Partnership for Patients and Transitions of Care

Atlanta—The Partnership for Patients, a public–private initiative to improve hospital care and transitions of care, was launched in April 2011 by Kathleen Sebelius, secretary of the US Department of Health and Human Services, and Donald Berwick, administrator of the Centers for Medicare & Medicaid Services. The partnership is committed to reducing preventable hospital-acquired conditions by 40% compared with 2010 levels and decreasing preventable complications during transitions of care by 20% compared with 2010 levels. The initiative is expected to save 60,000 lives over the next 3 years while saving the healthcare system $35 billion, including as much as $10 billion in Medicare costs. The partnership has been endorsed by >500 hospitals as well as physician groups, consumer groups, and employers. At a Contemporary Issues session at the AMCP meeting, William Francis, MBA, RPh. director of pharmacy, University of Arizona Health Plans (UAHP), outlined plans to reduce hospital readmissions in their community, including current procedures as well as components planned for the future. Mr. Francis began with an overview of UAHP. Located in Tucson, the plan covers 137,690 lives in 8 counties in southern Arizona and Maricopa County. It provides all aspects of healthcare management for the University Family Care and the Maricopa Health Plan (Arizona Health Care Cost Containment System–managed Medicaid plans), University Care Advantage (a dual-eligible special needs plan), and the University Physicians Healthcare Group (a state-sponsored health plan for small businesses). He continued by defining transitions of care: “the movement of our members from one healthcare practitioner or setting to another as their condition and care needs change.” He noted that care transitions occur at multiple levels, including between settings (hospital to subacute facility or hospital to home) and across health states (curative care to palliative care or hospice or personal residence to an assisted living facility). Transitional care, as defined by UAHP, involves a set of actions “designed to ensure the coordination and continuity of healthcare as our members transfer between different locations or different levels of care.” The actions, based on a “comprehensive care plan and availability of well-trained practitioners that have current information about the member’s goals, preferences, and clinical status,” include logistic arrangements, keeping the patient and family informed, and coordination among the health professionals involved in the transition. Noting the inadequate transitions of care lead to medication errors, increased utilization of healthcare, inefficient or duplicative care, inadequate patient and caregiver preparation, inadequate follow-up care, and member dissatisfaction, Mr. Francis listed 7 essential intervention categories for successful care transitions: (1) medication management, (2) transition planning, (3) patient and family engagement and education, (4) information transfer, (5) follow-up care, (6) healthcare provider engagement, and (7) shared accountability across providers and organizations. The stated goal of the UAHP transitions-of-care program is to decrease hospital readmission rates; patients with acute hospitalizations are the target population, including all University Care Advantage members, hospitalized members with length of stay ≥5 days, and referrals from utilization management rounds for other reasons. The process calls for a plan representative to contact the member within 48 to 72 hours following discharge, complete a medication reconciliation, coordinate with the physician and other care providers as well as a family member to resolve any issues, and educate the member (and/or caregiver) about the prescribed medication regimen. Staffing resources include a nurse utilization manager, nurse case manager, clinical pharmacist, plan medical director, and a primary care physician. Mr. Francis outlined potential barriers to successful transitions-of-care programs, including staffing limitations, delays in data-sharing, paper-driven records systems, and multiple information systems that may not be easily combined. He suggested that health plans take steps to overcome those barriers by making a transitions-of-care program collaborative, working with hospital partners to understand the concerns and challenges regarding implementation of a transitions-of-care program. Resources National Transitions of Care Coalition (NTOCC), www.ntocc.org Transitional Care Model, www.transitionalcare.info Care Transitions Program, www.caretransitions.org