Centers for Medicare & Medicaid Services Funds Local Program to Assist Older Adult Patients after Discharge from Hospital

August 20, 2012

Triad Consortium First in North Carolina to Receive Federal Funding

A consortium of local health and social service providers has been announced by the Centers for Medicare & Medicaid Services (CMS) as one of 17 additional sites across the nation to participate in the Community-based Care Transitions Program (CCTP). The consortium will implement a new, two-year program to help Medicare fee-for-service & Medicaid eligible patients fully recover from serious illnesses after being discharged from a hospital. The Triad consortium is the first in North Carolina to receive CMS funding for a hospital to home transition program.

The CCTP is an initiative of the Partnership for Patients, a nationwide public-private partnership launched in April 2011 that aims to cut preventable errors in hospitals by 40 percent and reduce preventable hospital readmissions by 20 percent over a three-year period. CCTP’s goals are to reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measureable savings to the Medicare program.

The consortium, Northwest Triad Care Transitions Program (NTCTP), includes Wake Forest Baptist Medical Center, Forsyth Medical Center, Kernersville Medical Center, Northern Hospital of Surry, Hugh Chatham Memorial Hospital, Lexington Medical Center, Thomasville Medical Center, Medical Park Hospital, as well as a large group of community-based health care providers: Northwest Community Care Network, Piedmont Triad Regional Council Area Agency on Aging, Forsyth County Senior Services, Davidson County Senior Services, Surry County Senior Services and Winston-Salem Right at Home.

The goal of the program is to reduce hospital readmissions in this patient population by 20 percent.

The program, which can be extended annually for the remaining 3 years if performance goals are met, is designed for Medicare recipients in Forsyth, Davidson and Surry counties who are admitted to a participating hospital with heart failure, heart attack or pneumonia.

Another goal of the program is to have everyone involved in a patient’s care talking to each other rather than operating in silos, said Ronald Gaskins, associate director of the Northwest Community Care Network, which will be acting as the lead community-based organization for the program.

“This is a vulnerable group of patients due to their age and high-risk medical conditions,” said Gaskins. “We are trying to bridge the transition from hospital to home so these people have what they need to get well. Communication among the various care and service providers is critical to the ongoing health and well being of the patients and their ability to remain independent in the community,” Gaskins said. “Simple things, such as filling prescriptions and getting to follow-up doctor appointments, can be daunting if they live alone or don’t have a strong social support network to help out.”

Using a model designed at Forsyth Medical Center called the Hospital to Home Program, each participating patient will be assigned a social worker who gathers initial information in the hospital and coordinates their care during the first days and weeks after discharge, when there is the greatest danger of relapse and subsequent readmission to the hospital for the same condition.

In addition to coordinating medical care and patient education through home visits and telephone consultations, the social worker will arrange for home care services such as light housekeeping, grocery shopping and transportation as needed. The social worker also will work with the local Aging and Disability Resource Center to arrange longer term services, such as Meals on Wheels when appropriate.

Gaskins said it was the collaboration between Wake Forest Baptist Medical Center’s Sticht Center on Aging, Forsyth Medical Center and Senior Services of Forsyth County that resulted in the development and submission of this application and was the key in receiving CMS funding for the project.

“The initial success of this program, which has demonstrated a 40% reduction in hospital readmissions, will become even more apparent as the project is implemented at other medical facilities in our region,” he said.

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