The following resources can help Journal of Healthcare Contracting readers understand the work that their physicians and other providers are doing to improve care transition.
Project BOOST
Project BOOST, or “Better Outcomes by Optimizing Safe Transitions,” is a national initiative led by the Society of Hospital Medicine, that is, the association for hospitalists. It aims to:
- Identify patients at high risk of re-hospitalization and target specific interventions to mitigate potential adverse events.
- Reduce 30-day readmission rates.
- Improve patient satisfaction scores and HCAHPS scores related to discharge.
- Improve the flow of information between hospital and outpatient physicians and providers.
- Improve communication between providers and patients
- Optimize discharge processes.
Key elements include:
- A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence.
- A comprehensive implementation guide with step‐by‐step instructions and project management tools, such as the Teach Back Training Curriculum, to help interdisciplinary teams redesign hospital discharge workflow, as well as plan, implement, and evaluate the intervention.
- Face‐to‐face training and a year of expert mentoring and coaching to customize and implement BOOST interventions. Through monthly coaching calls, mentors guide local teams to build a culture that supports safe and complete transitions. Teams receive a train‐the‐trainer DVD and curriculum for nurses and case managers on using the Teach Back process. Quarterly all‐site teleconferences and webinars target the educational needs of other team members including administrators, data analysts, physicians, nurses and others.
- The BOOST Online Community, which allows sites to communicate with and learn from each other via the BOOST Listserv, document and resource sharing.
- The BOOST Data Center, which allows sites to store and benchmark data against control units and other sites, and generate reports
As of February 2014, the project BOOST toolkit had been downloaded over more than 6,000 times from the Society of Hospital Medicine website. The year‐long mentoring program had been implemented at 180 hospital sites.
For more information, go to http://www.hospitalmedicine.org/boost/
Project RED
Project Re-Engineered Discharge is a research group at Boston University Medical Center that develops and tests strategies to improve the hospital discharge process in a way that promotes patient safety and reduces re-hospitalization rates. The RED intervention is founded on 12 components:
1. Ascertain need for and obtain language assistance.
2. Make appointments for follow-up medical appointments and post-discharge tests/labs.
3. Plan for the follow-up of results from lab tests or studies that are pending at discharge.
4. Organize post-discharge outpatient services and medical equipment.
5. Identify the correct medicines and a plan for the patient to obtain and take them.
6. Reconcile the discharge plan with national guidelines.
7. Teach a written discharge plan the patient can understand.
8. Educate the patient about his or her diagnosis.
9. Assess the degree of the patient’s understanding of the discharge plan.
10. Review with the patient what to do if a problem arises.
11. Expedite transmission of the discharge summary to clinicians accepting care of the patient.
12. Provide telephone reinforcement of the discharge plan.
For more information, go to http://www.bu.edu/fammed/projectred/
Care Transitions Program®
Based in the Division of Health Care Policy and Research at the University of Colorado Denver School of Medicine, the program, under the leadership of Eric Coleman, MD, MPH, aims to:
- Support patients and families.
- Increase skills among healthcare providers.
- Enhance the ability of health information technology to promote health information exchange across care settings.
- Implement system-level interventions to improve quality and safety.
- Develop performance measures and public reporting mechanisms.
- Influence health policy at the national level.
During a four-week program, patients with complex care needs and family caregivers receive tools and work with a “Transitions Coach” to learn self-management skills, designed to ensure their needs are met during the transition from hospital to home. The intervention comprises a home visit and three phone calls.
The intervention focuses on what the organization calls the “Four Pillars”:
1. Medication self-management.
2. Use of a dynamic, patient-centered Personal Health Record.
3. Timely primary care/specialty care follow-up.
4. Knowledge of red flags that indicate a worsening in their condition and how to respond.
The model is said to draw from principles of adult learning, and uses simulation to enhance self-management. Patients who received this program were significantly less likely to be readmitted to the hospital, and the benefits were sustained for five months after the end of the one-month intervention, according to the organization. Project sponsors are the John A. Hartford Foundation and The Robert Wood Johnson Foundation.
To learn more, go to www.caretransitions.org
Community-based Care Transitions Program
The Community-based Care Transitions Program (CCTP), created by the Affordable Care Act, tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries.
Launched in 2011, the CCTP is scheduled to run for five years. Participants are awarded two-year agreements, which may be extended annually through the duration of the program based on performance. Up to $500 million in total funding is available for 2011 through 2015.
One hundred and two sites are involved in the Community-based Care Transitions Program. (To view a list, go to https://data.cms.gov/dataset/Community-based-Care-Transition-Program-Filtered-V/jew6-k2tq)
To learn more about the Community-based Care Transitions Program, go to http://innovation.cms.gov/initiatives/CCTP/