What is Transitional Care?

Partnership for Patients
Office Hours
Community- Based Care Transitions
Program 101
Featuring VNA Health Group representing the
Central New Jersey Care Transitions Program
Co-Hosted by NJHEN and HQSI
CCTP 101
Marie Perillo, RN, BSN, Director of Care Coordination
Kimberly Mora, RN, BSN, Care Coordination Manager
Victoria Peck, RN, MSN, Care Coordination Coach
What is Transitional Care?
The movement of a patient
from one setting of care
(hospital, sub-acute care, ambulatory care, primary &
specialty practice, long-term care, home health, etc.)
to another.
Source: Centers for Medicare and Medicaid Services, 2013.
What is Transitional Care?
• The American Geriatrics Society:
Transitional care is based on a comprehensive
plan of care and the availability of health care
practitioners who are well-trained in chronic
care and have current information about the
patient's goals, preferences, and clinical status.
Source: Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee.
Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American
Geriatrics Society. 2003;51(4):556-557.
What is Transitional Care?
What does Transitional Care mean?
Transitional Care is a
time-limited service
Transitional Care is
not case management.
Transitional Care Models
Transitional Care Models include:
Eric Coleman’s Care Transitions Model
Mary Naylor’s Transitional Care Model
The Bridge Model
Project RED
What’s different about CCTP?
The Community-Based Care Transitions Program (CCTP)
• Funded by Center for Medicare & Medicaid Innovation
• Part of Partnership for Patients national patient
safety initiative
• 3 part aim of CCTP is to:
Improve the care of
patients by reducing
Improve population
Decrease costs of
care delivery
The Central New Jersey Care Transitions Program is
the first Demonstration Project in the state of NJ
to receive funding from CMS
CNJCTP was awarded a 2-year contract that will be
extended on an annual basis for 3 additional years
based on performance.
CCTP requires participation in Learning
Collaborative Webinars and continuing training
and education of Coaches
Goals of CNJCTP
• CNJCTP will serve 4,000 patients yearly,
in 6 Partner Hospitals across the program:
CentraState Medical Center
Raritan Bay Medical Center
Robert Wood Johnson University Hospital
Robert Wood Johns University Hospital at Rahway
Saint Peter’s University Hospital
Trinitas Regional Medical Center
Our Home Care and AAA Partners
CNJCTP services are provided by
• Four Home Health Care Agencies
Community VNA
VNA Health Group
Holy Redeemer Home Care
Robert Wood Johnson (RWJ) Visiting Nurses
• Four Area Agencies on Aging
 Monmouth County Division on Aging, Disabilities and
Veterans Services
 Middlesex County Office of Aging and Disabled Services
 Union County Division on Aging
 Jewish Family Service of Central Jersey
Goals of CNJCTP
Reduce 30-day all-cause
readmission rates by 20%.
Reduce emergency room utilization for
high-risk Medicare beneficiaries.
Improve patient care,
improve population health,
and decrease costs
in the healthcare delivery system.
Goals of CNJCTP
• CNJCTP improves the quality of health care
delivery by:
• Improving communication across providers
• Coordinating care across settings
• Coaching patients in disease-specific
• Identifying socioeconomic barriers.
Eligibility Screening / Risk Assessment
Patients are eligible if:
At least 65 years old
Have Medicare Fee for Service (not managed Medicare)
Not been enrolled in the CNJCTP program in last 180 days
Are a FULL admission (no ED or OBS patients)
Not in Hospice program
Have a qualifying diagnosis
Diagnoses criteria include:
Acute Myocardial
Heart & Vascular
Heart Failure
Pulmonary Disease
Atrial Fibrillation
CNJCTP Workflow
• Coaches screen patients utilizing eligibility
criteria and risk assessment. Coaches also
receive referrals by collaborating with the
Case Management team.
• Eligible patients are approached for coaching
services by Care Coordination Coach (CCC).
• Once a patient accepts services the coach
conducts an in-hospital visit. This is required
by CMS.
CNJCTP Workflow
• Care Coordination Coach (CCC) visits patient within
24-72 hours after transition from hospital to home
or SAR/SNF. (Patients who transition to sub acute
facilities receive an additional visit in the home).
• If the patient is receiving home care services,
the CCC alerts homecare nurse that patient is
enrolled in CNJCTP.
• Once the first transition visit is made, the CCC
creates a care plan for follow up phone support.
CNJCTP Workflow
• If a need is identified, a referral for a social
work visit or an additional RN visit can be
planned at this time.
• Patients enrolled in CNJCTP are followed for a
30 day period.
• CCC may refer patient to homecare, Area
Office on Aging, or other services for
continuing care needs.
30-day episode led by a Transitions Coach
1 hospital visit
1 transitional home and/or SNF/SAR visit
Telephone monitoring weekly during episode
Note: may include additional visits, eg: social worker visit(s) or additional RN
visit, as needed
The Intervention Focus
Dr. Eric Coleman’s Four Pillars of the Care Transitions Model:
Patient Health
Source: Care Transitions Intervention®, Eric A. Coleman, MD, MPH. Retrieved from
The Good News
There is NO paperwork for Physicians
NO order necessary
FREE for Medicare FFS patients
This program does NOT replace homecare – CNJCTP
services are complimentary and supplemental to any
homecare that you may have already ordered.
• Patients do NOT have to be homebound in order to
receive CNJCTP services.
CCTP 101
Our CCTP project serves to foster self
According to Albert Bandura, selfefficacy is "the belief in one’s
capabilities to organize and execute
the courses of action required to
manage prospective situations."
Partnership for Patients Goal
By the end of 2014, preventable complications
during a transition from one care setting to
another would be decreased so that all hospital
readmissions would be reduced by 20 %
compared to 2010.
Save the Date
Transitions in Care Learning Session
May 8, 2014
NJHA Conference Center