The state colors of Pennsylvania are blue and gold but on Tuesday, May 24, silver and grey were the colors of choice. Secretary of Aging Brian Duke presented awards to Monongahela Valley Hospital (MVH) and Southwestern Pennsylvania Area Agency on Aging, Inc. (AAoA) for their work on a Care Transitions collaborative project in conjunction with Quality Insights of PA. The event was held at Riverside Place senior community center in Charleroi, operated by Southwestern Pennsylvania Human Services.
The Excellence In Action awards were created by the federal Administration on Aging, Centers for Medicare and Medicaid Services and the Department of Veteran Affairs as a means for states and local program sites to showcase some of the best practices and strongest partnerships across the aging network. A panel of federal agency representatives and past award winners reviews the nominations and recommends award recipients. The awards recognize exceptional commitment, creativity, leadership and success in achieving goals related to various award categories.
The Outstanding Partnership: Excellence In Action Award category honors AAoA and MVH for working together to promote community living by supporting individuals and families post-hospital discharge.
The project is titled Care Transitions because it strives to improve communication and patient handoff as patients change levels of care – particularly for hospital to a skilled nursing facility or hospital to home with visiting nurse services.
MVH and the Southwestern PA AAoA implemented the Care Transitions Intervention (CTI) Model to provide better management of patient transitions, improve continuity of care and increase patient control of their health care decisions. The overall goals of the program are to reduce unnecessary hospital readmissions through timely and appropriate linkages with community-based care providers, promote use of home and community-based services to enhance independence and positive health outcomes and reduce Medicare spending.
Members of this collaboration chose to focus on the reduction of 30-day readmissions in the Medicare population. This project is encompassing several different approaches to reduce 30-day readmissions as the current reasons for readmission are many and varied.
In addition to MVH, local nursing homes such as Mon Valley Care Center and area home health and visiting nurses’ associations are participating.
Of note is the relationship between the Hospital and Southwestern PA AAoA to implement health care coaching services – a coach provided by Southwestern PA AAoA will visit patients in their homes within 48 hours of discharge to evaluate patient knowledge, medication usage, and to ensure the patient has a timely follow-up appointment with the physician.
In presenting the award, Secretary of Aging Brian Duke said, “These organizations have attracted national attention and are serving a leadership role in health care. Their work is critical in helping older Pennsylvanians to better care for themselves at home so they will not have to return to a hospital.”
Donna Ramusivich, MVH senior vice president, thanked Secretary Duke and said, “We are pleased with the outcome of this initiative – MVH decreased the overall readmission rate by 2 percent from 2009 to 2010 and for the first quarter of 2011, we have decreased it by an additional 5 percent. We also are involved with two other projects that will decrease readmission rates for patients with two specific diagnoses – congestive heart failure and chronic obstructive pulmonary disease. We are anticipating that our readmission rate will continue to decline.”
Ramusivich thanked the MVH physicians and the staff members of the Utilization Review and Social Services departments and congratulated them on a job well done. “They willingly embrace any initiative that will improve the quality of life of patients in our community,” she said.