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$500M in Readmission Prevention Funds to Bypass Hospitals

 |  By cclark@healthleadersmedia.com  
   October 13, 2011

What if readmissions could be prevented by an Agency-on-Aging type of community-based organization that hires and trains "transition coaches" to improve post-discharge care, rather than leaving the job to hospitals?

Sound crazy? Think again.

This "revolutionary" idea is embedded in just over two pages of the Affordable Care Act's Section 3026, which allocates $500 million in federal spending over five years for the Community-Based Care Transitions Program or CBCTP.

In fact, the law directs CMS to give priority to community-based organizations with programs overseen by the Administration on Aging, known at state or local levels as Area Agencies on Aging. But, of course, there's a catch to who receives this money, and hospitals aren't very happy about it.

The funds are prohibited from being paid directly to hospitals. Instead, it must all go to CBOs, which are supposed to partner with hospitals to get referrals of high-risk Medicare patients about to be discharged. 

Hospitals might get a cut for referring the patient and working with the CBO. But the CBO would get the lion's share – $300 per patient according to one prominent care transitions model – to coach and coordinate support for at least one month after their discharge.

"The CBCTP is meant to provide funding to community-based organizations to address readmissions, regardless of whether the community-based organization partners with a hospital," said Lisa Grabert, senior associate director of policy for the American Hospital Association.

"The fundamental flaw in this model is that hospitals are the only entity eligible to be penalized for readmissions, yet hospitals are not eligible to directly receive any of the technical assistance funds available," she said.

It's a sea change in thinking. The CBOs that stand to receive funding are the same CBOs that now distribute food, run transportation, housing, or eldercare programs, and which already work with old, sick people in need and already have strong links to downstream providers, such as rehab facilities and nursing homes, or even Meals-on-Wheels.  

Jane Brock, MD, Chief Medical Officer for the Colorado Foundation for Medical Care, the Medicare Quality Improvement Organization (QIO) for Colorado, has been working with care transitions project models for years and is enthused by the idea.

QIO programs that tested the concept with "transition coaches" prevented 30% to 50% of readmissions, not just those that happened in 30 days, but over longer periods as well, Brock says.

As you might imagine, the program has hospital leaders asking lots of questions. Will CBOs be bound by medical confidentiality rules? Can a CBO competently do this difficult work? Who will these CBOs select to hire and train? The CBO will also have to a perform root cause analysis when a readmission occurs, and keep track of whether its interventions actually work.

In fact, Section 3026 makes hospitals so nervous, applications to the Centers for Medicare & Medicaid Services have barely trickled in and deadlines keep slipping. What's the holdup?

Apparently, part of the problem is a cultural gap that has made hospitals and CBO partnerships tough to forge. One hospital official commented on background that they "can't find a CBO that they can work with."

I interpret that statement as an indication they "can't find a CBO they can trust."

After all, CBOs speak a different language and work with different expectations than the hospital; one works in a rigid high-acuity medical/surgical role and, the other, in a more open-ended, social support one.

But that's the whole point, says a CMS representative.

"This was based on work done by 14 QIOs (who work under Medicare contracts with hospitals) who improved care transitions and reduced readmissions by working within their communities," said CMS spokeswoman Ellen Griffith Cohen.  

"Section 3026 was based on the idea that conducting these efforts at a community level is very important because hospitals are only one piece of the equation," she says. And, CMS is looking for a true "community partnership," she says, leaning more favorably "toward applicants that include downstream providers, as well as hospitals and CBOs." The CBOs "must be broadly representative of community stakeholders, including consumers," Griffith Cohen says.

"It's coaching, following the patient, providing transportation for example, to weave that patchwork together to make sure that once they are out of the hospital they proceed on a path to get them back to where they were before they were hospitalized," she says.

Keeping hospitals out of the revenue loop was intentional. Section 3026 was specifically designed to avoid the conflict of interest that occurs when a hospital, which receives its funding by providing acute care, is asked to launch efforts to prevent the need for that care, threatening revenue.

Brock, of the Colorado QIO, has some perspective on the hospital/CBO conflict.

"This is what's revolutionary about Section 3026, and this is why some in the medical service sector are uncomfortable with it," Brock says.

"It's an acknowledgement that much of what drives people back to the hospital is not medical. It's really embedded in the social milieu that they live their lives in: Do they have transportation? Do they have someone to call when they have questions? Do they feel comfortable in their home? Are their neighbors their friends?  Or do they not trust their neighbors?"

Brock has great hopes for the success of Section 3026, but she also understands the hospitals' reticence.

When Section 3026 passed, she recalls, a lot of hospitals thought it would give them money to standardize discharge processes, get electronic information to primary care providers. "I think many were hopeful this would...restructure a bucket of money for them." Instead, they were left out of the money flow.

"I imagine that upon first consideration, some hospitals might feel, 'Oh My Gosh, we are entrusting patients to this fly-by-night little CBO,'" she said.

"It might be a hard message (for a hospital executive or discharge planning team) to hear. You're telling me, a coach, a personal trainer, is going to be involved in my hospital's discharge process? That's a radical concept. And it's further underscored by the fact that these CBOs usually have no track record, no history of providing services in direct partnership with hospitals."

CMS spokeswoman Griffith Cohen clarified the eligibility requirements: "An eligible CBO can partner with any acute care hospitals in its community and is not limited to those on the file," she wrote. But CMS will give "some preference to applications that include at least one hospital from the high readmissions" list.

"Our preference is for a model with one CBO working with multiple acute care hospitals in a community and we will only accept a partnership of two (one CBO and one acute care hospital) in a rural area where there are no other hospitals to include in the partnership," she said.

It's hard to know whether meaningful programs will get off the ground if the money doesn't flow through hospitals to do it. But this effort should definitely be given the chance. But hospitals, alone, haven't been successful in the past. The fact of the matter is, Brock is right. What drives people back to the hospital is often not medical. And these non-medical programs might have a chance to fix that.

Maybe it will, as Hillary Clinton memorably said, take a village.

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