This bit of complex math celebrates the tremendous impact that three (3) Foundation grantees have had in shaping Section 3026 of the Affordable Care Act, the Community Care Transitions Program. This section, along with the incentive provisions of section 3025 (penalties and prizes for high and low rates of hospital readmission, respectively), creates the context for a national investment in new health care infrastructure. As opposed to bricks and mortar or a new "benefit" for which beneficiaries may or may not be eligible (and to which a piecework fee-for-service payment rate might be attached), this section will spend $500 Million over the next 5 years to create independent, community-based teams to facilitate safe transitions from hospitals to home for vulnerable Medicare beneficiaries.
The final program announcement is expected soon, but on December 3, 2010, Don Berwick, MD, Administrator of the Centers for Medicare and Medicaid Services, kicked off a day-long "coming out party" featuring those who have pioneered the care transitions work, called the CMS National Conference on Care Transitions. More than 300 people attended in person and many more by phone, representing parties preparing to implement one or more of the evidence-based models that can reduce the astounding 20% rate of 30-day hospital readmissions for older Americans. The three grantees are, of course, Eric Coleman of The Care Transitions Intervention, Mark Williams of BOOST (Better Outcomes for Older Adults through Safe Transitions), and Mary Naylor, long-time leader of The Transitional Care Model. Each of them presented at the meeting. Amy Berman and I were there, among hundreds of others, as appreciators-in-chief of the impact of this work. You can see a very Hartford-centric greatest hits reel on this video here as well as some related material on our YouTube Channel JHARTFOUND.
Of course, the roots of any such sudden victory are always tangled and deep, if unobserved and below the surface. For example, Eric Coleman, MD, was one of our first junior faculty trainees at the then new Center of Excellence at the University of Colorado in 1998. After the conclusion of our Geriatric Interdisciplinary Team Training initiative (which included a site at Colorado), Eric received a Geriatric Interdisciplinary Teams in Practice grant for a randomized, controlled trial of a nurse-coach intervention to reduce readmissions in 2000. Two additional grants followed to provide training and technical assistance to those adopting the model.
Mark Williams, MD, of Northwestern University in Chicago, is also a senior-member leader of the Society of Hospital Medicine (SHM). SHM was funded by the Foundation for several projects before focusing on BOOST. Dr. Williams also co-authored with Dr. Coleman and Stephen Jencks, MD, formerly of CMS, the influential 2008 NEJM paper on hospital readmission rates in fee-for-service Medicare.
Mary Naylor, PhD, RN, FAAN, is the Marian S. Ware Professor in Gerontology and
Director, NewCourtland Center for Transitions & Health at the University of Pennsylvania School of Nursing. In addition to her 25-year-long, highly successful research program on transitions in care of older adults, she has been a core faculty member of the Hartford Center of Geriatric Nursing Excellence at Penn since its inception in 2000, and led the RAND/Hartford Interdisciplinary Research Center in Aging at Penn from 2002-2005.
Only Santa delivers such big presents in just one night, or even one year. For the rest of us it takes a bit longer.
