Web Links and Articles

Web Links

• Medicare Transitional Care Management Services
  This document describes the requirements of the CPT TCM codes as modified for Medicare purpose in the CMS Final Rule (Federal Register / Vol. 77, No. 222 / Friday, November 16, 2012 / Rules and Regulations)
  
  Medicare Transitional Care Management Services (Document)
  Final Rule



• CMS: Survey & Certification Focus on Patient Safety and Quality—
  Draft Surveyor Worksheets
  The Centers for Medicare & Medicaid Services (CMS) is testing three new surveyor worksheets for assessing compliance with three hospital Conditions of Participation. Discharge Planning, Infection Control, and Quality Assessment and Performance Improvement as a means to reduce healthcare-acquired conditions and hospital readmissions. Via this memorandum, CMS is making these draft worksheets publicly available. CMS emphasizes that it expects to revise these worksheets over the course of FY 2012 and that it will not be made a formal part of the federal hospital survey process before FY 2013 (which starts October, 2012).



• Integrating Care for Populations and Communities National Coordinating Center
  • Engaging Physicians in Improving Care Transitions and Recuing Readmissions
    Physicians can be critically important allies in efforts to lead, facilitate, and participate in a range of activities and practice changes that will improve care, optimize communication during transitions of care, and reduce avoidable readmissions. This guide will provide you with insights and varied approaches to use when engaging physicians.


• National Transitions of Care Coalition (NTOCC)



• Partnership for Patients



• MedActionPlan
  Use this discharge planning tool to advance patient safety, patient education, and adherence to medication therapy.



• Sun Health Medication Management
  From free, customized medication profiles detailing your health and drug history to individual pharmacist reviews and a special pill box that monitors your usage electronically, this comprehensive program offers a suite of services to help manage the complexity associated with taking multiple medications and supplements.

Articles of Interest

The following articles provide an opportunity to gain a broader depth of knowledge of care transitions.

Sun Health Medication Management Program Featured in NYT / AZ Central Articles:
The New York Times and AZ Central recently featured the success of the Sun Health Medication Management Program in articles highlighting best practices to reduce hospital readmissions. The Program, launched one year ago, found that medication discrepancy was one of the biggest issues patients faced related to readmissions. To date, just 4.2 percent of 213 patients have been readmitted. Congratulations to Sun Health for the success of its Medication Management Program! To read more about this great Program, click on the links below.
The New York Times Article / AZ Central Article

Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents
The Centers for Medicare & Medicaid Services (CMS) recently announced seven cooperative agreement awards partnering with 145 nursing facilities to implement the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. The initiative will test models to improve the quality of care and help reduce avoidable hospitalizations among nursing facility residents by funding organizations that provide enhanced on-site services and supports to nursing facility residents. To read more and access more information, click here.

Kaiser Health News: Medicare to Penalize 2,211 Hospitals for Excess Readmissions
More than 2,000 hospitals—including some nationally recognized ones—will be penalized by the government starting in October because many of their patients are readmitted soon after discharge, new records show. Together, these hospitals will forfeit about $280 million in Medicare funds over the next year as the government begins a wide-ranging push to start paying healthcare providers based on the quality of care they provide. To read more and access more information about readmission penalties, click here.

Nursing Home Action Plan
The Nursing Home Action Plan guides The Centers for Medicare & Medicaid Services' (CMS') efforts to continue to improve nursing home safety and quality. The Plan aims to enhance consumer engagement; strengthen survey processes, standards, and enforcement; promote quality improvement, create strategic approaches through partnerships; and advance quality through innovation and demonstration. Click here to download the CMS 2012 Nursing Home Action Plan.

Improving Care Transitions—Optimizing Medication Reconciliation:
The American Pharmacists Association (APhA) and the American Society of Health-System Pharmacists (ASHP) recently released Improving Care Transitions: Optimizing Medication Reconciliation. The white paper provides a better understanding of the medication reconciliation process during transitions in care, its effect on patient care and outcomes, and how pharmacists can contribute to the improvement of this process through medication therapy management.

Integrated Care Cuts Hospital Admissions by a Fifth:
Integrated care can cut hospital admissions for elderly patients by at least one-fifth, according to a new report from RAND Europe, Ernst & Young, University of Cambridge and the Nuffield Trust.

Hospital Checklists Cut Readmissions, Medicare Costs:
In another win for in-hospital checklists, new research finds that a simple, one-page checklist can keep heart patients out of the hospital, as well as save Medicare billions of dollars, according to a presentation given at the American College of Cardiology's (ACC) annual scientific session.

Affordable Care Act Update: Implementing Medicare Cost Savings:
The Affordable Care Act reforms the Medicare program's payment and delivery systems to help drive system-wide cost savings and quality improvement. Cost-containment strategies resulting in 10-year projected savings are included in the article.

Hospital Readmission Among Participants in a Transitional Case Management Program:
The following article describes a study on the implementation of a telephonic transitional case management program (TCM) designed for patients discharged from an acute care facility. Results indicate an effective reduction in hospital readmissions.

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey:
Medicare beneficiaries rate discharge planning as the greatest dissatisfaction score. This document is the actual HCAHPS survey, which defines survey questions. Note: questions 18, 19, and 20 as they relate to care transitions.

Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions:
A review of 15 promising interventions to reduce hospital readmissions. The article includes evidence-based effectiveness and rehospitalization results, identifies issues of complexity, and illustrates cost benefits.

Hospital Readmissions Reduction Program
HealthReformGPS provides an overview and suggested items to monitor the Affordable Care Act. Categories of interest include definitions of readmissions, calculation of payment, and risk factors.

Rehospitalization Among Patients in the Medicare Fee-for-Services Program
This research methodology analyzes data from Medicare claims and patterns of rehospitalization. The authors provide a study of the relation of rehospitalization to demographic characteristics of the patients and to characteristics of the hospitals.

Preventing Hospital Readmissions: a $25 Billion Opportunity
This compact action brief by National Priorities Partnership provides a roadmap to identify opportunities to address readmissions, corresponding solutions, and drivers for change.

Health IT Tools Reduce Readmissions at Philadelphia Hospitals
This 18-month project reduced readmissions in 18 Philadelphia hospitals using electronic health records (EHRs). Results indicate a savings of $4 million for the third quarter of 2011.

Lessons from Medicare's Demonstration Projects on Disease Management, Care Coordination, and Value-Based Payment
This Congressional Budget Office article reviews outcomes of six disease management and care coordination demonstrations and four value-based purchasing demonstrations and recommendations for consideration to increase savings.

Family of Woman Who Died After a Medical Error Joins Hospital's Safety Panel
A young woman dies from a medical error at a hospital. The family joins the Advisory Council of a Chicago hospital in an effort to improve patient safety.