomes measurement.

HMS Care Transitions Series: Transition Management

Due to the infrastructure of our health care system, patients often encounter fragmented care when moving between health care settings.  Many elderly patients with chronic conditions and illnesses also require care from more than one provider.  The following are some of the contributing outcomes of poor transition management:

  • Poor communication between settings
  • Fragmented information
  • Patient confusion about how and who should manage their care
  • Medication errors
  • Lack of medication adherence
  • Adverse drug interactions
  • Duplicate prescriptions
  • Poor Primary Care Provider (PCP) follow up
  • Lack of knowledge about alternatives

Information that should be provided across care settings include:

  • Primary diagnoses and major health problems
  • Care plan that includes patient goals and preferences, diagnosis and treatment plan, and community care/service plan (if applicable)
  • Patient’s goals of care, advance directives, and power of attorney
  • Emergency plan and contact number and person
  • Reconciled medication list
  • Follow-up with the patient and/or caregiver within 48 hours after discharge from a setting
  • Identification of, and contact information for, transferring clinician/institution
  • Patient’s cognitive and functional status
  • Test results/pending results and planned interventions
  • Follow-up appointment schedule with contact information
  • Formal and informal caregiver status and contact information
  • Designated community-based care provider, long-term services, and social supports as appropriate.

Establishing standard practices and building seamless connections to community-based services are important to establish community standards and priorities essential to shaping a system that will provide safe and effective transitions across health care settings.  Click here to read more about Care Transitions.

HMS Care Transitions Series: Effective Care Transitions

Safe, effective, efficient care transitions and reduced risk of readmissions require cooperation among providers of medical, social and support services in the community and in long-term care facilities.

Hospitals, clinicians practicing in the ambulatory setting, home care agencies, community service providers, and post acute facilities are among the providers that must work together to ensure safe transitions. While much of the discussion addresses the transition from acute hospital to home or other post acute setting, the principles and resources are relevant for all transitions from one health care setting to another.

Because every patient’s wants and needs are unique, it’s important to understand the elements of a safe, effective and efficient care transitions plan.  Below are essentials to be sure to include:

  • Patient (or caregiver) training to increase activation and self-care skills.
  • Patient-centered care plans that are negotiated with patient and family and responsive to the medical and social situation and the availability of services and shared across settings of care.
  • Standardized and accurate communication and information exchange between the transferring and receiving provider in time to allow the receiving provider to effectively care for the patient.
  • Medication reconciliation and safe medication practices
  • Ensured transportation for health care-related travel
  • Procurement and timely delivery of durable medical equipment
  • Ensured responsibility for care of the patient by the sending provider until the receiving clinician/location confirms the transfer and assumes responsibility

Click here to read more about Care Transitions.