Earlier this month CMS announced 17 additional awards under its Community-Based Care Transitions Program (CCTP), which now encompasses 200 acute-care hospitals and their hospitalists partnering with community agencies and coalitions to improve transitions of care in advance of the Oct. 1 start for excessive readmissions penalties. Innovative solutions to the readmissions dilemma are being tested at the local level by a variety of partnerships with hospitals and hospitalists.
For example, William C. Cook, DO, chief of hospital medicine for the Ohio Permanente Medical Group in Cleveland, is part of a community-wide quality coalition called Better Health Greater Cleveland, one of 17 such groups in the Robert Wood Johnson Foundation’s Aligning Forces for Quality collaborative. The program includes 150 quality teams in 100 hospitals posting readmissions reductions and other quality metrics. Dr. Cook, who co-chairs Better Health’s Steering Committee for Transitions of Care, is spearheading a transitions pilot with two local nursing homes.
“From the hospitalist perspective, our role is to make care transitions safe and predictable,” Dr. Cook says. “The way I can contribute most to these transitions is by thinking ahead about what’s going to happen next—and how do I prepare the patient and the next provider.” One key step is taking time to complete the real-time discharge summary for each patient, he adds.
The idea, Dr. Cook explains, is to identify and communicate with collaborators across care settings so that the “coaching baton” can be passed in a manner that appears seamless to the patient.
Nearly a third of the 17 new CCTP sites participate in SHM’s Project BOOST, including three hospitals in California and one each in Illinois and Pennsylvania. Project BOOST is accepting applications for its next round of sites through September.