Hallmark Health System, in collaboration with Cambridge Health Alliance, Mystic Valley Elder Services and Somerville Cambridge Elder Services, is among the top performers in an innovative national pilot program aimed at reducing hospital readmission rates.

The four organizations, known collectively as the Mystic Valley Community-Based Organization, joined 47 other community-based organizations (CBOs) across the US in the Centers for Medicare & Medicaid Services (CMS)-commissioned Community Care Transitions Project (CCTP) in 2012. According to early findings by the CCTP, over a two-year period the Mystic Valley group reduced 30-day readmission rates in certain high-risk patient populations by 3.74 percent – the third best results in the national CCTP project. Their results were shared as a best practice at a national conference in Baltimore, MD in November 2014.

The goals of the CCTP are to improve transitions of patients from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high-risk patients and to document measurable savings to the Medicare program.
Thirty-day hospital readmission rates for certain high-risk patients have increased over recent years and CMS has initiated steep fines for hospitals whose patients return to the hospital within 30 days of discharge.

The Mystic Valley CBO has shown very promising results and was awarded an additional one-year extension based on their performance. The group has reduced 30-day readmission rates for a test group of complex medical/surgical patients over the age of 65 with a length of stay of three days or longer, and also of all heart failure patients, by 3.74%.

The CCTP incorporates a new service delivery model, using transition facilitators who meet with patients while they are still in the hospital and then meet with them again within three days of discharge. The transition facilitators’ role is similar to that of a health coach.

Additionally, hospital nurse practitioners visit with the newly-discharged patients in the home or other care settings such as a nursing home or rehabilitation facility. Nurse practitioners can write prescriptions and adjust medications and treatment plans in collaboration with the patients’ primary care providers.

“Between the transition facilitators and the nurse practitioners we are able to identify indicators that could eventually lead to a readmission and take immediate corrective action,” said Cheryl Warren, MS, RN, chief clinical integration officer at Hallmark Health. “The new teams can assess social and physical triggers and make adjustments to medications and treatments in real time in the patients’ home or care facility, keeping patients home, healthy and well cared for.”

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