At center, Adola DeWolf, care transition supervisor for Lifetime Care, speaks during the five-year celebration of the Care Transitions Intervention. With DeWolf are Lisa Wilson, at left, care transitions coordinator at UR Medicine, and Ann Marie Cook, president and CEO of Lifespan.

A partnership among senior and home-health service providers and area hospitals to help people successfully transition into and out of care settings recently marked five years of working together. The Care Transitions Intervention has been so successful over those five years that area hospitals have incorporated its procedures into their standard of care.

The collaboration among the nonprofit Lifespan, two home health care agencies (Lifetime Care and UR Medicine Home Care, formerly Visiting Nurse Service), area hospitals, FLHSA, grew from a goal of the 2020 Commission to reduce preventable hospitalizations in the region by 25 percent by 2014. The commission called for optimizing patient preparation for discharge, incorporating family and care givers into the process, arranging for timely and appropriate follow-up services and using patient and family coaching to make care transitions more successful.

“Research shows that the transition from hospital to home is a very critical time for patients,” said Annie Wells, director of care transitions for Lifespan. “It can be an opportunity for confusion, misunderstanding or a lack of coordination of care. People don’t understand their discharge instructions or a change in medications when they get home. Trying to negotiate that can be very difficult.”

Based on a model of patient engagement during care transitions developed by Dr. Eric Coleman, the Care Transition Intervention was supported in part by a New York State Department of Health Heal NY grant and the Centers for Medicare and Medicaid Innovation. The program created the nation’s first community-based multi-payer Clinical Transitions Intervention program aimed at reducing preventable readmission and improving quality of care by encouraging self-management in patients and their families.

To prevent hospital readmissions, nurses and social workers identify eligible patients entering the hospital and coach them during their stay to better manage their health. Patients in the target population were flagged if they met criteria including three or more chronic illnesses, five or more prescriptions and two or more admissions in 12 months.

Transition coaches help patients complete personal health records, communicate with primary care physicians or skilled nursing facilities to ensure follow-up after hospitalizations, and educate patients about warning signs and symptoms. The initiative also taps the resources of hospital pharmacists, who visit with patients to reconcile medication.

“Before the transition, medication reviews were inconsistent on admit and discharge,” said Melissa Wendland, director of strategic initiatives for FLHSA. “High-risk patients were not identified, there was inconsistent communication from the hospital to the primary care providers and skilled nursing facility. There was no hand-off to a coach. There was inconsistent linkage to community services, and inconsistent primary care provider follow-up.”

When the coaching program began, providers realized that hospital pharmacists were an untapped resource who could help facilitate more successful transitions, Wendland said. Pharmacists perform a medication reconciliation when patients are admitted and discharged. The pharmacists also follow up with phone calls to the patient, primary care provider and transitions coaches assigned to the patient.

Before the Care Transitions Intervention, this type of communication wasn’t performed, said Andrew Smith, transitions care pharmacist at UR Medicine’s Strong Memorial Hospital.

“There was no focus on discharge or afterwards,” Smith said. “There were pharmacists in institutions and pharmacists in retail settings, and there was no one in between that. There was no communication with primary care providers or with home care.”

Transitioning into a hospital is also a key time, as providers attempt to discern from a sick patient what medication has already been prescribed – and what they have taken.

“Right now when people come in, we find out what meds people are on, and as with discharge, there are a lot of things going on,” Smith said. “People are sick and they are stressed. It’s a huge difficulty.”

According to FLHSA research presented at the AcademyHealth 2014 Annual Research Meeting, those who were coached had lower readmission rates after 30 and 60 days, as compared to those who hadn’t been coached, regardless of which insurance payer a patient had and how many comorbid conditions the patient had.

According to Lifespan, the CTI initiative with Medicare Fee for Service beneficiaries has reduced the risk of 30-day hospital readmissions by 29 percent for participants who had either a hospital medication reconciliation or a coaching home visit, or both interventions.

“That is statistically significant, and the data showed even greater improvement after the coaching program had been in place longer,” Wendland said.