Grants Aid MetroWest Hospitals With Patient Transitions
Two MetroWest hospital collaboratives have been chosen to participate in a federal program that's part of the 2010 national health care reform law.
According to a statement by the Centers for Medicare & Medicaid Services (CMS), each organization will get a flat fee for patient care coordination efforts for each Medicare beneficiary deemed to be at a "high risk" for readmission.
This is the second round of funding from the Community-Based Care Transitions Program, with 30 medical organizations in the United States now receiving the grants, the CMS said in a statement. Up to $500 million may be spent on the program over five years, the agency said. The program aims to help hospitals ease transitions of patients that may be at high risk for readmission - such as elderly patients going from hospitals back home, or from a hospital to a rehabilitation facility - Massachusetts Hospital Association (MHA) officials said.
The hospitals that were announced during the latest round are MetroWest Medical Center in Framingham and Natick as well as Marlborough Hospital. Other hospital collaboratives taking part include Clinton Hospital, HealthAlliance Hospital of Fitchburg and Leominster, Saint Vincent Hospital and UMass Memorial Medical Center, both in Worcester. Partnering with the hospitals are Elder Services of Worcester and Bay Path Elder Services.
The Power Of Collaboration
As area hospitals prepared to apply to try out models to improve these health-care transitions, they got help from the MHA, which contributes education, outreach and technical assistance to member facilities.
Pat Noga, MHA's vice president of clinical affairs, said the reasons a patient's care transition might not be successful tend to run the gamut."Maybe they're not taking their meds or they don't have supports at home. There could be physical (logistics) in the home, their diet is really different or they don't understand what they're supposed to do," said Noga. "This requires community intervention and support."
In 2009, Noga said, an initiative called STAAR - State Action on Avoidable Rehospitalizations - was launched by the Cambridge-based Institute for Healthcare Improvement. The program sought to reduce rehospitalizations by "engaging payers, stakeholders at the state, regional and national level(s), patients and families, and caregivers at multiple care sites and clinical interfaces," its website states. The STAAR initiative is up and running in Massachusetts, Michigan, Ohio, and Washington so far, according to its website.
STAAR was more focused on people in hospitals, said Noga, and the new transitions program expands the concept. "We're forming a cross-continuum community team," said Noga, referring to the range of services available within or outside the health care sector. "It's how it has to work," she said, for anyone moving from one care setting to another.
Reducing hospital readmissions not only reduces health-care costs but also patient stress, said Noga. "Things aren't missing from care setting to care setting." Noga said people and agencies tend to function in silos and the Community-Based Care Transitions Program will help break down those walls with cross-continuum teams of 6 to 20 people - elder-care agencies, skilled nursing facilities, etc. - all working together.
As part of the application process, agencies addressed potential cost savings, which Noga said would benefit not just that facility but the state health-care system in general.
"I do think honestly the reason we have so many awards is we have those STAAR relationships, which really is where it's got to go," said Noga. "People are at the table that haven't necessarily been at the table all at the same time - these collaborations haven't been so coordinated in the past."
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