Excellence in Population Health A Successful Community-Based Care Transitions Program Model
Excellence in Population Health A Successful Community-Based Care Transitions Program Model
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DOI：
10.1097/ncm.0000000000000303
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发表时间：
2019-01-01
影响因子：
1.5
通讯作者：
Bittner, Nancy Phoenix
中科院分区：
文献类型：
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作者：
Warren, Cheryl;Lemieux, Amy A.;Bittner, Nancy Phoenix
目的/目标：基于社区的护理过渡计划（CCTP）定义了一个广泛的干预措施和服务的老年患者在高风险的医院再入院。由医疗保险和医疗补助服务中心开发的CCTP的目的是改善受益人从住院医院环境到其他护理环境的过渡，提高护理质量，减少高风险受益人的再入院，并记录可衡量的节省。该CCTP计划的目标如下：与基线相比，所有合作医院的30天全因再入院率降低20%;降低所服务的高风险队列的30天全因再入院率;以及实现全面入组的目标数量。主要实践设置：该伙伴关系包括急性护理机构和社区护理组织，这些机构多年来一直参与护理过渡计划，并有着长期的合作历史，为低收入，服务不足，种族和种族多样化的目标人群提供服务。结果/结论：该计划成功地过渡到全面运作的第一年内成立。到目前为止，急性医院环境和社区组织的合作伙伴关系已经达到并提供服务，近8,000人，超过了我们的目标招生目标。到目前为止，再入院率已下降到12.5%，这是自该计划开始以来下降了11%。
Purpose/Objective: The Community-based Care Transitions Program (CCTP) defined a broad spectrum of interventions and services for elderly patients at high risk of hospital readmission. The purposes for a CCTP as developed by the Centers for Medicare & Medicaid Services are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high-risk beneficiaries, and to document measurable savings. The goals for this CCTP initiative were as follows: achievement of a 20% reduction in the 30-day all-cause readmission rate across all partner hospitals compared with baseline; reduction in the 30-day all-cause readmission rate among the high-risk cohort served; and achievement of the target volumes for full enrollment. Primary Practice Settings: The partnership included acute care institutions and community-based care organizations that have been involved with care transition programs for years and have a long history of working collaboratively to provide services to a largely low-income, underserved, and ethnically and racially diverse target population. Findings/Conclusions: The program successfully transitioned to full operation within the first year of inception. To date, the partnership of the acute hospital setting and the community-based organizations has reached and provided services to nearly 8,000 total individuals, surpassing our target enrollment goal. To date, the readmission rate has decreased to 12.5%, which is an 11% decline since inception of the program.