“Our goal is to establish a credible model that could be used throughout the country,” said Bailey, who added that it is an “absolute plan” for the collaborative to continue after the funding period ends.
In Boston, clinicians at Beth Israel Deaconess Medical Center will build on the efforts of a six-month pilot project to improve patient outcomes and lower hospital readmissions.
The CMS has awarded Beth Israel Deaconess $4.9 million for the Post-Acute Care Transitions, or PACT, program, which will prospectively enroll all Medicare patients at the hospital through referrals from any one of six affiliated primary-care practices, including one community health center.
At the heart of the project is a care transition specialist who will build strong relationships with the hospital and primary-care site to provide better treatment for the patients, said Dr. Julius Yang, director of inpatient quality at Beth Israel Deaconess. Another important component is the presence of a pharmacist who will work in concert with the care transitions specialist to help patients manage their medications.
In the three-year period, the initiative is expected to affect 8,000 patient discharges, train 11 healthcare workers and yield nearly $13 million in savings.
“The landscape is changing rapidly in Massachusetts,” Yang said, adding that he doesn't know what the healthcare system will look like after the three-year funding period has ended. (See related story: "Tweaking the system") “If we can prove this improves outcomes and reduces costs, the system will find a way to pay for it,” he said, adding that two possible funding sources could be health plans or one of the five accountable care organizations in eastern Massachusetts participating in the Innovation Center's Pioneer ACO Model.
Yang said a care transition specialist is “your travel agent for discharge,” likening these specialists to travel agents 30 years ago, when these professionals were in high demand to manage trips for travelers. Today, travelers book their own trips and manage their own itineraries, making the need for travel agents unnecessary.
“If those two worlds—the outpatient practice and the hospital—become integrated enough, then eventually you don't need that,” he said, referring to the care transitions specialist. “That's another way this program phases out: You solve the problems as you go.”
HHS will announce the second and last set of innovation grants in June.