Breaking Down Organizational and Community Silos is Key for Texoma Care Transition Coalition

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February 25, 2013
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March 25, 2013

Breaking Down Organizational and Community Silos is Key for Texoma Care Transition Coalition

News Release
For Immediate Release

SHERMAN, March 20, 2013 – Research into increasing hospital readmissions and conversations with community members revealed to Texoma Council of Government’s (TCOG) Area Agency on Aging (AAA) staff that a link was missing in their community’s efforts to keep patients from going back to the hospital. Health care providers and organizations were working independently, not collectively, toward a solution.

“We believe we can promote healthy living for our seniors by preventing rehospitalizations and teaching them to be active in their health goals, so we chose to focus on care transitions,” said Karen Bray, director of TCOG’s AAA.

But with a hospital readmission rate over 18 percent in Sherman and one of the highest senior populations per capita in the state, TCOG’s AAA knew the problem was too big to take on alone.

We believe we can promote healthy living for our seniors by preventing rehospitalizations and teaching them to be active in their health goals, so we chose to focus on care transitions.

Karen Bray, Aging Services Department Director

As a community-based organization, they were in an ideal position to formally organize players across the community to reduce hospital readmissions. From this effort, the Texoma Care Transition Coalition was born, and its mission defined: to eliminate unnecessary readmissions of Medicare beneficiaries in local hospitals by enabling safe and effective transitions of patients between all settings of care, and empowering patients and their families to manage their health.

“We had the organizational skills and care coordination infrastructure in place to begin, but we lacked the technical skills and terminology to understand all that’s involved in care transitions,” said Bray. “I was told at a national conference on aging that we needed a Quality Improvement Organization to get the Coalition off the ground, and there’s no way we could have done it without TMF Health Quality Institute.”

With TMF’s help, the Coalition organized a kickoff meeting and invited 300 providers, including hospitals, dialysis centers, nursing homes, pharmacies, hospice and home health agencies in Cooke, Grayson and Fannin Counties.

In addition to improving care for patients in this tri-county area, the Coalition is working to collaborate with an Area Agency on Aging in Oklahoma, with whom they share mutual clients near the state border.

“The Coalition’s purpose is to knock down barriers between provider types,” said Ina Miller, Ombudsman working with the Coalition. “For example, a nursing home may not share with another nursing home a problem it is having, so neither knows about broader problems that may exist or how other providers are handling them.”

“The complete information needed to take care of an individual patient may be lacking because of this breakdown in communication,” Miller said. “That’s what the coalition aims to resolve.”

An important part of the Coalition’s plan is to train three AAA staff members to become patient coaches in the Care Transitions Intervention (CTI) model created by Dr. Eric Coleman and the Care Transitions Program Team. CTI coaches follow patients when they are discharged home to make sure they are equipped to take care of themselves. They guide patients toward a successful recovery in areas such as understanding how to take their medicines properly or finding transportation to follow-up appointments.

More than 75 health care providers attended the first Coalition meeting, which was divided into groups based on provider type. During the meeting, the providers voiced that they preferred more collaboration and would rather meet as one large group. Going forward, the large group Coalition will meet monthly to exchange information and problem-solve across provider types. Sub-groups will focus on specific issues.

To date, 29 health care providers have officially signed the Coalition’s charter, including hospitals, skilled nursing facilities, home health agencies and other community stakeholders.

“The Coalition gives individuals an opportunity to see what’s involved in other providers’ roles and then address the gaps in information exchange between those providers—both in the community and within individual organizations—to more successfully care for patients,” said Mandy Krebs, a member of the Coalition staff.

The Texoma Care Transition Coalition’s website shares their mission, upcoming meeting dates and helpful tools to reduce readmissions. To learn more, visit, email Mandy Krebs or call 903-813-3507, Ina Miller or call 903-813-3569. Visit the Readmissions category of TMF’s Resource Center for more information about the Care Transitions Intervention and other approaches to reducing hospital readmissions.

The Texoma Council of Governments is a voluntary association of the local governments in Cooke, Fannin, and Grayson Counties. Established in 1968, the Texoma Council of Governments promotes economy and efficiency in the coordinated planning and development of the tri-county region through its community and economic development activities. Either directly, or through contractors, the Council provides housing, utility assistance, and weatherization services for low-income citizens in the region and assists the elderly through a variety of Area Agency on Aging programs. The Council also facilitates the delivery of grant funding for homeland security and criminal justice.