1. Capital Care Transition Coalition
CCRC to Community Based Organization
Collaboration, Innovation, Transformation
Eileen McGivern, RN,BSN
Brewster/Topeka, Kansas

2. Brewster-CCRC in Topeka, Ks.
Our site has a continuum of care (from Independent to Skilled nursing services, including sub-acute rehab)
Additionally, we offer a off-campus , community program that serves 65 members called BrewsterConnect

3. A Few Things You Need to Know about Kansas

4. KANSAS JAYHAWK BASKETBALL!!

5. Brewster Provides support to our Elders as they transition-
Between different levels of care on the Brewster campus
(Independent living, catered living, assisted living, skilled care and sub-acute rehabilitation)
From acute-care hospital/Brewster sub-acute rehabilitation
and back to their Brewster Campus Independent Home
Also provide support to our BrewsterConnect membership
(65 members who live in the Topeka community)

6. BREWSTER
We recognize that transitions from one setting to another – Can be a source of anxiety and fear Elders may have a inability to comprehend all that has occurred due to physical and emotional exhaustion Cognitive deficits, hearing and vision impairments Lack of medical literacy

7. BREWSTER
As a CCRC, we are EXPERTS in Care Transitions! Our Goal is for Elders to be successful and prevent acute hospital readmissions or abrupt changes in their level of care.

8. BREWSTER
How do we do that? Meet the Elder “right where they are” in regard to- medical literacy Build on their strengths Provide support and resources/services for challenges Empower them to take ownership of their conditions with disease- state education

9. BREWSTER
We know what pitfalls cause them to return to the acute-care hospital or higher levels of care following a hospitalization- Medication changes Mis-information about after-visit summaries /discharge instructions

10. BREWSTER
Our Business Plan has Four Core Strategies- 1.Nurture the Community 2. Diversify Services 3. Align with Others 4. Grow our Financial Strength

11. BREWSTER
What opportunities do embracing our Four Core Strategies provide? What are we experts at? How do we diversify our services? Who do we align with ? What value can our expertise provide them? How can we change the way our community and the larger national communities view BREWSTER, CCRC’s and AGING SERVICES?

12. BREWSTER
“The times, they are a changin’ “
Bob Dylan

13. BREWSTER
Hospital Re-admission Penalties by CMS/Medicare- Patients who return to the acute care hospital and are re-admitted with-in 30 days after dismissal “One in five Medicare patients discharged from acute care hospitals (2.6 million seniors) are readmitted within 30 days at a cost of $26 billion every year.”

14. BREWSTER
The Center for Medicare and Medicaid formed the Centers for Innovation. ( Created by 302c of the Affordable Care Act) Community –Based Care Transitions Program Demonstration Project was developed. Call for applications from Community- Based Organizations to apply to become sites (Must be not-for profit, have expertise in aging services and connecting Medicare recipients to community resources) Hospitals did not qualify

15. BREWSTER
Community Based Organizations in CCTP- (CBO’s) Were typically Area Agencies on Aging in the communities they were to serve (AAA) Had access to the Older Americans Act Fund to provide start up funding THE GOAL OF THE CCTP WAS TO REDUCE HOSPITAL READMISSIONS BY 20%

16. BREWSTER
How can Brewster Core Strategies use the CCTP as a vehicle to meet our Goals?
1. We wanted to nurture our community by providing the best transition services to Elders to increase their health and empower them to higher levels of wellness.
2. Diversify our services by serving community members who live in our greater community and not just on our campus.
3. Align with the acute-care hospitals in our community, support them in their readmission prevention efforts and in doing so, change their perception of Brewster and Aging Services as a whole.

17. COLLABORATE
Process for application to CMS/ CCTP for the Center for Innovation- Volunteered to serve as Community Based Organization for the Project Formed the Capital Care Transitions Coalition (Saint Francis Hospital, Stormont-Vail Medical Center and included Washburn University School Of Nursing, VNA, Jayhawk and NE Kansas AAA, Shawnee Co. Health Dept) Performed root cause analysis of readmission data, diagnoses of the population we would serve, geography of area we would serve, model we would use to provide coaching of patients, services we would offer to patients .

18. COLLABORATE
As CBO, Brewster submitted application to CMS Included in the application- Narrative for implementation of the project Letters of support by the hospitals Governance structure of the CCTC Budget worksheet which outlined our per transition cost and what would be provided to each patient

19. INNOVATION
Because we were not the typical CBO we wanted our application to be as innovative as possible- BEClose Technology- (Medication reminders/Fall prevention, elopement safety) Provide opportunity for the Washburn University School of Nursing Students /Math Department students (care delivery is changing, community-based care is the future, acute care hospitals are less central, data collection related to healthcare informatics)

20. Innovation
Our care transition would be modeled after the Care Transition Intervention (Evidence- based Coaching model )- Non-medical coaches Meet patients in hospital Schedule home visit hours after dismissal Discuss 4 Pillars Connect to community resources/empower through coaching techniques Follow up phone calls at 7, 14, and 30 days following dismissal

21. TRANSFORMATION
WHY BREWSTER? WHY NOT?! What is best for our shared patients? (Payment models are changing but we are not quite there!)) Community-based services are the future of healthcare. (cost savings and increased patient satisfaction) Phone calls received (National Thought Leaders)

22. TRANSFORMATION CMS reported readmission rates (all cause) 17.8%
Brewster/ CCTP readmission rates – 3.8%

23. Brewster
What is the value of the transition? Cost of Care Transition to CMS (Includes meeting in hospital, home visit at hour post discharge, medication reconciliation, goal setting, disease and symptom exacerbation education, development of action plan and role play, resources, transportation to doctor’s appointment if needed, follow up phone calls at 7, 14 and 30 days.) Cost of readmission to CMS- 15, 000 or more? ER visit, lab, x rays, physician’s bill, medications, possible admission.

24. Collaboration, Innovation, Transformation
Ask Yourselves- What are our goals? (for our community or nationally) What are we excellent at? Who do we need to collaborate or partner with to show our expertise? How do we share our success and new identity? What do we need to do to continue to grow and change to serve?

25. Thank you!
Questions?