American College of Physicians: Internal Medicine — Doctors for Adults ®


Take the C-TraIn

Hospital-funded transitions-of-care program targets underserved patients

From the March ACP Hospitalist, copyright © 2012 by the American College of Physicians

By Jessica Berthold

It started with a single uninsured patient. The middle-aged man—a long-haul trucker by trade—was admitted to the hospital with pneumonia and comorbid hypothyroidism, sleep apnea and depression. Though given a list of low-cost clinics at discharge, he didn't understand the process for getting care and couldn't afford his medications.

The man developed progressive edema and fatigue, eventually losing his job (then housing) because he couldn't stay awake. He was later readmitted to the intensive care unit for severe hypercarbic respiratory failure, volume overload and hypothyroidism—and stayed for 19 days, at an unrecouped cost to the hospital of $130,000.

Key members of the Care Transitions Innovations (C...

Key members of the Care Transitions Innovations (C-TraIn) team include, from left, Devan Kansagara, MD, FACP; Stephanie Peña, RN; Jackie Sharpe, PharmD; Char Riley; Nic Granum; Honora Englander, MD, ACP Member; and Leann Michaels. Photo courtesy of Oregon Health & Science University.

The event led two internists at Oregon Health & Science University (OHSU), Honora Englander, MD, ACP Member, and Devan Kansagara, MD, FACP, to convene an academic conference on how to improve the link between inpatient and outpatient care for uninsured and underinsured patients. Two years and dozens of meetings later, the Care Transitions Innovation (C-TraIn) was born in the general medicine ward of Portland's OHSU Hospital.

Several elements set the C-TraIn initiative apart from other transition-improvement efforts. For one, OHSU directly pays three community clinics to provide outpatient care and serve as the medical homes for low-income patients discharged from the hospital. OHSU has also developed its own low-cost pharmacy formulary for low-income patients. The hospital pays for 30 days of formulary prescription medications at discharge, and medications are continued afterwards at a cost of $4 per month per patient.

“Something different about this is that it's funded by the hospital itself, not a grant. So it's an example of the hospital taking a proactive stake in improving the quality of care of patients, and paying for care upstream in an outpatient setting,” said Dr. Englander, an assistant professor of medicine in the division of hospital medicine at OHSU and an internist at Old Town Clinic, one of the three outpatient clinics in Portland to which the hospital refers C-TraIn patients.

What happens in the hospital

From the patient perspective, the C-TraIn program kicks in on admission. Since Drs. Englander and Kansagara are running a clinical trial on C-TraIn through April, the first step is for a research team to meet each publicly insured and uninsured patient and do a baseline needs assessment. (After the trial is over, this assessment will be done by a nurse).

“We ask about patients' utilization of care, about substance use, about functional status and mobility, about access and barriers to medication and care, about social support,” Dr. Englander said.

The team then talks to the program's transitional care nurse, Stephanie Peña, RN, who speaks with the patient about his or her experience with care, gathering information for a personal health record that's been adapted for the underserved population. She helps the patient develop self-management goals and serves as the main patient educator and care coordinator throughout the patient's stay, as well as for 30 days postdischarge.

The patient also receives a visit from a pharmacist, who assesses his or her understanding of medications; educates him or her about the medications; reconciles and simplifies regimens; and addresses barriers to adherence. The pharmacists involved with the program are additionally responsible for steering hospitalists and other physicians toward the medications that are available on the C-TraIn formulary.

Indeed, hospitalists work with Ms. Peña and the pharmacists on a daily basis to modify care plans to a patient's particular needs. In the end, this organized approach makes the physicians' jobs easier, Dr. Englander noted.

“I think there is a lot less scrambling for the hospitalist attending and residents, and they do less work outside their scope of practice, now that [C-TraIn] is in place,” she said. “[Hospitalists] are not on the phone making patient appointments, for example, because we have a system integrated to make that happen.”

Brianna Sustersic, MD, ACP Member, a clinical instructor at OHSU and internist at Old Town Clinic, worked with the program quite a bit during her residency, which ended in June. She currently attends at OHSU for 10% of her work time, and feels more comfortable discharging underserved patients who are part of the C-TraIn program than those who aren't, she said.

“You feel like they have a safe place to go, like they have good connections on the outside,” said Dr. Sustersic. “If you happen, on a particular day, to not be covering a ward team that has C-TraIn patients—because those patients are in the control arm of the study—it's upsetting. You think, ‘If only we had C-TraIn in place here, we could have this great discharge plan for them’.”

Rebecca Harrison, MD, section chief for the division of hospital medicine at OHSU, agreed that she and her colleagues “can breathe more easily knowing there is a plan in place” for C-TraIn patients. “It helps with morale, to know that we are a team—we can help patients medically and the help doesn't stop there,” she said.

A few residents have grumbled about the fact that C-TraIn entails getting discharge summaries done more quickly than usual, Dr. Sustersic said. “The discharge summary has to be ready early on the day of discharge, for better planning, and some find that burdensome,” she said. “But really, that's good care; that's the way it should be all the time.”

For Dr. Harrison, the only downside to the program is that it's not in place for all patients, everywhere. “Any hospital, all over the country, could benefit from having a designated individual who works on care transitions,” she said.

What happens outside the hospital

The linchpin of the program at OHSU is Ms. Peña, the transitional nurse who not only coordinates care inside the hospital, but oversees it for a time after the patient leaves.

Within 24-72 hours after discharge, Ms. Peña visits most patients at home, then follows up by phone one and two weeks later. This routine can vary based on a patient's intervention needs—some she visits at home several times, while others only receive phone calls, she said.

Challenges can arise with patients whose phones have run out of paid minutes, or who are homeless, Ms. Peña noted. Most homeless patients she meets at their primary care clinic.

“Most patients, even those who are homeless, have phones, but sometimes they aren't activated or the minutes have run out and I can't reach them. I don't know if they dropped out of the program, relapsed [or] left the state,” she said.

Ms. Peña also sets up appointments with the program's three community clinics that serve as medical homes for patients without a regular source of primary care. These clinics comprise an academic general internal medicine clinic that has access to specialty care, a federally qualified health center (FQHC) with integrated substance abuse treatment, and a FQHC that serves a more rural population. The latter two have more explicit mental health services than the first, said Dr. Kansagara, an assistant professor of medicine at OHSU in the internal medicine department.

C-TraIn's inpatient pharmacists (a subset of the overall pharmacy team at OHSU) are also involved with outpatient matters, Dr. Englander said. They try to determine barriers patients might have to medication adherence once discharged, then talk to the pharmacists in the outpatient clinics about them. In addition, if a necessary medication isn't covered by the C-TraIn formulary's $4 plan, the inpatient pharmacists help patients obtain it through state medical assistance programs.

The in- and outpatient players—nurses, pharmacists, physicians, hospital administrators and case managers—also meet once a month to share feedback, review patient cases, and work on quality improvement.

“Part of the purpose of the monthly meeting is to identify ways the program is or isn't working,” Dr. Kansagara said. “I think we have been surprised, in a good way, by how important these face-to-face cross-site meetings are. Pharmacists and case managers from inside and outside the hospital learn about things they didn't know outside their silo—basic logistical things like who to call with a question.”

Having engaged community clinic partners, each with designated champions, that participate in ongoing quality improvement “is key to bringing together siloed elements of the health system and to sustaining and improving the program,” Dr. Englander added.

Perfecting the program

Aside from securing institutional buy-in to proceed with the project (see sidebar), challenges arose in both the planning and implementation phases. Defining the scope of work for C-TraIn team members was a big one, said Dr. Kansagara.

“You can imagine, for a low-income population, finding an overwhelming number of issues to address,” Dr. Kansagara said. “One way we handled this was to identify a core of things we wanted every patient to have before they left, and emphasize it with a predischarge checklist.”

That core includes a scheduled outpatient follow-up appointment, a personal health record, and a medical home, he added. “The emphasis was on getting all of these things in the core done for 100% of the patients, rather than trying to address every single problem, and only succeeding for some patients.”

There are also checklists for the initial encounter, for subsequent hospital days, and for day of discharge, Dr. Englander added. The success of the checklists depends on having a transitional care nurse who works well within the existing health system infrastructure, as Ms. Peña does, she noted.

“The role really requires an ability to communicate and collaborate with many different types of people inside and outside the hospital,” Dr. Englander said. “He or she needs to identify gaps in a patient's care early on, so the rest of the team can act on them.”

Ms. Peña enrolls at least one new patient a day in C-TraIn; her caseload is 15 to 20 patients. Her biggest challenges, she said, are patients who aren't motivated to manage their own health, and medical needs that aren't covered by existing programs.

“Getting diabetic supplies for patients has been a grueling situation where we can't always find a cost-effective situation; the glucometers are free, but to buy the test strips is expensive and there's no program to help the general population with that,” Ms. Peña said.

Because she visits patients in their homes, Ms. Peña also encounters problems she can't readily solve through her medical expertise, and for which she needs to get outside help from home health agencies or Medicaid.

“One apartment I visited was infested with bedbugs. In another, the patient was a hoarder, with things stacked very high up the walls and presenting a fire hazard. I've seen people who had no food in their homes,” Ms. Peña said. “I've also, at times, had to refer patients for closer follow-up, because they were becoming confused and disheveled and were losing weight; they clearly couldn't live independently anymore.”

There has been some discussion of employing a social worker in the C-TraIn program to deal with some of these nonmedical issues, Ms. Peña added.

Assessing value

The C-TraIn trial is ongoing until April, with outcomes pending and numbers yet to be crunched. Still, the program made enough financial sense on paper to convince administrators of its worth, and its creators believe it is likely to continue after the trial ends.

In their initial calculations, Drs. Englander and Kansagara estimated that readmissions for uninsured patients cost the hospital about $10,000 per patient on average. C-TraIn cost estimates include $10,800 for every 100 patients who receive 30 days of free medication, and $1,620 per uninsured patient paid to outpatient clinics that serve as medical homes. Other costs include Ms. Peña's salary (i.e., one full-time-equivalent [FTE] registered nurse) and 0.4 FTE hour of an inpatient pharmacist's salary. During the study period, 0.5 FTE hour is also paid for a research assistant.

Beyond the potential savings, administrators seem convinced the program makes sense from a quality-of-care standpoint and that it can serve as an example for other parts of the hospital, Dr. Englander said.

“There are a number of projects like ours developing in the geriatric, neonatal, and cardiology departments, and because we have worked closely with the administration and developed a robust toolkit, our program is serving an institutional learning function,” Dr. Englander said. “[Clinicians] are very supportive of what we are doing in terms of patient experience, too.”

While the program was developed at an academic medical center, and began as a research project, it could be adapted to other settings, such as a community hospital, Dr. Kansagara said.

“Being at an academic facility makes it easier to study it and run a trial, but there is nothing in the program core elements that couldn't be done elsewhere,” he said. “It could absolutely be used in other kinds of facilities and environments.”

Those interested in learning more about how to develop similar programs at their hospital can contact Dr. Honora Englander by e-mail.



Securing support

A multidisciplinary, multisite project like C-TraIn can only begin in one way: Meetings. Lots and lots of meetings.

Honora Englander, MD, ACP Member, and Devan Kansagara, MD, FACP, who started the project at Oregon Health & Science University (OHSU), began by arranging an academic conference on how disconnections in their local health system contributed to poor patient outcomes and avoidable hospital costs. They invited stakeholders directly involved with the peri-discharge period, like doctors, nurses, hospital administrators, social workers, case managers and community safety-net providers. They also invited a patient who had suffered as a result of some of the systemic problems.

One hospital administrator who attended the meeting became an important ally, helping the researchers pinpoint key people at OHSU to join the effort. More meetings with administrators ensued, with Drs. Englander and Kansagara steadily building their business case and gaining leadership support. Nine months after the conference, senior leadership agreed to fund an assessment of the needs of underserved patients, as well as a program to address those needs.

Use of existing resources was important in getting the program off the ground, Dr. Englander noted. “Volunteer students helped with the needs assessment, and the hospital's business development office provided utilization data to help with the business case,” she said.

One year after the assessment, and following a four-week pilot test, the C-TraIn program officially began.


Fast facts

Where: Oregon Health & Science University (OHSU), a large, tertiary care academic medical center and medical school in Portland.

Who: Uninsured, Medicaid, dually eligible Medicaid/ Medicare, and low-income Medicare hospitalized patients admitted to the OHSU general medicine ward.

What: A transitions-of-care program involving a registered nurse for care coordination and outpatient follow-up; pharmacy support including a low-cost formulary and consultations to simplify medication regimens; hospital payments to outpatient clinics to serve as medical homes; and monthly implementation meetings.

When: June 2010 to April 2011 for the research study, though the program is likely to continue afterward.

Why: Low-income patients are often challenged by limited access to pharmacy services and primary care, by financial and transportation constraints, and by unstable housing. These factors contribute to low adherence to follow-up care, including doctors' appointments and medications. Avoidable readmissions and higher health care costs are the end result.


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