Transforming the Care Transition Process

SCHA is Offering Sponsored Access to a Field-Leading Care Transitions Intervention Program

Over the last five years, the South Carolina Hospital Association has been working with healthcare systems and communities across the state to improve the transition from hospital to home for our patients and families. As South Carolina hospitals strive to become highly reliable, this initiative focuses on creating safe, high-quality care transitions through robust process improvement, standardizing and customizing approaches to patient care, and fostering community connectivity. 

After piloting an intensive program with several hospitals targeting specific diagnoses over the last five years, we’ve seen marked decreases in readmissions in those areas. We know targeted interventions into the process can work. So now SCHA is doubling down our efforts to get all-cause readmissions reduced statewide. To that end, we’re sponsoring up to two staff members (a $3750 per person value) from any of our member hospitals to take part in the Care Transitions Intervention® (CTI®) program training, the nation-leading, evidence-based approach that has been proven to reduce readmissions by 20-50%.

The CTI®  program is under the direction of Eric A. Coleman, MD, MPH, a care transitions researcher and advocate who has won a MacArthur Fellowship (or “genius grant”) for his efforts to manage risk and empower patients during the process of transitioning from one type of care to another. His methods are uniquely focused on activating patient and family caregivers in their own care, something which can be a transformative experience for both hospital and patients alike. Specifically co-designed with patients and families and evaluated using rigorous, randomized controlled trials, the CTI®  program is the gold standard for improving readmission numbers.

South Carolina hospitals across the state have already begun adopting the Coleman model—in one instance, a recent grant awarded by the Health Resources and Services Administration to the Upper Midlands Rural Health Network (UMRHN) provided the support for Fairfield Memorial, Chester Regional Medical Center, and Springs Memorial to implement CTI© programs.

Karen Nichols, Executive Director of UMRHN, says the program is effective primarily because it doesn’t try to replicate existing hospital services but rather adds an additional method for engaging patients. 

“It's hard to communicate what the model really is,” she says. “Hospital personnel, in particular, need to realize that it's not direct patient care, it's not going in the home and doing for the patient. It's really this coaching model that's different than what a lot of hospital personnel are used to. It's not replacing anybody's job, it's adding a new element to transitional care.”

Part of what makes CTI®  so effective is that it begins with a customized readiness evaluation that pays careful attention to the workflow process and partner engagements at each specific institution. This evaluation is a key part of identifying how your new Transitions Coach® will function within your system. 

“Going through the readiness assessment and attending the in-person training should not be taken lightly, ” says Nichols, noting that she’s seen other hospitals struggle when trying to implement a CTI® -style program on their own.

“We saw other people in different states who tried to implement the model based on what they had read about the program.  Then they attended the training and they had to unlearn it, and relearn it, and that was [very] confusing for them.” Plus, she notes, Dr. Coleman’s method is specific and copyrighted in an effort to make clear that the promised return on investment stem from utilizing his company’s guidance. 

Nichols also points to the fact that, following the day and a half in-person training, that the program supports its Coaches with a year of follow-up support through monthly calls. 

“I’ve learned just as much on those calls as I did in the training,” she says, noting that it’s helpful to get assistance on the “nitty gritty details” on a regular basis.  

Now, all South Carolinas hospitals have a chance, with the Collaboration of Care Journey’s support, to implement the CTI®  model. In addition to the support from CTI®, the Collaboration of Care Journey initiative will also be supporting continued learning through coaching calls, data benchmarking, and one-on-one coaching. 

 We encourage all hospital leaders to attend a leadership recruitment webinar on August 7, 2017 from 3:30 to 4:30 p.m. and seriously consider taking part in this system-changing training. 

CCJ is sponsored by BlueCross BlueShield of SC and SCHA.