Siouxland Selected to Participate in Care Transitions Program
The Centers for Medicare and Medicaid Services (CMS) recently announced Sioux City as the sole city in the state of Iowa to be a recipient of funding for a Community Care Transition Program (CCTP). The Siouxland Care Transitions Initiative was included in the fourth round of program approvals. Nationally there are 102 CCTP pilots. The intent of the pilot programs is to reduce the number of readmissions to the hospital within 30 days of discharge. The goal of this effort is to ultimately lead to reduced healthcare costs and better outcomes for patients in Siouxland.
Siouxland Aging Services, Siouxland Community Health Center, Winnebago Tribe of Nebraska, Mercy Medical Center and St. Luke’s Regional Medical Center are working in collaboration on this project to make the Siouxland Care Transitions Initiative a benefit for the whole community.
“We are excited these organizations will partner with us by working to improve collaboration among caregivers and providers.” said Marilyn Tavenner, CMS Acting Administrator. “We are increasing our efforts to reduce costly hospital readmissions that are harmful to patients. Coordinating care among multiple doctors and other providers is an important tool to prevent complications that can arise when a patient leaves a hospital.”
The program covers a 13 county area in western Iowa, eastern South Dakota and eastern Nebraska. Within that area, 8 zip codes have been targeted as High Community Need Index Communities (underserved and with high readmis¬sion rates). The people who will benefit from the Siouxland Care Transitions Initiative are defined as Medicare Fee For Service beneficiaries who are admitted to either hospital and meet one or more of the following criteria: 1) Have an admitting diagnosis of pneumonia, congestive heart failure, acute myocardial infarction, and/or chronic ob¬structive pulmonary disease; 2) Native American (any diagnosis) and 3) Live in the targeted high Community Need Index communities (any diagno¬sis). “What makes this program particularly effective is the nature in which all our healthcare providers are working together,” says Barb Morrison, Executive Director of Siouxland Aging Services. “Patients who meet the program’s criteria will be referred by St. Luke’s or Mercy to Siouxland Aging Services. We will then assign them a Transition Coach who will work closely with them for the next 30-90 days.”
Some of the care methods that will be implemented to achieve the goals of this program include: reinforcing patient education, promoting scheduled follow-up care with their physician, arranging transportation, providing meals, assisting with cares and managing medications prescribed to the patient.
The need for this program is clear. Nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors—are readmitted within 30 days, at a cost of over $26 billion every year. The Community-based Care Transitions Program (CCTP), created by Section 3026 of the Affordable Care Act, tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries.
The Siouxland Cares Transition Initiative is based on the CCTP model to help patients in our community move from one health care provider or setting to another with ease. Together, Siouxland Aging Services, Siouxland Community Health Center, Winnebago Tribe of Nebraska, Mercy Medical Center and St. Luke’s Regional Medical Center are improving care for the people of Siouxland.
About the Author
Nakia Tyler Nakia is a Web Specialist at Team Creative Fire. When she isn’t exercising her creative muscle, she spends her time fan-girling over Doctor Who, playing with her adorable niece, and channeling her inner Hello Kitty. If you see her out and about having adventures, feel free to say hi. She’ll probably be wearing pink.
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