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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 10 |
August 2009 |
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| Educational Events |
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FREE WEBINAR:
Wed., August 12,
Noon-1:00 p.m.
"Diabetes Empowerment Education Program (DEEP) Overview"
Karina Loyo, PhD, MBA, Diabetes Program Coordinator, Austin/Travis County Health and Human Services Department
Complete descriptions and registration information for TMF events >> |
| Newly Posted |
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 Visit the"What's New" section of the Care Transitions Web site to access newly posted resources and tools. |
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Care Transitions News is brought to you by
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In the News
New Versions of the Care Transitions Reporting Tools Posted
Providers participating in the Texas Care Transitions project should begin using the newest versions of the monitoring reports. These tools are available on the Care Transitions Web site on the Provider Monthly Reporting page. |
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Transitions of Care and Rehospitalizations Focus of NPR Story
This recent National Public Radio (NPR) broadcast describing the University of Pennsylvania Health System's transitional care model illustrates how coaches can help patients stay home and cut health care costs. Sources interviewed include Dr. Steve Jencks, author of the New England Journal of Medicine article that has raised new awareness about avoidable hospitalizations of Medicare patients.
CMS Proposes Payment Rules and Changes for Multiple Settings
The Centers for Medicare & Medicaid Services (CMS) has released final payment rules and changes that will affect the following care settings (follow the links for more information):
National Transitions of Care Coalition Offers Free Newsletter
Founded in 2006, the National Transitions of Care Coalition (NTOCC) seeks to address problems associated with transitions of care by focusing on the gaps in care that affect the safety and quality of care for transitioning patients, particularly seniors. NTOCC publishes a free newsletter that details the group's efforts as well as marks trends and emerging issues in transitions of care. Sign up at the NTOCC Web site or read the Spring 2009 newsletter (2-page PDF).
Free Resources for Patients to Better Self-Manage Their CareThe National Transitions of Care Coalition (NTOCC) has created a tool for patients and their families to use in transitions of care. This free two-page PDF download covers pertinent questions during the physician appointment, and an easy-to-follow medicine list is printed on the reverse side. The Agency for Healthcare Quality and Research (AHRQ) is offering on its Web site a tool kit of information and resources for patients moving from the hospital setting to follow-up care. Home Health Interventions Associated with Lower Medicare Spending and Rehospitalizations
Medicare patients with diabetes, chronic obstructive pulmonary disease or congestive heart failure who used home health care within 3 months of discharge from a hospital cost the program $1.71 billion less and had 24,000 fewer re-hospitalizations than similar patients that used other forms of post-acute care over a two-year period. Cleveland Clinic Elevates Patient Monitoring for Chronic Conditions
Selected patients from the Cleveland Clinic are participating in an expanded home monitoring program that keeps physicians posted on patients' chronic conditions such as hypertension, diabetes and heart failure. The pilot program involves nearly 500 patients and was launched in November 2008.
CMS Responds to Journal Article on Readmissions
In a letter to the editor of the New England Journal of Medicine, Center for Medicare & Medicaid Services (CMS) officials discuss the 14-state Care Transitions program and state that CMS plans to take the program nationwide in August 2011.
AHRQ Shares End-of-Life Care Research for Helping Patients Plan Their Care A two-part report from the Agency of 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.
Texas Legislature Addresses Preventable ReadmissionsHouse Bill 1218 from the 81st Regular Session of the Texas Legislature requires the Health and Human Services Commission to establish a health information exchange pilot program to share hospitals' performance with respect to preventable readmissions. The bill takes effect September 1.
New Resource Focuses on Nursing Care and HIT
The Robert Wood Johnson Foundation has released a new publication in its "Charting Nursing's Future" series. "Addressing the Quality of Safety Gap-Part II: How Nurses Are Shaping, and Being Shaped by, Health Information Technologies" highlights promising models of nursing-related health information technologies. |
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How Nursing Can Contribute to Building Your Culture of Safety
A new publication from the Robert Wood Johnson Foundation, "Addressing the Quality and Safety Gap-Part I: Case Studies in Transforming Nursing and Building Cultures of Safety," explores the five tenets of highly reliable organizations and highlights the resources available through the Agency for Healthcare Research and Quality Innovations Exchange.
San Antonio Hospital Included in Bundled Payment Demo
Baptist Health System of San Antonio is included in the hospital-based Acute Care Episode demonstration, which will test the use of bundled payment for hospital and physician services for a select set of inpatient episodes of care. The goal is to improve the quality of care delivered through Medicare fee-for-service.
Readmissions Now Included in Hospital Compare Site
The Centers for Medicare & Medicaid Services has expanded the Hospital Compare Web site to now report how frequently patients return to a hospital after initial discharge. The data covers 30-day readmissions for heart attack, heart failure and pneumonia. |
| HOME HEALTH and HOSPICES
Telehealth Kiosks Focus on Seniors and Blood Pressure Management
Based in rural nutrition centers that provide meals for low-income seniors, a novel telehealth project is piloting in Ohio to monitor blood pressure management among older adults. Clients with hypertension will be encouraged to use the kiosks to check their blood pressure when then they visit the center to receive a meal. Collaborating with the participants' primary care physicians, researchers will track the data from a central server.
CMS Rolls Out Home Health Patient Satisfaction Surveys
The Centers for Medicare & Medicaid Services (CMS) is adding home health to the care settings included in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. Once four quarters of CAHPS data are reported, results will be made public through the CMS Web site.
OASIS 2.0 in Draft Stage
The Centers for Medicare & Medicaid Services (CMS) has asked the Office of Management and Budget for approval to modify the Outcome and Assessment Information Set (OASIS). A draft version of the data specifications along with an explanatory document is available at the CMS Web site. |
PHYSICIANS and CLINICS
New Standards Developed for Patient-Centered Medical Homes
The systemic use of patient-centered, coordinated care management processes forms the core of measures the National Committee of Quality Assurance will use to assess medical practices seeking recognition as a patient-centered medical home. | |
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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-09-69
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