The Denver Regional Council of Governments (DRCOG) received Colorado’s first Community-based Care Transitions (CCTP) Grant from the CMS Innovation Center. CCTP is a program enacted by the Accountable Care Act to pilot care transitions programs. Just over 100 pilots are being funded for three years, with the potential to receive an additional two years of funding. Area Agencies on Aging (AAA) were given special consideration due to their critical roles as community hubs. DRCOG is the Denver region’s AAA serving eight counties and their transitions program, Denver Regional Care Connection (DRCC), focuses on reducing readmissions for Medicare beneficiaries with sepsis, pneumonia, heart failure, and chronic obstructive pulmonary disease.
In addition to these diagnoses, the patient will also have a discharge disposition to home either with or without home health services. The initiative will use Dr. Eric Coleman’s Care Transitions Intervention model and patient needs will be determined using the Patient Activation Measure (PAM). As part of the care transitions process, coaching begins during hospitalization and continues after discharge. The coaching is designed to engage the patient and/or the family in care, facilitate medication self-management, ensure adequate medical follow-up, and to establish alert and responses systems for when red flags occur. The DRCC will be further supported by care management through in-home assessments of existing and needed supports as well as nutrition, personal care, and transportation services based on each patient’s PAM score.
The DRRC will begin with two hospitals, Presbyterian/St. Luke’s and St. Joseph’s, and one care transitions coach, and will build from this foundation. The transitions process begins when hospital rounds trigger a referral to DRCOG’s coach. The coach visits the patient after payer verification, diagnosis verification, and the patient has given consent for the coach to visit. During the meeting with the patient, the coach verifies that the patient is not part of an Accountable Care Organization and screens for the program by completing the Patient Activation Measure. Once the patient is determined to be eligible for the DRCC, DRCOG obtains written consent to participate and proceeds with implementing Dr. Coleman’s Care Transitions Intervention.
Based on previous evidence outcomes in Colorado, national evidence for the proposed interventions, and DRCOG’s own root-cause analysis, there are several expectations for the outcomes of the DRRC. DRCOG is anticipating increased patient activation, reduced readmission and admission rates, and decreased Medicare costs within the community. If the program achieves a 20 percent reduction in readmissions during their first three years, they will be eligible for additional funding.
Colorado has been awarded two CCTP awards, the second to the Upper Arkansas Area Council of Governments, which will focus on the medically underserved in small communities. CIVHC will continue to track the progress of the DRCC in addition to other care transitions initiatives and interventions across the state through the multi-stakeholder Healthy Transitions Colorado umbrella campaign. Healthy Transitions Colorado will launch on July 8, 2013, and will provide a resource hub and best practice sharing platform for care transitions initiatives across the state. For more information, click here.