MARIN -- A partnership between Marin County public health and two of the county's hospitals is among 30 similar programs nationwide -- and the first in all of California -- that will be recognized as a "Community-based Care Transitions Program," an initiative stemming from health care reform that aims to curb costly hospital readmission among Medicare patients.
Advanced Care Transitions, or ACT, is a new partnership between Marin County's Division on Aging and Adult Services and Marin General and Novato Community hospitals. It will provide "transitional" care services to "significantly reduce hospital readmissions among Medicare beneficiaries," according to a description provided by the Centers for Medicare and Medicaid Services, which is overseeing the new program. It will target "at-risk" populations up and down the Highway 101 corridor as well as rural West Marin.
"We're the first and only site in California selected for this program," said Nick Trunzo, director of Aging and Adult Services for the county. He added that his department is a natural fit to provide coordination that leads to both better outcomes and savings in the health care system. "We have a very solid history of working with the hospitals and helping older adults, so this new program really helps us enhance what we're doing," he said.
Approximately 5,000 Medicare admissions occur annually between Marin General and Novato Community hospitals, representing some 4,100 patients. The ACT program initially hopes to target about 700 patients, based on those who are most likely to benefit, according to Mr. Trunzo.
Specifics on how much the county might save in Medicare costs were not immediately available, but Mr. Trunzo estimated it to be in the "hundreds of thousands of dollars in Marin."
The five-year program overseen by CMS was launched in 2011, with seven initial participants. Another 23, including ACT, were named last week by CMS. The program now includes more than 126 hospitals nationwide and an estimated 223,172 Medicare beneficiaries across 19 states.
"I've seen the very real difference that support from organizations like our partners in the Community-based Care Transition Program can make to people's post-hospital care and their health," said CMS Acting Administrator Marilyn Tavenner, in announcing the new participants.
Participating organizations initially sign a two-year contract with CMS, with the option to renew each year for the remainder of the program. The organizations will be paid a flat fee for helping coordinate patient care after a hospital stay for each Medicare beneficiary who is deemed "high risk" for readmission. As part of the Affordable Care Act, the federal program is budgeted for $500 million over five years. With the latest round of agreements, about half of that money has been allocated, according to CMS.
Advanced Care Transitions and the other programs will coordinate with CMS to provide support for patients as they move from hospitals to new settings, including skilled nursing facilities and their homes, with the hopes of preventing another hospital visit within 30 days, according to CMS.
The transition programs will help those patients maintain contact with their primary care physician, make sure medications are being taken and that medications are understood, Mr. Trunzo said.
The ACT program will utilize county nurses, nursing students and others in carrying out the coordination, Mr. Trunzo said. Each hospital will have a "Hospital Transition Team" that includes nurse case managers, discharge planners, a pharmacy technician and an ACT community coach or nurse, all of whom will work to screen, educate and orient patients. When the patient is back within their community, the ACT coach or nurse will lead a "community transition team" that includes student nurses, pharmacy techs and volunteers that will all assist the patient.
Mr. Trunzo said there are no startup costs associated with the program, since it is similar to services it already provides.
High risk patients include those with diabetes, heart failure, pneumonia and other chronic illnesses. Marin County was able to meet criteria set forth by CMS to qualify, including medically undeserved areas in small and rural communities, as well as coordination with multiple hospitals or medical practitioners. Preference is given to organizations that specifically target older adults with coordinated care.
The Community-based Care Transitions Program is part of Partnerships for Patients, a public-private effort overseen by CMS that aims to cut preventable hospital errors by 40 percent and reduce preventable hospital readmission by 20 percent over three years. CMS says achieving these goals has the potential to save up to 60,000 lives, while preventing millions of injuries and saving up to $50 billion from Medicare over 10 years.
Hospitalizations account for 33 percent of all Medicare spending, according to CMS, which estimates that about $15 billion in billing is due to readmission, of which roughly $12 billion worth is considered preventable.
"Although there is a clear benefit for the nation, for the taxpayer, our clear goal is to support the individual," Mr. Trunzo said. "That's our work. Our focus is is really helping people when they're vulnerable and under stress. An outcome of that is reduced readmission."