Capital Care
Transition Coalition
CCRC to Community Based Organization
Collaboration, Innovation, Transformation
Eileen McGivern, RN,BSN
Brewster/Topeka, Kansas
Brewster-CCRC in Topeka, Ks.
• Our site has a continuum of care (from Independent to
Skilled nursing services, including sub-acute rehab)
• Additionally, we offer a off-campus , community program
that serves 65 members called BrewsterConnect
A Few Things You Need to
Know about Kansas
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Brewster
Provides support to our Elders as they transitionBetween different levels of care on the Brewster campus
(Independent living, catered living, assisted living, skilled care
and sub-acute rehabilitation)
From acute-care hospital/Brewster sub-acute rehabilitation
and back to their Brewster Campus Independent Home
Also provide support to our BrewsterConnect membership
(65 members who live in the Topeka community)
BREWSTER
We recognize that transitions from one setting to another –
Can be a source of anxiety and fear
Elders may have a inability to comprehend all that has occurred
due to physical and emotional exhaustion
Cognitive deficits, hearing and vision impairments
Lack of medical literacy
BREWSTER
As a CCRC, we are EXPERTS in Care Transitions!
Our Goal is for Elders to be successful and prevent acute
hospital readmissions or abrupt changes in their level of
care.
BREWSTER
How do we do that?
Meet the Elder “right where they are” in regard tomedical literacy
Build on their strengths
Provide support and resources/services
for challenges
Empower them to take ownership of their conditions with
disease- state education
BREWSTER
We know what pitfalls cause them to return to the acute-care
hospital or higher levels of care following a hospitalizationMedication changes
Mis-information about after-visit summaries /discharge
instructions
BREWSTER
Our Business Plan has Four Core Strategies-
1.Nurture the Community
2. Diversify Services
3. Align with Others
4. Grow our Financial Strength
BREWSTER
What opportunities do embracing our Four Core Strategies
provide?
What are we experts at?
How do we diversify our services?
Who do we align with ?
What value can our expertise provide them?
How can we change the way our community and the larger
national communities view BREWSTER, CCRC’s
and AGING SERVICES?
BREWSTER
“The times, they are a changin’ “
Bob Dylan
BREWSTER
Hospital Re-admission Penalties by CMS/MedicarePatients who return to the acute care hospital and are
re-admitted with-in 30 days after dismissal
“One in five Medicare patients discharged from acute care
hospitals (2.6 million seniors) are readmitted within 30 days at a
cost of $26 billion every year.”
www.cms.gov
BREWSTER
The Center for Medicare and Medicaid formed the Centers for
Innovation.
( Created by 302c of the Affordable Care Act)
Community –Based Care Transitions Program Demonstration
Project
was developed.
Call for applications from Community- Based Organizations to
apply to become sites
(Must be not-for profit, have expertise in aging services and
connecting Medicare recipients to community resources)
Hospitals did not qualify
BREWSTER
Community Based Organizations in CCTP(CBO’s)
Were typically Area Agencies on Aging in the communities
they were to serve (AAA)
Had access to the Older Americans Act Fund to provide start up
funding
THE GOAL OF THE CCTP WAS TO REDUCE HOSPITAL
READMISSIONS BY 20%
BREWSTER
How can Brewster Core Strategies use the CCTP as a vehicle to
meet our Goals?
1. We wanted to nurture our community by providing the best
transition services to Elders to increase their health and
empower them to higher levels of wellness.
2. Diversify our services by serving community members who
live in our greater community and not just on our campus.
3. Align with the acute-care hospitals in our community,
support them in their readmission prevention efforts and in
doing so, change their perception of Brewster and Aging
Services as a whole.
COLLABORATE
Process for application to CMS/ CCTP for the Center for InnovationVolunteered to serve as Community Based Organization for the Project
Formed the Capital Care Transitions Coalition
(Saint Francis Hospital, Stormont-Vail Medical Center and included
Washburn University School Of Nursing, VNA, Jayhawk and NE Kansas
AAA, Shawnee Co. Health Dept)
Performed root cause analysis of readmission data, diagnoses of the
population we would serve, geography of area we would serve, model
we would use to provide coaching of patients, services we would offer
to patients .
COLLABORATE
As CBO, Brewster submitted application to CMS
Included in the applicationNarrative for implementation of the project
Letters of support by the hospitals
Governance structure of the CCTC
Budget worksheet which outlined our per transition cost and
what would be provided to each patient
INNOVATION
Because we were not the typical CBO we wanted our application
to be as innovative as possibleBEClose Technology(Medication reminders/Fall prevention, elopement safety)
Provide opportunity for the Washburn University School of
Nursing Students /Math Department students
(care delivery is changing, community-based care is the future,
acute care hospitals are less central, data collection related to
healthcare informatics)
Innovation
Our care transition would be modeled after the Care Transition
Intervention (Evidence- based Coaching model )Non-medical coaches
Meet patients in hospital
Schedule home visit 24-48 hours after dismissal
Discuss 4 Pillars
Connect to community resources/empower through coaching
techniques
Follow up phone calls at 7, 14, and 30 days following dismissal
TRANSFORMATION
WHY BREWSTER?
WHY NOT?!
What is best for our shared patients?
(Payment models are changing but we are not quite there!))
Community-based services are the future of healthcare.
(cost savings and increased patient satisfaction)
Phone calls received
(National Thought Leaders)
TRANSFORMATION
CMS reported readmission rates (all cause) 17.8%
Brewster/ CCTP readmission rates – 3.8%
Brewster
What is the value of the transition?
Cost of Care Transition to CMS286.00
(Includes meeting in hospital, home visit at 24-48 hour post
discharge, medication reconciliation, goal setting, disease and
symptom exacerbation education, development of action plan
and role play, resources, transportation to doctor’s
appointment if needed, follow up phone calls at 7, 14 and 30
days.)
Cost of readmission to CMS- 15, 000 or more?
ER visit, lab, x rays, physician’s bill, medications, possible
admission.
Collaboration, Innovation,
Transformation
Ask YourselvesWhat are our goals?
(for our community or nationally)
What are we excellent at?
Who do we need to collaborate or partner with to show our
expertise?
How do we share our success and new identity?
What do we need to do to continue to grow and change to
serve?
Thank you!
Questions?