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Care Transitions is a Centers for Medicare & Medicaid Services quality improvement project for Texas' Lower Rio Grande Valley administered through TMF Health Quality Institute. It is a regional, collaborative effort to reduce avoidable hospitalizations by improving patient care transitions.

  Volume 1, Issue 6 April 2009
 
In This Issue
Unplanned Rehospitalizations Cost $17 Billion, Financial and Health Burdens of Chronic Conditions Grow, AHRQ Offers Free Webinar on Data Collection
Hospitals: Hospitals Using Health IT Provide Better Care at Lower Cost, Disproportionate Share Hospitals Eligible for Stimulus Funds, IHI Two-Day Transitions Seminar Slated for June in Orlando
Home Health: MedPAC Recommends No Payment Updates for Home Care, GAO Finds Coding Abuse in Home Health
Skilled Nursing Facilities: Nursing Home QI Group Shares Front-Line Success Stories in Podcast, Free and Updated Interact Communications Tools, The Joint Commission Announces New Leadership for LTAP
Physicians: Palliative Care for Latino Patients and Their Families, Doctor-Patient Conversations at End of Life Associated with Lower Expenses
TMF Upcoming Webinar
Register Now Reducing Heart Failure Readmissions Through Improved Care Transitions
 
Wednesday, April 22, 2009 at noon CT (FREE)
 
Learn how the basic tenets of an effective care transitions program resulted in a significant drop in heart failure readmission rates. Presented by Margie Namie, RN, BSN, MPH, CPHQ, vice president of quality, Mercy Health Partners of Cincinnati.
 
Complete descriptions and registration information for TMF events >>
Newly Posted
 Newly posted resources to Care Transitions Web site.Visit the"What's New" section of the Care Transitions Web site to access newly posted resources and tools. 
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In the News
Unplanned Rehospitalizations Cost Medicare $17 Billion in 2004
The New England Journal of Medicine found that unplanned rehospitalizations among Medicare beneficiaries are prevalent and costly. Nearly 11.8 billion, or one-fifth, of discharged patients were rehospitalized within 30 days--and half of these patients didn't see a physician after discharge.

Financial and Health Burdens of Chronic Conditions Grow
Of the 72 million working-age Americans who live with chronic conditions, three in 10 live in families having problems paying medical bills. This six-page report from the Center for Studying Health System Change reviews the results from the Community Tracking Study.

AHRQ Offers Free Webinar on Data Collection in the Health Care Setting
Learn new ways to approach health care data collection analysis during a free Webinar sponsored by the Agency for Healthcare Research and Quality (AHRQ). The 90-minute event is Wednesday, April 29, 1 to 2:30 p.m. CT.

Association Updates Guidelines on Heart Failure
Calling it a "critical performance measure for care coordination and transition," the American College of Cardiology issued updated guidelines for the diagnosis and management of heart failure in adults. The guidelines address discharge instructions as well as patient education on activity, diet, medications and follow-up appointments, and what to do if symptoms worsen.

Poor Transitions, Coordination Pose Barriers to Quality Chronic Disease Care
Quality care is impeded by poor transitions between health care facilities and lack of care coordination within the delivery system, according to "Chronic Care: A Call to Action for Health Reform," a report issued by AARP last month.
 
Health Literacy and Patient Safety Highlighted in AHRQ Podcast
The Agency for Healthcare Research and Quality (AHRQ) monthly "Perspectives on Safety" podcast recently featured Dean Schillinger, MD, director of the Center for Vulnerable Populations at the University of California, San Francisco. Topics covered included teach-back, informed consent and health literacy measurement.

Preventing Catheter-Associated Urinary Tract Infections (CME)
CMS will no longer reimburse health care institutions for care related to preventable conditions, including catheter-associated urinary tract infections, which account for about 40% of infections acquired in health care facilities. (Free Medscape registration required.)

HHS Issues Final Rules Regarding ICD-10 Code Sets and Standards for E-Transactions
The U.S. Department of Health and Human Services (HHS) released two final rules to facilitate the ongoing adoption of electronic health records, including the expanded ICD-10 code set and updated standards for electronic transactions.

New Survey Results Show Huge Burden of Diabetes
This national survey is the first in 15 years to include findings from the oral glucose tolerance test, which is more sensitive in identifying pre-diabetes and diabetes. Vulnerable groups, such as the elderly and minorities, continue to have high incidence rates.

Advance Care Planning from AHRQ
This report from the Agency for Healthcare Research and Quality (AHRQ) discusses how physicians and other health care professionals can help their patients with advance care planning and assess patient preferences for care at the end of life.

NCHS Fact Sheet Focuses on Heart Disease
This one-page fact sheet from the National Center for Health Statistics (NCHS) presents the most recent data on a variety of aspects of heart disease.

Is Care Coordination Too Expensive for Medicare?
This blog post from New York Times writer Anne Underwood discusses the costs and benefits of care coordination programs, and whether they make financial sense for Medicare to pursue.

Assessments and Best Practices in Care of Older Adults
The complexity of caring for older adults requires a solid foundation of assessment skills. This library of videos demonstrating evidence-based geriatric assessment tools to help working nurses improve their skills in providing quality care specialized to this patient group.

Obama Administration Proposes $630 Billion Reserve Fund for Health Care Reform
President Obama's administration is seeking a $630 billion reserve fund over 10 years to finance an overhaul of health care.
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HOSPITALS
Hospitals Using Health IT Provide Better Care at Lower Cost
The first study to directly measure physicians' use of health information technology in the hospital setting found that relatively modest increases in technology use produced dramatic results in care and costs.

Disproportionate Share Hospitals Eligible for Stimulus Funds
The U.S. Department of Health and Human Services announced that $268 million in stimulus funds has been designated to help pay for treatment of low-income or uninsured patients.

IHI to Host Upcoming "Hospital to Home" Seminar in Orlando
The Institute for Healthcare Improvement (IHI) will offer a transitions-themed two-day seminar in Orlando, June 15 and 16. Topics areas include enhancing communications, supporting patients and families, and improving workflow using tested strategies.

Hospitals Can Earn New Certification in Heart Failure Care
The Joint Commission, in collaboration with the American Heart Association, announced a certificate of distinction program that recognizes hospitals that make exceptional efforts to foster better quality of care for heart failure patients.
HOME HEALTH
MedPAC Recommends No Payment Updates for Home Care
The Medicare Payment Advisory Commission sent Congress its payment recommendations for fiscal year 2010. No updates were included for home health.

GAO Finds Coding Abuse in Home Health
Fraudulent "upcoding" by home health agencies was one of the major contributors to Medicare home health spending and utilization, according to a Government Accountability Office (GAO) report.
NURSING HOMES
 
Nursing Home QI Group Shares Front-Line Success Stories in Podcast

The Advancing Excellence in America's Nursing Homes project has reached out to nearly half of the U.S.'s nursing homes with a widely lauded quality improvement (QI) campaign. In this podcast, organization leadership and on-the-ground staffers share how and why this effort is making a difference.

Free and Updated Interact Communications Tools
TMF's Care Transitions project Web site has a full set of Interact tools designed specifically for the skilled nursing facility. Download them individually or in a complete set in a ZIP file.

The Joint Commission Announces New Leadership for LTAP
The Joint Commission recently tapped Gina Zimmerman, M.S., to lead its Long Term Accreditation Program (LTAP). Zimmerman is the former head of business development for the Commission, and she has announced that the standards for accreditation will continue to undergo revisions to improve access and reduce redundancies.

Nursing Home Transparency Legislation Reintroduced
Sens. Chuck Grassley (R-Iowa) and Herb Kohl (D-Wis.) have re-introduced a bill to give consumers more information about individual nursing homes and their record of care.

PHYSICIANS and CLINICS

 
Palliative Care for Latino Patients and Their Families
Concrete suggestions are offered for providing culturally sensitive care to Latino patients and their families in the end-of-life setting.

Doctor-Patient Conversations at End of Life Associated with Lower Expenses
Few physicians are eager to discuss end-of-life care with their patients. Yet such conversations may result in better quality of life for patients and could lower national health care expenditures for cancer care alone by tens of millions dollars each year.

Medicare Medical Home Demonstration Updates Available
The large number of questions regarding locations and start date of this demonstration has prompted the Centers for Medicare & Medicaid Services to provide a subscriber-only notification list.

Care Coordination Daunting for Physicians Treating Medicare Patients 
A typical primary care physician who treats elderly Medicare patients must coordinate care with 229 other physicians working in 117 different practices, according to this study by researchers at HSC, Memorial Sloan-Kettering Cancer Center and the Dana-Farber Cancer Institute.

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This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 9SOW-TX-CT-09-32