Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. Background on Rush University Medical Center Transitional Care Programs

10/29/2013

About Rush System for Health and Rush University Medical Center

Rush System for Health is a not-for-profit academic medical center comprising RUMC (which we also refer to as Rush in this report), Rush University, Rush Oak Park Hospital, and Rush Health. Rush encompasses a 664-bed hospital, serving adults and children, including the Johnston R. Bowman Health Center. The Bowman Center provides acute inpatient and day rehabilitation services for older adults and people with short-term and long-term disabilities,and has apartments for moderate to low-income seniors.

The mission of Rush is to provide the very best care to patients. Their education and research endeavors, community service programs and relationships with other hospitals are dedicated to enhancing excellence in patient care for the diverse communities of the Chicago area now and in the future. The vision is for Rush to be recognized as the medical center of choice in the Chicago area and among the very best in the United States. Rush was named one of the nation's top 50 hospitals in 11 out of 16 specialty areas, including geriatrics in 2012-13 U.S. News & World Report.

Department of Health and Aging and Transitional Care Programs

Rush has a Department of Health and Aging under the direction of Robyn Golden, LCSW. Robyn has an extensive background in health care including acute care, LTPAC, and HCBS. In addition to her health care background, Robyn also has an in-depth understanding of policy issues from her Fellowship on Capitol Hill working for Senator Hillary Clinton and collaborating with agencies such as the Centers for Medicare that Medicaid Services (CMS) and the Office of the Assistant Secretary for Planning and Evaluation. She and her team strive to evolve practice by creating and testing new models of care by merging practice, research, policy and education.

The mission of Rush Health and Aging (RHA) is "to promote wellness by improving access to psychosocial and medical resources for patients, those who care for them and the community." RHA conducts research, develops programs, and provides service to improve healthy aging. RHA services include:

  • Health promotion and disease prevention.

  • Social work services focusing on wellness through assessment and connections to resources.

  • Transitional care for moving from the hospital to home and coordination of services for at-risk seniors.

  • Resource centers with information on program, services and supports (Anne Byron Waud Resource Center for Health and Aging at the Johnston R. Bowman Resource Center and the Tower Resource Center at the Tower Hospital Building).

  • Rush Generations (a membership program for individuals and caregivers who are concerned about aging well that provides tools and resources on healthy aging).

  • Developing and testing new models of care and health care innovations.

Within the Department of Health and Aging is the Transitional Care Team under the management of Madeleine Rooney, MSW, LCSW. The transitions team is comprised of social workers who provide direct services to support the discharge planning process and coordinate services with community caregivers and programs.

Enhanced Discharge Planning Program

The Enhanced Discharge Planning Program (EDPP) was designed by the Rush transitional care team to aid in patients' transitions from the hospital to their home (beyond the typical hospital discharge planning process). The transition services are coordinated by social workers who provide telephone followup and short-term (30 day) care coordination for recently discharged adults. The social workers conduct a bio-psychosocial assessment that includes a review of medical records, discharge plans and participation in pre-discharge interdisciplinary rounds.

The social workers interact, typically by telephone and some e-mail, with patients and caregivers after discharge to identify gaps in care and help address identified needs. The social workers are a resource for patients and caregivers. A randomized control trial showed a decreased in hospital readmission rate at 30, 60, 90, and 120 days post-discharge. Participants were more likely to make and keep followupappointments, had a better understanding of medication management, experienced reduced caregiver burden and had lower mortality rates as a result of the EDPP interventions.

Illinois Transitional Care Consortium

Rush is a member the Illinois Transitional Care Consortium (ITCC).2 Originally convened by Rush, the Consortium was formed in 2008 to bring together leaders from area organizations who were struggling with issues related to care transitions. The stakeholders are described below and cut across the silos of health care to discuss their mutual challenges and strategies to address the problems. Some of the challenges the ITCC set out to tackle included:

  • Improved access to information to support community-based organization (CBO) programs including better longitudinal data on the patient's history, past service utilization and access to relevant medical record information (such as the name of the primary care physician, followup appointments, demographic data, diagnoses, medications, and cognitive and physical function assessments).

  • The need for improved funding models that supported transitions and coordination with community organizations.

  • The need for improved relationships and recognition by hospitals of community providers and organizations to support the transition and care coordination process.

Over time the ITCC developed, tested, and refined concepts to address their mutual challenges. One of those concepts is known as the Bridge Model and was the foundation for a CMS Community-Based Care Transitions Grant (both described below). The Bridge Model concept was inspired by the Rush EDPP and then developed by the merging of best practices identified by the ITCC members.

The ITCC includes partners from CBOs, hospitals and research, evaluation and policy groups. ITCC includes the following partners:

Community-Based Organizations

  • Aging Care Connections.3 Aging Care Connections is a private, not-for-profit organization dedicated to serving older adults and their families through community-based services that promote dignity, self-respect and independence. Aging Care Connections is the suburban Chicago Area Agency on Aging (AAA) and Aging and Disability Resource Center (ADRC) and is the central administrator for ITCC. Services provided by Aging Care Connections include: information and assistance about resources, care coordination, education and training, chore keeping, transportation, home-delivered meals, respite, support groups and more.

  • Shawnee Alliance for Seniors.4 Shawnee Alliance for Older Adults programs serve persons over the age of 60 and their caregivers. Programs provide access to services that enable older adults to maximize their independence and remain in the community, advocating for the rights of older adults and their quality of life in the community and in nursing homes, and protecting older adults from abuse, neglect, and exploitation. They have developed and administer preventive primary health and social services and also provide services such as case management and counseling.

  • Solutions for Care.5 Solutions for Care serves the adult community and the people who for care for them. They work to find the resources that preserve independence and dignity, that lead to greater self-sufficiency and a higher quality of life. They work with individuals to access the resources available to manage their care.

Research, Evaluation and Policy Groups

  • Health and Medicine Policy Research Group.6 The Health and Medicine Research Group is an independent, not-for-profit research and advocacy institute with a focus on Illinois public health and care for the poor and under-served.

  • University of Illinois at Chicago (UIC), School of Public Health.7 The UIC School of Public Health works in partnership with community and governmental organizations to improve the health of the public and provide a learning experience for students and advance innovative research.

Hospitals

  • Rush University Medical Center -- Health and Aging.8

    • RHA offers innovative programs and services designed to measurably improve health and quality of life through its program, services, and innovative research. The RHA focuses on adults and caregivers as discussed earlier in this report.
    • Other Chicago Area Hospitals include Adventist LaGrange Memorial Hospital, Memorial Hospital of Carbondale, Herrin Hospital, and MacNeal Hospital.

The Bridge Model

The ITCC developed the Bridge Model to improve care coordination. It was originally developed with a focus on older adults, but is merging as a program for adults of all agencies with chronic conditions. Inspired by the EDPP noted earlier in the report, the Bridge Model9 is a social work based approach to transitional care that builds off of the aging network, designed to help older adults with chronic conditions discharged from an inpatient hospital stay to safely transition back to the community through intensive care coordination that starts in the hospital and continues after discharge to the community. The Bridge Transitional Care Program is a hospital and community partnership. There is physical office space at Rush for the Bridge Care Coordinators (BCCs) to receive referrals and access hospital and community records. The BCCs have expertise in geriatrics, strong clinical and advocacy skills, experience working in both community and hospital settings, and knowledge of state, federal and community resources. At Rush, the BCCs are their employees, but at other area hospital sites the Aging Care Connections and Shawnee Alliance for Seniors employ the care coordinators.

The Bridge Model was built and refined based on the experiences of the Consortium members and the challenges their patients' faced at care transition when they transitioned across various health care providers, payers and service delivery models. The ultimate goal was to coordinate existing systems (Figure H-1) to better serve older adults and their caregivers.

FIGURE H-1. Bridge Program Systems Targeted for Coordination

FIGURE H-1. Bridge Program Systems Targeted for Coordination

The Bridge Model assesses transition/discharge plans and issues related to home health, medical care, medication management, self-management and psychosocial complications using a proprietary accountability and communication tool called PERFECT (see Attachment H-1) to improve transitions to home care. The PERFECT form defines the mutually agreed upon expectations for care, documents the services identified and communicates problems and resolutions. A pilot project was conducted by the ITCC and anecdotal results found that PERFECT helps to identify risk elements for readmissions.

BCCs work with the discharge planners to screen for and coordinate post-hospital medical and community services for older adult care. BCCs often work out of dedicated Aging Resource Centers (ARCs) inside hospitals. The ARCs provide a dedicated space for older adults and their caregivers to explore community resources, health information and caregiving materials, and to develop community care plans prior to discharge. The Bridge Model is comprised of three phases:

  • Pre-Discharge. BCCs within the hospital identify older adult patients who may be at risk for post-discharge complications. Referrals can originate with hospital discharge planners or be generated through an integrated risk screen in the Epic EHR. The BCCs meet with older adults and/or their caregivers in the hospital room or in the ARC to identify unmet needs and to set up services prior to discharge. BCCs may also prepare individuals for discharge by reviewing medical records or meeting with an interdisciplinary team within the hospital.

  • Post-Discharge. Often new needs are frequently identified soon after an older adult returns home. BCCs call consumers within 24-48 hours after discharge to conduct a secondary assessment and intervene on identified needs. Areas of need include understanding discharge instructions, transportation issues, physician followup, burdened caregivers, problems with home health care, difficulty obtaining and/or understanding medications and others.

  • 30-Day Followup. The BCCs followup with patients at 30 days post-discharge to track their progress and address emerging needs and to ensure that people are connected to longer-term support services.

Evidence has shown a positive impact on readmissions, physician followup, understanding of discharge plans, understanding of prescribed medications, access and timeliness of community services, and mortality. Bridge community partners reported improvements in receiving more complete information at the point of transfer and understanding patient more completely before services are started.

Rush University Medical Center Case Management

Rush has case management services lead by Sandy McFolling, Hospital System, Director of Case Management. The director also oversees the utilization review and clinical documentation improvement functions as well as social workers who work in transplant and chemotherapy. The case management strategy is to develop partnerships in the community and build collaboration with the hospital.

The focus of LTSS programs at Rush relates to improving care transitions through a patient-centered approach that engages a multidisciplinary health care team to identify and address barriers in collaboration with community providers. Their multidisciplinary team includes: nursing, physicians, nurse and social work case managers, pharmacists and Bridge social workers.

Rush has multiple departments/business units and five programs focused on improving care transitions:

  • Facility Transitions in Care (July 2008 - Current). The case management department makes a followup phone call within 24 hours to the receiving SNF to determine if pertinent information was received and correct, the patient presented as expected, and the patient/family was satisfied with the plan. The goal is to resolve issues immediately and establish a basis for collaborative problem solving and process improvement between case management, nurses, physicians and facilities. Since the program started, Rush reported readmissions to the hospital within 30 days of discharge decreased from 43.9% in 2007 to 11.9% in 2012.

  • Skilled Facility Rush Coordinated Care -- Rush Physicians and Nurse Practitioners (2012 - Current). A program at four SNFs is aimed to improve coordination of care through engagement of Rush nurse practitioners and physicians. With this program, the patient is seen by the physician or nurse practitioner post-hospital discharge at least twice in the first week and then weekly until they are stable. The nurse practitioner works closely with the nursing home staff through face-to-face discussions, bedside teaching and ongoing availability by cell phone. Quarterly meetings are held with the Rush Coordinated Care Director, each skilled facility owner/administrator, and Case Management Director. Monthly data is tracked to identify areas of success and need for improvement.

  • HHAs Care Transitions (2010 - Current). Since 20% of persons discharged from Rush are discharged to HHA services, this project was initiated to improve coordination. There are a number of initiatives that are underway with HHAs that provide services to Rush patient's to improve the coordination of care, patient quality and safety around the following common goals:

    • Increase patient satisfaction;
    • Decrease hospital readmissions;
    • Provide patient/family centered care;
    • Perform accurate and timely medication reconciliation;
    • Provide timely referrals;
    • Improve hand-offs and provision of discharge services; and
    • Decrease frequency of Bridge social work followup calls related to issues.

    The HHAs that are part of the CMS Community-Based Care Transitions Program (CCTP) also participate in a pilot project where the care team holds a weekly care conference to monitor the patient's clinical and social status to identify issues and implement timely interventions to prevent readmissions and/or address chronic problems such as poorly controlled pain. The goal is to operationalize the best practices that emerge from the CCTP grant at Rush and with community partners.

  • Inpatient Collaborative Care Model (August 2010 - Current). This pilot project developed and tested a standardized set of interdisciplinary care coordination protocols on one medical unit to promote patient satisfaction, reduce readmissions and decrease fragmented care. The program utilized concepts from the Bridge Program and Project Better Outcomes for Older Adults through Safe Transitions (BOOST).

  • Readmission Reduction Project RED Pilots (October 2012). The goal of this project was to maintain an overall readmission rate of less than 12.32% at Rush. Under this project, Rush is developing and implementing processes and maintenance metrics to achieve a reduction of 20% in the overall readmission rate. At the time of the site visit, Rush completed initial meetings, identified a bundle of 12 reinforcing interventions, and started a pilot. Next they will implement daily risk reports and use a new discharge advocate flow sheet in Epic to analyze results.

  • The Bridge Program. Described above.

The success of Rush's care transition and community engagement programs is dependent on having the right people, processes and information available. The section titled "Health Information Exchange Information Flow" will describe the information needed at key points of transition and shared care. These programs have been recognized for their innovation and success having won awards from the Case Management Society of America and URAC (an organization that promotes health care quality through accreditation, education and measurement programs).


  1. See http://www.transitionalcare.org/.

  2. See http://www.agingcareconnections.org/index.html.

  3. See http://www.shsdc.org/index.php?page=senior_services.

  4. See http://www.solutionsforcare.org/.

  5. See http://www.hmprg.org/.

  6. See http://publichealth.uic.edu/

  7. See http://www.rush.edu/rumc/page-1099611550952.html.

  8. Illinois Transition of Care Consortium, Bridge Model. http://www.transitionalcare.org/the-bridge-model.

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