Carondelet Health Network is participating in an evidence-based model to improve transitional care for patients after they leave the hospital. The “Transitional Care Navigation Program” will be piloted by Carondelet Health Network in partnership with The Pima Council on Aging (PCOA). This effort works to ensure discharged Medicare and Dual Eligible patients who are diagnosed with heart failure, acute heart attack or pneumonia will have the guidance and support they need to cope with any medical and social needs they might have post-hospitalization. The University of Arizona Center on Aging will provide care transitions training for the partner hospital and community-based transition teams. Carondelet and PCOA have been selected among the first 30 organizations around the nation to participate in the Community-based Care Transitions Program (CCTP). The Centers for Medicare and Medicaid Services (CMS) announced the second group of CCTP partner organizations March 14, 2012.

Through the CCTP, community-based organizations will form partnerships with hospitals to help patients transition to home and reduce hospital readmissions. The CCTP is an initiative of the Partnership for Patients, a nationwide public-private partnership launched in April 2011 that aims to cut preventable errors in hospitals by 40 percent and reduce preventable hospital readmissions by 20 percent over a three-year period. CCTP’s goals are to reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measureable savings to the Medicare program.

“The ultimate goal is to keep patients from having to be re-admitted to a hospital,” said Donna Zazworsky, RN, MS, CCM, FAAN, Carondelet’s Vice President of Community Health and Continuum Care. “Healthcare is changing dramatically and so are our responsibilities as healthcare providers and caregivers. We now focus not just on the health and well-being of a patient while they are in our hospital, but also on what our role should be in helping them manage their health and chronic care needs after they leave the hospital.”

The Transitional Care Navigation Program will utilize a special transition team of expert nurses, social workers and community health outreach workers called navigators who will monitor and support patients with heart failure, acute heart attack or pneumonia and chronic care needs for weeks after they leave the hospital. The team will visit patients in their homes and attend their doctor appointments with them to ensure program participants can properly take prescribed medication, provide self management education, manage their special dietary needs and coordinate their aftercare.

The three Tucson-based organizations who are partnering in this effort each contribute uniquely to the project. Carondelet Health Network (CHN), this area’s largest, faith-based, integrated health care delivery network, will lead the effort by identifying patients for the program as they are discharged and supplying the expert nurses to provide self management education, medication reconciliation and care coordination with the patient’s medical team. PCOA will provide social services and navigator support for program participants during the post-hospitalization transition period. The University of Arizona Center on Aging will provide educational training for Carondelet’s and PCOA’s transitional team.

“This is a wonderful opportunity to show how community partners can work together to help our seniors and their families navigate the healthcare system in their most vulnerable time of need,” added Zazworsky. She says the goals outlined in CCTP are an integral part of national healthcare reform. The program allows hospitals and community organizations to work together and support vulnerable populations.

Jim Murphy, PCOA’s Chief Executive Officer, said his organization is excited about the partnership. “While one of PCOA’s core services is to assist Medicare recipients in understanding the many complexities of the myriad of Medicare insurance offerings, CCTP gives PCOA the opportunity to bring our social service and community knowledge to work with physicians, nurses and other hospital-based personnel in ensuring that patients who are discharged do not have a readmission within thirty days due to a lack of coordination and availability of in-home and community services,” said Murphy. “This outcome will enhance the patient’s well-being and save taxpayer dollars.”

Carondelet & PCOA Transitional Care Navigation Program’s 2-year agreement with CMS may be extended on an annual basis for the remaining three years based on performance. “Carondelet’s purpose is to provide access to excellent care for the people in our community,” said Zazworsky. “And, this effort fits perfectly into that purpose. We have always sought to provide healthcare that works, healthcare that is safe, and healthcare that leaves no one behind.” Zazworsky says the new initiative will launch within the next few months.

About Carondelet Health Network Located in Tucson, Arizona, Carondelet Health Network is a Catholic, not- for-profit healthcare system dedicated to responding to the health, prevention, education, and wellness needs of Southern Arizonans. Carondelet was founded by the Sisters of St. Joseph of Carondelet 131 years ago. Carondelet’s Tucson facilities include St. Mary's Hospital, St. Joseph's Hospital, Carondelet Heart & Vascular Institute and Carondelet Neurological Institute at St. Joseph’s Hospital and in Nogales, Arizona, Carondelet Holy Cross Hospital. Carondelet’s family of services also include nearly 20 primary and specialty care offices, an ambulatory surgery center, several imaging centers, Hospice and Palliative Care, and a variety of other outpatient services. Carondelet Health Network is a ministry of Ascension Health, the nation's largest Catholic, non-profit healthcare system. In Fiscal Year 2011, Carondelet provided nearly $52 million in Community Benefit to improve the health of our community and increase access to healthcare. More information about Carondelet Health Network is available at www.carondelet.org.