Clinton Memorial Hospital joins regional effort to reduce avoidable hospitalizations among seniors

Clinton Memorial Hospital (CMH) has joined a regional collaborative of health care organizations working to help hospitalized seniors get home, stay healthy, and reduce the need for return visits to the hospital.

The program, which began at CMH earlier this summer, uses health coaching at home to help Medicare patients avoid hospital readmissions. Called Care Transitions, the program is seeing increasing numbers of seniors at CMH and providing them with tools to better manage their diseases and chronic conditions once they go home.

"Patients and their families are embracing the project and are eagerly participating with the hope of avoiding readmission to the hospital," said CMH Chief Quality Officer Amy Donaldson, RN, MSN.

"Working with our case managers and social workers, our coach has already established an extensive client list for follow-up. Patients appreciate the opportunity for empowerment."

Medicare patients who are discharged from hospitals are often readmitted within a short period of time sometimes in as little as 30 days.

Helping those patients as they transition from the hospital to another care setting – usually their home – can reduce avoidable readmissions, saving millions of dollars in Medicare costs while resulting in better health outcomes for older adults. Beginning in October, hospitals with higher-than-anticipated readmission rates will have a portion of their Medicare reimbursement withheld.

CMH has one Care Transitions Coach® employed and trained by Council on Aging. Patients are identified by hospital Case Managers and other hospital staff. They are further screened by the coach who then meets with them at the hospital and explains the program.

The Southwest Ohio Care Transitions Collaborative, of which CMH is a part, received a major federal contract from the federal Centers for Medicare and Medicaid Services to implement Care Transitions. The Care Transitions Collaborative was one of the first sites in the country to receive a contract.

The Care Transitions Collaborative is led by the Council on Aging of Southwestern Ohio, in partnership with the Greater Cincinnati Health Council. Besides CMH, other partners include the Health Collaborative; Health Care Access Now; HealthBridge; Hamilton County Mental Health and Recovery Services Board; The Christ Hospital; The Jewish Hospital - Mercy Health; Mercy Health Fairfield Hospital; and UC Health - University Hospital. The program aims to reach more than 3,000 patients at the five hospitals. Its primary goal is to reduce hospital readmissions among high-risk Medicare beneficiaries by 20 percent.

After participating patients are discharged from the hospital, the coach visits them either at home or at a nursing facility and also telephones at regular intervals during the four-week program. Using a model developed by Eric Coleman, M.D., of the University of Colorado, the coach works with patients and their caregivers on:

• Managing medications

• Follow up with primary care physician and other health care professionals.

• Recognizing medical condition "red flags."

• Creating a personal health record to take to all health care encounters.

• Connecting the patient with community resources.

More information about Care Transitions is available at Council on Aging's website, www.help4seniors.org.