Grants target transition from hospital to home

By Bernie Monegain
04:14 PM

The Center for Technology and Aging has awarded a total of $500,000 to California, Indiana, Rhode Island, Texas and Washington to help each state evaluate the benefits of technologies, such as personal health records and EHRs, for improving patients' transitions from hospitals to their homes or other settings.

The Technologies for Improving Post-Acute Care Transitions, Tech4Impact, will be administered through each state's Aging and Disability Resource Center (ADRC).

The grants were made in collaboration with the Administration on Aging (AoA) and the Centers for Medicare & Medicaid Services (CMS) initiative that helps older Americans and persons with disabilities manage their long-term care support services.

According to Medicare data, the United States has an 18 percent rate of hospital readmissions within 30 days of discharge and as many as 76 percent of these are preventable. It is estimated that as much as $25 billion could be saved each year if these unnecessary readmissions were avoided.

[See also: CMS adds mortality, readmission data to its online hospital rating site.]

In remarks Feb. 15 in Baltimore, Md, at the 2011 AoA and CMS grantee national meeting, Kathy Greenlee, assistant secretary for aging, U.S. Department of Health and Human Services, said, "I want to thank the Center for sponsoring this innovative grant program that encourages ADRCs to expand the use of technologies that support their existing care transitions initiatives. I'm certain this public-private partnership will serve as a national model and will have a ripple effect across the nation for those seeking better transitional care solutions for their patients."

"Better management of transitional care can dramatically improve an individual's quality of life, as well as avoid billions of dollars in unnecessary healthcare expenses," said David Lindeman, executive director of the Center for Technology and Aging. "It is a privilege to be a part of a national effort that encourages broader use of exciting, but underused technologies that enable clinicians and other caregivers to keep patients from being readmitted to hospitals unnecessarily."

States will use the Tech4Impact funds to further expand technology use in ADRCs that are already implementing transitional care interventions. Two states are expanding use of technologies that enhance care transitions program evaluation and planning and three states are expanding use of technologies that better empower consumers in the care transitions process.

[See also: Remote patient monitoring improves outcomes for chronically ill, study shows.]

The projects:

  • California: This project enables patients to manage chronic conditions and locate resources via a personal health record (PHR) and Network of Care (NoC) online resources. The collaborators include: San Diego ADRC, Sharp Memorial Hospital, Trilogy Integrated Resources and the San Diego Futures Foundation.
  • Indiana: This project will enhance and help evaluate the Geriatric Resources for Assessment and Care of Elders, GRACE, model of care in order to improve the Veteran Administration's (VA) confidence in this model. The effort includes participation by the Indianapolis ADRC and VA Medical Center, the Indiana University School of Medicine, and the Indiana Family and Social Services Administration Division of Aging.
  • Rhode Island: This project seeks to reduce medication problems following a patient's hospital discharge by implementing an electronic health record (EHR) that is coupled with pharmacy services. Participants include the Rhode Island Department of Elderly Affairs and statewide ADRC, in collaboration with the University of Rhode Island College of Pharmacy, Rhodes to Independence, Quality Partners of Rhode Island and ER Card.
  • Texas: This project expands the Care Transitions Intervention (CTI) model evaluation process by modifying a single data collection and reporting system for CTI coaches in the Scott & White Healthcare system. The Texas Department of Aging & Disability Services will conduct project oversight and support activities.
  • Washington: This project expands the CTI model through the use of the web-based Shared Care Plan PHR platform used in Whatcom and Skagit Counties, and by creating a training curriculum for the Shared Care Plan. Participants include the Whatcom Health Information Network and the Northwest Regional Council.