Chicago Southland Coalition for Transition of Care (CSCTC



Community-based Care Transition Program
▪ Created by Section 3026 of the Affordable Care Act ▪ Administered through the Center for Medicare and Medicaid Services (CMS) ▪ Tests models for improving care transitions from hospital to other settings ▪ Reduces readmissions for high-risk Medicare beneficiaries ▪ Community-based organizations (CBO’s) must have formal relationships with acute care hospitals and other community providers

Hospital Readmissions
20 to 25% of all Medicare and Medicaid patients return to the hospital within 30 days of discharge, costing $15 billion annually. Hospitals within the upper quadrant with these occurrences will be penalized 1% of their entire Medicare reimbursements if they do not reduce their readmissions by at least 20% by 2013 If the reductions do not occur by 2015, the penalty increases to 3%

Program Requirements
1. Identify community-specific root causes of readmissions 2. Define target population and strategies for identifying highrisk patients 3. Specify care transition intervention that will impact root causes identified 4. Describe how care transition strategies will incorporate culturally appropriate and effective approaches 5. Provide implementation plan with milestones 6. Provide clear budget 7. Demonstrate prior experience

Our Collaboration
Catholic Charities of the Archdiocese of Chicago (CBO) partnered with Metropolitan Family Services to provide coaching services to four neighboring high readmission hospitals: - Ingalls Memorial Hospital
- MetroSouth Medical Center - Franciscan St. James Health - Little Company of Mary Hospital and Health Care Center

Open Kitchens will provide post-discharge meals Several out-patient/community pharmacies will provide medication management services. Independent Living Systems (ILS) will provide the PASS system used for this model

Mission and Vision
The mission of CSCTC is to reduce preventable hospital readmissions as an opportunity to improve quality of care and reduce costs in the healthcare system. The coalition is committed to reducing 30-day readmission rates by 20% over three years, and to develop community partnerships to eliminate barriers to successful care transitions

The Chicago Southland Coalition for Transition of Care is targeting 70 ZIP Codes in Southern Cook County, an area that includes portions of Chicago’s South side and its surrounding suburban area.

Implementation Plan
1. Hospitals provide list of eligible participants 2. Coaches initiate hospital visit and introduce PASS program to patient 3. Medication reconciliation occurs by pharmacy prior to discharge 4. Coach initiates home visit within 48-72 hours after discharge 5. Referral for home delivered meals, if necessary 6. Post-discharge follow-up calls occur on the 2nd, 7th, 14th, and 30th day after discharge

1. Conduct initial hospital visit and related components 2. Conduct home (post-discharge) visit and related components 3. Assist in care coordination follow-up calls 4. Provide client education during visits using care transition components. 5. Maintain client’s personal health record and electronic client file.

Typical Failures Following Discharge from the Hospital
• Medication errors • No follow-up appointment • Follow-up appointment left up to patient • Lack of emergency plan with number the patient should call first • Confusing discharge instructions • Lack of social support • Follow-up appointment too long after hospitalization • Lack of transportation to keep follow-up appointments • Multiple care providers • Lack of patient adherence to self-care due to poor understanding or confusion

The Five PASS Pillars
1. Medication self-management 2. Nutrition management 3. Personal Health Record 4. Primary Care and Specialist Follow-Up 5. Red Flags/Signs & Symptoms

Example of “Red Flags”

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