Partnership will help keep patients healthy, reduce hospital readmission
by Patrick J. Bradley
Niagara Falls Memorial Medical Center
Niagara Falls Memorial Medical Center and The Dale Association have been selected to join a consortium of Western New York hospitals and community-based organizations leading a pioneering effort to improve the quality of care for patients being discharged from the hospital.
Among the first 30 organizations around the nation to participate in the community-based care transitions program (CCTP), P2 Collaborative of Western New York will lead this program locally with technical assistance provided by the Centers for Medicare and Medicaid Services.
Through the CCTP, community organizations form partnerships with hospitals to help patients transition to home and reduce hospital readmissions. The goals of the CCTP include:
•Improving transitions of beneficiaries from the inpatient hospital setting to other care settings
•Improving quality of care
•Reducing readmissions for high risk beneficiaries
•Documenting measurable savings to the Medicare program
The CCTP is an initiative of the Partnership for Patients, a nationwide public-private partnership that aims to reduce preventable errors in hospitals by 40 percent and reduce preventable hospital readmissions by 20 percent over a three-year period.
Memorial will partner with The Dale Association to provide care transition services to Medicare fee-for-service patients with a history of a hospital readmission within 30 days of discharge. In addition, Memorial will offer the care transitions services to patients who will not receive skilled nursing care at home when they leave the hospital.
"This effort will provide vital assistance to frail patients who are transitioning from the hospital to their homes. The program aims to ensure that participating patients have their prescriptions filled, maintain compliance with their medication regimen, visit their primary care physician within a week after their discharge from the hospital and follow at-home care instructions," said Memorial Vice President and Chief Operating Officer Sheila K. Kee. "Making sure their needs are met during and after their transition to home will play a huge role in limiting their need to be readmitted to the hospital."
A team of care coaches has been specially trained to work with patients and their families in the key areas of encouraging patients to schedule a follow-up appointment with their doctor, maintaining medical record/care goals, monitoring medication and knowing warning signs. The coaches will also use the opportunity to discuss additional community resources that will keep patients healthy and safe. Coaches will be working with patients for 30 days after they are discharged from the hospital, which is a critical time.
"The team of care coaches that is available for people in Niagara County as they transition from the hospital to home is a great benefit for patients. The care coach coordinator, Angie Blackley, has been working with seniors for over 20 years; her caring and compassionate approach is sure to help the individuals remain healthy and safe," said Maureen A. Wendt, The Dale Association's acting president/CEO. "We are also thrilled to be working with a hospital like Niagara Falls Memorial on a service that will improve patients' quality of care and benefit the patients and the community."
The WNY Rural Care Transitions Consortium will build upon an existing regional effort around care transitions intervention, the evidence-based model developed by Dr. Eric Coleman, professor of medicine at the University of Colorado.
The consortium will serve more than 2,600 Medicare patients per year. Besides Niagara Falls Memorial, participating hospitals include:
•Brooks Memorial Hospital, Dunkirk
•Jones Memorial Hospital, Wellsville
•Olean General Hospital, Olean
•Orleans Community Health, (Medina Memorial Hospital), Medina
•TLC Health Network Lake Shore Health Care Center, Irving
•United Memorial Medical Center, Batavia
•Westfield Memorial Hospital, Westfield
•WCA Hospital, Jamestown
•Wyoming Community Hospital, Warsaw
In addition to the Dale Association in Niagara County, other community-based organizations that will coordinate this effort are:
•Allegany County Office for Aging, Belmont
•Cattaraugus County Department of the Aging, Olean
•Chautauqua County Office for the Aging, located in Mayville, Dunkirk and Jamestown
•Community Concern of WNY Inc., Derby
•Genesee County Office for the Aging, Batavia
•Orleans County Office for the Aging, Albion
•Wyoming County Office for the Aging, Warsaw
The consortium identified eligible patients for this program after conducting a thorough analysis that included review of hospital readmissions data, chart reviews and patient and partner interviews. Participating counties will provide care transitions services for Medicare fee-for-service patients with a history of a hospital readmission within 30 days of discharge.
Assisting the P2 Collaborative and its partners in securing funding from section 3026 of the affordable care act for care transition services to effectively manage Medicare patients' transitions and improve their quality of care, the Community Health Foundation of Western and Central New York supported the development of the application to CMS through grant funding and expertise provided by its advisors.
For more information on the WNY Rural Care Transitions Consortium, contact the P2 Collaborative of Western New York at 716-580-3680.