A stated goal of the Affordable Care Act is to lower readmission rates among hospitals. The hope is that people with serious or chronic illnesses don’t end up revisiting the emergency department or hospital again soon after being discharged. The better option is that patients see their primary care provider regularly, and learn good habits and ways to manage their disease. When disease is well controlled, people are less likely to need emergency care.
That’s the premise behind why Prowers Medical Center chose to participate in a pilot program by the Centers for Medicare & Medicaid Services (CMS). The program, called CTRAC, maintains contact with high risk patients after discharge, helping them stay on track with care instructions and follow up visits. They are one of just a few Colorado hospitals that have chosen to participate in the volunteer program.
“We assess every patient that is discharged from the hospital, and if we believe they are high risk for being readmitted, they are put on the CTRAC program. A nurse then calls them weekly to help with follow up appointments, review medications, and answer questions,” said Stephanie Martinson, Quality Director with the hospital.
The program was started in 2016, and involves a team effort. The CTRAC team, made up of case managers, the quality manager, the CTRAC nurse, care coordinators, and the RCCO coordinator meet weekly to discuss CTRAC cases and measure progress. Besides keeping patients on track with discharge instructions and follow up visits, the CTRAC nurse also goes over red flags—signs that a patient’s health might be changing for the worse.
“For example, if you have congestive heart failure, our nurse might ask if you’ve gained five or more pounds in the last week. If so, that’s a red flag and you should call your provider. The goal is to get you into the office quickly as opposed to you getting sicker and needing emergency care,” she said.
If a patient has trouble getting a ride to an appointment, obtaining medications, or getting food, the CTRAC team helps connect them to community resources that can help. One example is referring patients to Meals on Wheels.
The CTRAC program also fits well with the recent trend in healthcare to offer “care coordination.” The hospital learned about the pilot program from their CMS Medicare QIO contact and jumped on the chance to participate. Last month, team members attended a healthcare conference in Denver to educate other hospitals on the CTRAC program.
“CMS is seeing that the program is having benefits in its pilot communities, so they’d like other rural hospitals to adopt it as well,” Martinson added.
The CTRAC team is tracking data, but they haven’t collected enough yet to see a trend at the hospital. A positive, side result of CTRAC is that now nearly every person admitted to the hospital leaves with a follow up appointment with their primary care provider. The hospital has made it a priority to set follow up appointments upon discharge, and 85% of patients go home with an appointment, today. It’s just one of the many quality efforts Prowers Medical Center has adopted to improve patient care.