ARC, Area Hospitals Partner to Improve Patient Outcomes, Reduce Costs

ARC Press Release

(ATLANTA – January 18, 2012)  The Atlanta Regional Commission (ARC), the Area Agency on Aging for metro Atlanta, along with federal and local partners, has been tapped to implement Medicare’s new Community-based Care Transitions Program in the Atlanta region. ARC is one of seven community-based organizations in the country to test this new way to improve care for people with Medicare.

ARC will work with six metro Atlanta hospitals, the Department of Health & Human Services, Centers for Medicare & Medicaid Services and Administration on Aging in a public-private partnership to improve care for people with Medicare, while at the same time saving the system money. The six hospitals are Emory University Hospital Midtown, Gwinnett Medical Center Lawrenceville, Piedmont Hospital, Southern Regional Medical Center and WellStar Cobb and WellStar Kennestone hospitals.

Care Transitions is an evidence-based model that was developed by Dr. Eric Coleman, a geriatrician and professor of medicine at the University of Colorado to put patients more in charge of their healthcare. Care Transitions coaching gives patients and family caregivers the tools and skills they need to be more comfortable and confident in talking with physicians and other providers about their care as they move from the hospital to home or rehab. The goal is to lower hospital readmission rates by preventing problems after patients leave the hospital. While many return trips to the hospital are unavoidable, Medicare estimates that avoidable readmissions nationally cost the system $12 billion a year.

“The program recognizes that even with good discharge planning in the hospital, things can go wrong once the patient gets home,” said Cathie Berger, director of the Area Agency on Aging at the Atlanta Regional Commission. “ARC and its partners in the Aging Network have a long history of working with older adults in their homes and communities, and are in an ideal position to provide the coaching and support seniors need to stay out of the hospital.”

The six hospitals participating in the project were selected based on readmission rates, profiles of their patient populations or existing Care Transitions initiatives. Prior to applying as a provider through Medicare’s Community-based Care Transitions Program, ARC had conducted a pilot program using Dr. Coleman’s model with Piedmont, Southern Regional and WellStar Cobb hospitals.

Medicare fee-for-service patients from the six hospitals with a diagnosis of congestive heart failure, heart attack or pneumonia will be referred to ARC, who will follow patients for 30 days after discharge from the hospital. The hospitals will identify eligible patients.

Following the referral, a Care Transitions coach from ARC will provide a bedside consultation in the hospital to summarize the program and schedule a home visit within a week of discharge. The home visit will cover medication management, the importance of follow-up visits with physicians, red flags or warnings that warrant immediate contact with the patient’s physician and how to keep a personal health record. In addition, the coach will assess the need for support services and order them where appropriate. Weekly phone calls over the following three weeks will reinforce patient self-management, the patient’s progress toward goals and any changes in health status or medications.

ARC’s agreement with Medicare will run for two years, with the option to extend. ARC expects to see approximately 4,000 patients per year. While the initial program includes only three diagnoses and six hospitals, ARC anticipates the program will add other hospitals and diagnoses as the benefits of the program are demonstrated.

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