| Tony Lewis, President & CEO of Cobble Hill Health Center - discusses implementation of Center for Medicare & Medicaid's Community-based Care Transitions Program (CCTP) - its role in better coordinating transitions between hospitals and other settings, reducing hospital readmissions and lowering costs of health care delivery while improving care. CMS uses consumer satisfaction, readmissions and community-specific root cause analysis data collected by CCTPs to determine trends and facilitate CCTPs' learning collaboratives. The program has potential to save billions of Medicare dollars. Introduction & History of Cobble Hill Health Center, serving frail and physically disabled population and its emphasis on providing long term home health care. |
| CCTP-Funded Reforms to Improve Coordination and Reduce Hospital Readmissions High hospital readmission rates is the primary reason Cobble Hill Health Center chose to participate in the Community-based Care Transitions Program (CCTP), part of the Affordable Care Act. Tony Lewis discusses specific CMS-funded care transition services implemented at the health center to help reduce hospital readmissions – assigned RN coaches assist with medication reconciliation, patient education, dynamic patient-centered health information record, color coded symptom breakdown with appropriate action explanation, and follow-up contact. All aspects of the program improve coordination between hospitals and the community-based center, reducing re-hospitalizations for high-risk Medicare beneficiaries. Mr. Lewis suggests that the goal of CMS’ Partnership for Patients initiative to reduce readmissions by 20% by 2013 is achievable in context of Cobble Hill center’s work. CCTP is “really making a very big difference because … it has forced and required hospitals to work with community based organizations. We are now fully integrated with two hospitals throughout their whole admission and discharge planning process …. They are utilizing, very effectively, the resources that we bring to the table, which is good care management, good patient education and monitoring in the community. Without the CCTP, this simply wouldn’t have happened…. There is a level of cooperation and collaboration that has grown out of the CCTP I simply haven’t witnessed before.” – Tony Lewis |
| Center for Medicare and Medicaid (CMS) as Facilitator of CCTP Learning Collaboratives Cobble Hill Health center will be collecting readmissions and consumer satisfaction data, conducting community-specific root cause analysis – all information submitted to CMS that will analyze trends and patterns of behavior that isolate most effective programs. The information will be used to teach back, as part of a recently set up learning collaborative with all CCTP projects on regional and national basis and will also change how hospitals are looking at their discharge planning process – all components will ultimately prevent unnecessary readmissions for acute care. Local Quality Improvement Organization (QIO) iPro, which represents CMS in NYC area, worked closely with Cobble Hill to design the program, helps the center gather research and provides access to data nationally gathered by CMS. This generates feedback and suggests if certain specific aspects of the program must be re-evaluated. “I think what’s been interesting with the CCTP approach … one having community-based organizations lead, which says a lot, particularly coming from CMS, which is a government body and certainly top heavy in terms of structure and organization - really looking to community based organizations, going right back down to the roots of any community … because I think they’ve recognized solutions are not always those that are coming from … the government but actually grow out from the communities where they know the local conditions, the local needs, and have a better understanding of the local resources available. What’s been remarkable about this whole project, while they had certain criteria for inclusion in the project, they haven’t been proscriptive in the way you have to design this…. They really look for local organizations to work collaboratively to design their own programs…. The CMS, other officials from government see themselves as facilitators and not giving direction to this, because I think they’ve recognized its growth needs ... to come from the communities who know the best ways ultimately to care for the people living in the community…. This allowed us to design and incorporate different elements from different programs that exist out there, into one we think best meets the needs of our community.” - Tony Lewis |
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CCTP Funding to Prevent Unnecessary Acute Care Will Save Billions of Medicare Dollars
Community-Based Organizations (CBOs) will be reimbursed a pre-determined per-patient rate for the transition services – payment to keep patients out of hospital as opposed to payments solely for services received at the hospital, as it has been the case before. The payment has enabled Cobble Hill center to hire and train the staff, use tracking and monitoring programs, medication management and much more. CMS has come up with an incentive to enable organizations to be paid to keep patients out of acute care where it wasn’t absolutely necessary. Medicare currently pays $12 billion/year for preventable readmissions. Mr. Lewis suggests that CMS projections regarding reduction of costs of health care delivery from such preventable readmissions are somewhat realistic, as there will surely be savings of billions of dollars across the country from reduction in unnecessary hospital stays. ACA reduces Medicare outlays by $507 billion during the 2012-2021 period, while already saving $200 billion through 2016. Mr. Lewis suggests that if the cuts in expenditure are in fact offset by unnecessary re-hospitalizations, the patient will ultimately be better off. “This program simply could not have happened unless … the payment was there to make it happen. I think it was really a stroke of genius for the government to actually consider paying people to keep patients out of acute care when traditionally … you could only bill Medicare for the provision of medical services.” - Tony Lewis “Just in this [New York] area alone if we achieve our target, over the three year period, you’re talking of savings of millions of dollars.” - Tony Lewis “What looks like a cut actually is a far better use of government money. And those savings, I believe, are actually offset by better quality of care in the community. Keeping [patients] from unnecessary hospitalizations can be a very positive outcome for” them. - Tony Lewis |
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Additional Benefits Stemming from the ACA
Preventing duplication of unnecessary testing, movement towards bundled payments and increased focus on outcomes. |