A group called Bridging Care Across the Inland Northwest formed by health and elder care organizations has developed a new hospital transitional-care model to reduce readmission rates for elderly patients.

Before the end of this year, the group hopes to garner a federal contract to get Medicare reimbursements to help fund the model, based on a request being submitted in September after an earlier, less-detailed request failed.

At its core, the model seeks to improve care transitions for seniors after hospital stays and to prevent confusion over follow-up medical instructions through a "care-transitions coach" working with a patient at discharge for 30 days. It also encourages patients to keep a form with a personal health record that can be carried with them as they see various providers.

Older patients with chronic illnesses often end up back in the hospital within six months for a preventable reason, such as due to confusion about what medication to take, says Cindy Corbett, a Washington State University Spokane nursing professor who has helped develop the model.

"There's a lot of communication issues related to care transition," she says. "This model is about empowering patients and families to gain knowledge and be more aware of medications."

She adds, "Any time a patient is moved, you're transferring health history."

Corbett has studied strategies to improve chronic illness self-management and patient safety. Her research to improve the safe use of medications during care transitions has received funding from the Robert Wood Johnson Foundation and the National Institutes of Health, among other agencies. She also serves as a scholar-in-residence for Providence hospitals in Spokane.

Corbett is part of the team working on the care-transitional model here. Some of the hospitals and organizations participating in the effort include Providence Sacred Heart Medical Center & Children's Hospital, Providence Holy Family Hospital, Kootenai Medical Center, Area Agency on Aging of North Idaho, and Aging & Long Term Care of Eastern Washington.

In early September, Aging & Long Term Care of Eastern Washington, as the lead agency, plans to submit a contract request that uses the model to The Centers for Medicare & Medicaid Services. The Spokane-based Aging & Long Term Care organization offers a network of services for in-home and long-term care and is a member of the state Washington Association of Area Agencies on Aging, based in Olympia, Wash.

If the contract with the transitional-care model is approved, Medicare would offer an estimated reimbursement of $80 to $100 per elderly patient if that person doesn't return to the hospital within six months, Corbett says. The patients would need to elect to participate.

The group had applied for such a contract earlier this year, but CMS turned down that request because details still were needed for a regional model to be eligible, says Nick Beamer, executive director of Aging & Long Term Care of Eastern Washington.

"We had to do a root-cause analysis," Beamer says, which meant the group had to submit a report on the region's population and major causes of illnesses resulting in hospital readmissions. Some of those health issues now detailed include diabetes, chronic obstructive pulmonary disease, and congestive heart failure, Beamer says.

The agency is submitting the request under a provision of the Patient Protection and Affordable Care Act, and it also began piloting the transitions care model in recent weeks, Beamer adds.

"We are currently starting to do this with Sacred Heart and Holy Family," he says, and the effort includes sending a transitions-care coach to each of those facilities. "We've long wanted to connect better with clients in the hospital setting, and it's not been easy to do."

Beamer says the model will start with elderly patients who have chronic illnesses.

"The coach will be facilitating the transfer, most likely to a home or a nursing home or transitional care home, and do follow-up visits within 24 hours, and additional phone follow-ups for at least 30 days," he says.

Although participants in the group found out earlier this summer that the first contract request had been denied, Corbett says the group decided to try to move the model forward and resubmit it with the additional needed data.

"We know it's going to improve health care in our community," she says. "There's also an incentive that hospitals will be penalized by CMS if patients are readmitted within 30 days. The Medicare reimbursement won't be as high in the future."

Corbett says group members also believe there will be future opportunities for reimbursement because of steps being taken nationally to create an accountable health care system and contain costs.

The model draws from one developed by Dr. Eric Coleman, a geriatrician and University of Colorado professor, Corbett says. The WSU College of Nursing has invited Coleman to speak Sept. 5 in Spokane about improving transitional care and related national policy efforts.

For the Inland Northwest, Corbett says, "We're using Dr. Coleman's model as an example. We've personalized it a little for this community. Also, we had older adults who gave us feedback."

She says the model proposes four pillars. The first is self-management of medicine. Secondly, it encourages use of a patient personal health record typically on two double-sided pages to list such items as prescriptions, allergies, health issues, and doctors. The third pillar includes physician follow-up after a hospital stay, and that primary care providers and specialists participate in the model. The fourth pillar encourages providers to watch for red flags that lead to hospital readmission.

"The hope is that in our community we start seeing people with this personal health record beyond the 30 days" after a hospital stay, she says. To achieve that would require released patients developing an appreciation for the value of updating their personal health care forms, and hopefully it would be aided by area health providers encouraging them to do so.

She adds, "We want it to be like your health insurance card, and a person knows they have to have the form with them."

Corbett says another common transitional care issue occurs when a hospital staff person, during the admission of a senior, asks for a list of the prescription medicines the person takes, and the senior forgets to mention all of them.

Upon discharge, the hospital care instructions then doesn't list a regular prescription, so patients sometimes think they no longer need to take it, and they end up back in the hospital, she adds.

"Twenty percent of people with Medicare insurance are readmitted within 30 days," Corbett says. "Up to 60 percent are what CMS considers preventable."

She says electronic records that follow a patient through a network of doctors and hospitals may help avoid confusion, but sometimes a specialist's prescription or treatment isn't documented.

Corbett says she was tapped to help with the community transitions care model because of her research, and her work with both Providence and Aging & Long Term Care of Eastern Washington.

"It can't be managed by just a hospital," she says. "It has to be a community approach."

She adds, "There are probably at least 15 entities that signed a memorandum of understanding, not necessarily for getting the reimbursement," but that they would help implement the model.

Regarding which entity does get reimbursed, Corbett says, "It would depend on who would provide the transitional coaching. Aging & Long Term Care has had a transitions coach now for six or eight weeks based at Sacred Heart. We're hoping that will help with the next application."

She says it's possible a portion of reimbursement might go to a hospital in some cases, if a hospital shares in some managing of the transitional care upon a patient's discharge from the hospital.

The other main hospital group here, Rockwood Health System, which includes Deaconess and Valley hospitals and Rockwood Clinic PS, also has taken several steps in the past year focused on preventing readmissions of patients with chronic illnesses, says Sasha Jackowich, director of marketing and communications for Deaconess and Valley hospitals.

"This is something hospitals all over the country have been focusing on, because, nationally, Medicare is seeing too many readmissions," Jackowich says.

She says one of the steps Rockwood Health System is taking is the increased use of health coaches.

"We have 10 health coaches right now within the system," and of the 10, two are dedicated to each of the hospitals to focus on management of chronic conditions and readmission prevention. Case management directors at each hospital also review readmissions and causes, she adds.

The Rockwood system also recently held an educational session for professionals at 25 to 30 assisted living centers here regarding readmissions and care after a hospital stay, she adds, as one example among other regular meetings between hospital staff and care facility providers.