WNY rural care transitions consortium

WNY Rural Care Transitions Consortium Selected for the CMS Community-based Care Transitions Program

A consortium of 10 hospitals and eight community-based organizations led by the P2 Collaborative of Western New York has been selected among the first 30 organizations around the nation to participate in the Community-based Care Transitions Program (CCTP). The announcement was made by the Centers for Medicare and Medicaid Services (CMS) on March 14, 2012.

Through the CCTP, community-based organizations will form partnerships with hospitals to help patients transition to home and reduce hospital readmissions.

The CCTP is an initiative of the Partnership for Patients, a nationwide public-private partnership launched in April 2011 that aims to cut preventable errors in hospitals by 40 percent and reduce preventable hospital readmissions by 20 percent over a three-year period. CCTP’s goals are to reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measureable savings to the Medicare program.

“We are very pleased that our WNY consortium was selected to take part in this groundbreaking initiative,” said Shelley Hirshberg, executive director of the P2 Collaborative of Western New York. “The P2 Collaborative is thrilled to have this opportunity to work with its rural partners in seven of the eight counties of Western New York to improve quality of care for patients making the transition from hospital to home.”

The WNY Rural Care Transitions Consortium will build upon an existing regional effort around Care Transitions Intervention, the evidence-based model developed by Dr. Eric Coleman, professor of medicine at the University of Colorado. The Consortium will serve more than 2,600 Medicare patients per year.

The 10 participating hospitals include:

• Brooks Memorial Hospital, Dunkirk, NY
• Jones Memorial Hospital, Wellsville NY
• Niagara Falls Memorial Medical Center, Niagara Falls, NY
• Olean General Hospital, Olean, NY
• Orleans Community Health, (Medina Memorial Hospital), Medina, NY
• TLC Health Network Lake Shore Health Care Center, Irving, NY
• United Memorial Medical Center, Batavia, NY
• Westfield Memorial Hospital, Westfield, NY
• WCA Hospital, Jamestown, NY
• Wyoming Community Hospital, Warsaw, NY

The community-based organizations that will coordinate this effort include:

• Allegany County Office for Aging, Belmont, NY
• Cattaraugus County Department of the Aging, Olean, NY
• Chautauqua County Office for the Aging, located in Mayville, Dunkirk and Jamestown, NY
• Community Concern of WNY, Inc., Derby, NY
• The Dale Association, Lockport, NY
• Genesee County Office for the Aging, Batavia, NY
• Orleans County Office for the Aging, Albion, NY
• Wyoming County Office for the Aging, Warsaw, NY

The consortium identified eligible patients for this program after conducting a thorough root cause analysis that included review of hospital readmissions data, chart reviews and patient and partner interviews. All counties will provide care transitions services for Medicare Fee-For-Service patients who are readmitted to the hospital within 30 days of a previous hospitalization.

In addition, nine of the ten participating hospitals will flag specific high readmission conditions like Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Pneumonia and Diabetes.

Assisting the P2 Collaborative and its partners in securing funding from Section 3026 of the Affordable Care Act for care transition services to effectively manage Medicare patients' transitions and improve their quality of care, the Community Health Foundation of Western and Central New York supported the development of the application to CMS through grant funding and expertise provided by its advisors.

The Foundation has worked for more than six years to support organizations in their mission to improve care transitions for elders, focusing on building more effective partnerships between health care providers and caregivers to improve continuity, reduce errors and delays and increase the amount of control patients and their caregivers have over health decisions.

For more information on the WNY Rural Care Transitions Consortium, contact the P2
Collaborative of Western New York at (716) 580-3680.