ADAPTING TRANSITIONAL CARE PROGRAMS
WITH PERSON-CENTERED INTERVENTIONS TO
IMPACT READMISSION RATES
June Simmons, MSW
President and CEO, Partners in Care Foundation
Partners in Care Foundation
Who do we serve?
• Partners serves older adults, adults
with disabilities, and medically fragile
adults who require in-home supports
after hospital discharge or ongoing
supports to avoid institutionalization
• We offer tailored, person-centered
services to patients with diverse
health and psycho-social needs in
English, Spanish, and Armenian across
the state of California
• Most patients receive managed
Medicare
Evidence-Based Transitional Care Services
•
Bridge
Model
•
•
In-Home
Medication Review
& pharmacist
intervention
One-time
HomeMeds
•
In-hospital visit and postdischarge phone calls
30 day duration
Care
Transitions
•
•
CTI
(Coleman Care
Transitions
Intervention)
Partners offers all three interventions at our CCTP* communities.
*CCTP: CMS-funded Community-based Care Transitions Program
In-hospital and
in-home visits
4 week duration
Person-Centered Care
• Partners’ staff consider which of the 3 care
transitions interventions, or combination of
interventions, is best suited to decreasing
the likelihood of readmission for each
individual patient.
When selecting an intervention with the
patient, we consider the patient’s:
• Personal goals
• Level of health risk
• Social support needs
• Cognitive status
• Availability of family/caregivers
• Neighborhood & local resources
• Personal comfort and preferences
• Cultural and linguistic characteristics
Interventions
Interventions
Unique to Bridge
Bridge & CTI
Set up services prior to discharge
Pre-discharge hospital visit
Use Personal Health Record (PHR)
tool
Assess for and address emerging
needs post-discharge
Conduct one home visit 24-72
hours post-discharge
Provide discharge preparation
information sheet prior to discharge
Call patient within 48 hours of
discharge
Telephone follow-up to ensure
adherence to plans
Make additional calls or schedule
visits to resolve identified problems
Use health record to relay
information to other providers
Track patients progress and address
emerging needs at 30-days post
discharge
Coordinate with other providers
and agencies
Unique to CTI
Actively engage patient in
medication reconciliation
Use role-playing and other tools to
transfer skills
Perform 3 follow-up phone calls to
reinforce coaching , selfmanagement, sharing PHR
Bridging the Gap
Providing flexible, tailored programming for each patient’s needs means
reducing readmission risk
The Bridge Model allows us to serve patients who:
• Refuse home visits due to cultural reasons or personal discomfort;
• Are cognitively impaired and difficult to coach
• Are still too ill to take responsibility for behavior change
• Lack caregiver or are otherwise in need of social supports and incapable of
making own arrangements
• Are geographically beyond our reach
Across Partners’ 3 CCTP communities, over 9,096 patients were
enrolled in the Bridge Model as of 9/30/15.
Increasing Bridge Interventions
12/13-9/15
Number of Bridge Cases vs CTI Cases
A UCLA Study on Partners’ Bridge Patients
7/14-12/14
9.78% Readmission Rate
For further information contact:
• June Simmons, CEO at [email protected]
• Or check our website: picf.org