Quality Matters
Q&A: Care Transitions in the National Spotlight

Eric ColemanEric A. Coleman, M.D., M.P.H., professor of medicine and head of the University of Colorado School of Medicine's Division of Health Care Policy and Research, has spent more than two decades working to improve care transitions for patients.  His Care Transitions Intervention has been widely used to provide patients with the tools and skills to manage their medications, recognize signs of deterioration, and communicate key information to health care providers, and has been shown to reduce readmissions and improve health outcomes. It gained further traction with the passage of the Affordable Care Act, which allocated $500 million over five years to community-based organizations that propose strategies for improving care transitions for Medicare beneficiaries; many have chosen the Care Transitions Intervention as part of their approach.

By Sarah Klein and Martha Hostetter

Quality Matters: Medicare's Community-Based Care Transitions Program brings your intervention into the national spotlight. What sort of changes do you expect to see from the program?

Coleman: The biggest changes are likely to be in the nature of relationships between hospitals and community-based organizations (CBOs), such as Area Agencies on Aging. To date, the majority of hospitals have not seen the value of collaborating with CBOs —or have not had the time—and have avoided it even though CBOs are expert in helping individuals with complex care needs return to community living. The program is structured to promote a primary role for CBOs in determining which hospitals to partner with and also in managing the finances with CMS. This creates an incentive for hospitals to tap the CBOs' expertise.

Quality Matters: What are some of the benefits of having a community-based organization handle care transitions?

Coleman: When you look at the reasons why patients are readmitted, social or economic barriers often play a central role—maybe they don't have the financial means to purchase newly prescribed medications, a way to get to their follow-up visit, or perhaps their family caregiver experiences a health problem. It's a misperception that patients are willfully noncompliant. Most hospitals don't really know what they are supposed to do with those issues or don't have the ability to provide outreach beyond a day or so after hospital discharge—that's where a social services agency comes in. These are things they know how to do: provide transportation services, connect patients to programs that promote medication safety, and ensure home safety. 

Quality Matters: This is the first time that Medicare has agreed to pay for care coordination for fee-for-service beneficiaries—what's different this time? 

Coleman: In the past, Medicare has worried about adding care coordination benefits for fear of having six different agencies billing them for the same patient—the introduction of a new billing code for care coordination might drive more utilization rather than much-needed cost containment. This program attempts to reduce such concerns by creating a single billing code, with the community-based organizations billing an all-inclusive rate for a Medicare beneficiary over a 180-day time period. 

Quality Matters: What factors are likely to determine the effectiveness of the various participants' efforts? 

Coleman: The key to improving the quality of care transitions is to reaffirm a commitment to person-centered care that remains notably absent in how we typically design and deliver health care. In our Care Transitions Intervention, we operationalize this approach by meeting patients at their level. The patient's goal drives all interactions with our Transitions Coaches, whose primary role is to facilitate skill transfer for a core set of self-care activities. In doing so, we strive to help the patient move from the back seat to the passenger's seat to the driver's seat in assuming a more assertive role in managing their condition and their transitions. We know from principles of adult learning that patients learn best from simulation or practicing these newly acquired skills and from having the opportunity to also make mistakes and learn from mistakes. Under the current delivery system, health professionals tend to do things for patients—which is analogous to giving a person a fish. To produce a more sustained benefit, we are attempting to teach patients to fish.    

Quality Matters: The initial funding for the Community-Based Care Transitions program is $500 million over five years, with some potential for a second round of funds if results appear promising. Are you worried about what happens when this money runs out? 

Coleman: The program is not our sole mechanism for improving quality and safety during care transitions. CMS has proposed language that would reimburse primary care practices for care coordination activities under a new fee-for-service benefit. Hospital Engagement Networks and Accountable Care Organizations also have financial incentives for fostering similar cross-setting collaborative relationships among hospitals, skilled nursing facilities, home care agencies, outpatient physician offices, and potentially community-based organizations.  

Quality Matters: What have been some of the biggest obstacles you've encountered in spreading the model?

Coleman: The simplicity of the Care Transitions Intervention is its greatest asset and its biggest liability. Many health professionals think they understand coaching but all too often this translates into old wine in new bottles—renaming former approaches and programs as coaching. Often these programs are missing the key elements of skill transfer and true person-centered and person-directed care, which are driven by the goals articulated by the individuals undergoing transitions. 

Quality Matters: If you could modify the Community-Based Care Transitions program in any way, what would you do? 

Coleman: Having interacted with many of the awardees, I believe these communities are poised to transform health care delivery. My concern is that each setting is charged with not only delivering their interventions, but also simultaneously collecting a significant amount of required data and measures from those Medicare beneficiaries who participate. This data collection burden comes at a potentially high price if it distracts or detracts from the essential elements of each community's interventions. Ultimately the funded sites have a very limited opportunity to interact and engage with the beneficiary and I believe that at least 90 percent of the time should be preserved for this purpose, with no more than 10 percent of time devoted to data collection. 

Quality Matters: When you think about the communities that have been or are likely to be most successful, what are their key attributes?

Coleman: The most successful communities will be those that philosophically and practically take ownership for their health and that this translates into the values that drive the local organization and delivery of health care. Just as communities value clean drinking water and highly effective educational institutions, so could they also embrace health as an essential community focus.


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