Held at the Malta Community Center, Malta
Present: Cindy Harrington (Shelters of Saratoga), Cindi Lisuzzo and Jennifer Baldwin (Saratoga Hospital), Sandi Cross, Mary Rickard and Ardis Armer (Saratoga County Office for the Aging), Phyllis Stoker (Care Links), Kim Swire and Briana Clear (CHOICES), Kym Hance (Home Helpers), Donna Rudzinski (Experience Works), Krissy Goodspeed (Interim), Pam Clark (Herzog Law), Maria Geizer (Home Instead Senior Care), Holly Pajak (Design in Mind), Cathy Tucker (Ameriprise Financial), JoAnn Zales (National Grid), Dawn Lincoln & Kathy Wallace (SAIL), Richard Amico (St. Edwards’s Church, Pastoral Care), Carole Kyer (DOH), Linda Little (Calvary Episcopal Church, Parish Nurse), Paul Stote (NYS Division of Vetrans Affairs), Jane Hurst (RSVP Volunteer), Ann Quinn and Karen Clark (Home Health Care Partners), Robin Peters (Eddy VNA), Rebecca Zohn (Concepts of independent Choices), Reed Lehan (Saratoga County Adult & Family Services, DSS)
Introductions
Cindy Harrington welcomed all the attendees and announced that the next meeting would be held on July 10th at the Saratoga United Methodist Church. Next week topic is Senior Independent Living Options (SILO). Speakers will be:
Edward Malone, Director Environment Modifications, Prime Care Medical Equipment
Sandra Nardoci, Senior Real Estate Specialist, Prudential Manor Homes, Realtors
Mary Musso, Licensed Senior Loan Originator, Homestead Funding Corp.
Holly Pajak, Design in Mind.
Participants introduced themselves.
Announcements
Home Instead is sponsoring a Volunteer of the Year award.
“Living the 50plus Lifestyle”, Friday, September 21st, Holiday Inn, Wolf Rd., Albany. Exhibitors and Seminars will be offer to answer questions on varies subjects regarding retirement. Telephone (917) 723-5030 or access the internet site, www.livingthe50pluslifestyle.com for additional information.
The Alzheimer’s Association is offering a five-week training series entitled “The Savvy Caregiver”. The trainings will be held at The Fortunate Cup, 120 West Avenue, Saratoga Springs, Tuesdays, June 19th, 26th and July 3rd, 10th and 17th from 10 am to 12 noon. The program is free of charge and registrations will be accepted by contacting Jamie Mitchell at (518) 867-4999 ext. 209.
Home Helpers and the Alzheimer’s Association are offering a new Caregiver Support Group beginning June 21st at 5:30 pm. Meetings will be held on the 3rd Thursday of each month at Home Helpers and Direct Line, 120 West Avenue, Suite 302, Saratoga Springs. For more information, contact Debra Obenhoff, 584-5885 or debra@homehelpersny.com.
The Alzheimer’s Association is holding a Gala fund raiser on Saturday, June 23rd at the Hilton Garden Inn, Troy from 6 – 10 pm.
Shelters of Saratoga is expanding to meet the needs of 13 adult homeless individuals. A new facility located at 20 Walworth Street, Saratoga Springs will open on Thursday, June 28th. An open house including lunch and a ribbon cutting ceremony will be held on June 28th from 11 am – 2:00 pm. If you wish to attend, reply by June 25th to 581-1097 or email to sosdevelopment@nycap.rr.com.
The Saratoga Arts Center, 320 Broadway, Saratoga Springs is offering “ A Day Out for Women Veterans” on Saturday, June 16th from 2 – 7 pm.
Today’s Topic and Presenters:
Community Care Transition Program (CCTP)
Cindi Lisuzzo, Director of Care Management , Saratoga Hospital
Sandi Cross, Director, Saratoga County Office for the Aging
The Community Care Transition is collaboration between the Saratoga County Office for the Aging and Saratoga Hospital. It is funded by CMS, Centers for Medicare and Medicaid Services, as a result of the work done by IPRO, Island Peer Review Organization of NYS. The program focuses on improving the quality of care to Medicare patients with chronic conditions. The goal is to improve quality of care by promoting seamless transitions from hospital to the home environment and to reduce readmissions. The program is scheduled to begin July 1st.
Trained coaches will assist with coordinating services for patients among medical services providers, community health support agencies and other caregiver services. The program provides a safely net and is meant to empower patients to help them navigate their own healthcare needs.
To encourage a reduction in hospital readmissions, CMS has built in a pay for performance measure.
According to the results of several patient surveys:
1. One in four patients reported experiencing medical errors.
2. One is five reported that their health care provider did not communicate well.
3. One in seven said that they did not get a follow-up appointment after they were discharged.
4. One out of five said that their transitional care was not well coordinated.
5. They were inadequately prepared for the next setting.
6. They received conflicting advice for illness management.
7. The patient was unable to reach the “right practitioner”.
8. They were unable to complete the tasks from their discharge care plan.
9. Patients were confused about their medications.
Research has shown that with a comprehensive discharge plan in place and with post discharge support, older Americans have a 25% reduction in the risk of readmission.
The CMS initiative’s goals are:
1. Reduce overall readmission rates by 2% for acute Myocardial Infarction, Heart failure and Pneumonia
2. Implementation of interventions to improve communications, transfer of information, patient/caregiver self-management and follow-up care
3. Improve patient satisfaction measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) performance for discharge and medication information
The Saratoga Hospital and Saratoga County Office for the Aging will collaborate together to promote the North Eastern Region Community Care Transition Program. They will be will be joined by 9 hospitals and 6 community based organizations (CBO’s) to form a partnership to improve quality of care for patients and to reduce readmissions. The program will target patients with 30 day readmissions and those with chronic diseases such as: CHF, AMI, COPD, Renal failure, DM and Pneumonia. Eligible patients must have original Medicare or be dual eligible for Medicare and Medicaid. The Community Care Transition Program will follow the Coleman Care Transition Intervention (CTI) Model. Trained coaches will support patients with tools and teach self-management skills. Saratoga County Office for the Aging filed a grant application and selected the CBO’s to serve in the Saratoga County community. Office for the Aging will receive funding for the program.
Prior to initiating this program, Office for the Aging conducted a Root Cause Analysis. Surveys were mailed to 10,000 persons over the age of 60. Names and addresses were provided by the tax rolls. 5,000 surveys were returned, many responders stated that they did not know how to access services and thought that Medicare was confusing. Saratoga Hospital conducted a review of readmission medical records for 617 inpatients and 50 readmission patients were interviewed. Other organizations involved with the Root Cause Analysis were SIP Physicians, SFP Wilton, Dialysis Centers, Saratoga Cardiology Associates, Skilled Nursing Facilities, Home Health Care Agencies as well as many others. The surveys identified problems that support the program.
The Coleman Care Transitions Intervention (CTI) Coach Model was developed by Dr. Eric Coleman at the University of Colorado and is based on teaching the skills, knowledge and attitudes necessary to empower and coach patient’s to manage and navigate their own care. A team of six coaches were certified on May 24th. More coaches are expected to be added in the future.
The coaches will assist patients in completing a Personal Care Record (PHR) which will record their medical history, current diagnosis, doctors, medical appointments, medications and etc. Patients will establish their own personal health goal. Participants will become knowledgeable of their medications and aware of “red flags” on a zone tool for chronic conditions chart.
Patients will be identified in the hospital and paired with a coach. The coach will make a home visit to the clients within 24 - 48 hours of their hospital discharge. The initial visit is expected to last 1 – 3 hours depending on the case. After 15 days, a phone call will be placed to the patient to check on their progress and another call 30 days after their discharge date. Coaches are expected to spend an average of 5 hours on each case.
Sandi Cross stated that a new position was created to coordinate the program and to process the necessary paperwork. This is not a referral program, as are most of Office for the Aging programs. Eligible patients, who fit the program’s criteria, will be identified by the hospital. The program will start July 1st and certain benchmarks will be met to reduce readmissions to the hospital and to provide patient satisfaction.
The next meeting will be held at the Saratoga United Methodist Church, Corner of Henning Road and Fifth Avenue, Saratoga Springs on July 10th at 2:00 pm.
Respectively Submitted,
Jane Hurst
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