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Care Transitions Program Designed by Carondelet and Pima Council on Aging a National "Best Practice" in Reducing Hospital Readmission Rates
[August 25, 2014]

Care Transitions Program Designed by Carondelet and Pima Council on Aging a National "Best Practice" in Reducing Hospital Readmission Rates

TUCSON, Ariz. --(Business Wire)--

With the overall goal of improving the quality and safety of patient care, while at the same time reducing hospital readmissions, a collaborative program between Carondelet Health Network and the Pima Council on Aging (PCOA) is receiving national praise. The Centers for Medicaid and Medicare Services (CMS) recognized the Tucson program as a Best Practice and says this community-based Care Transitions Program is a valuable model for other communities to consider.

The program focuses on Medicare patients with multiple chronic illnesses who have been discharged recently from the hospital. Carondelet nurses and PCOA care coordinators partner on making regular visits to the homes of these patients, providing much-needed medical follow-up care and a variety of other kinds of social support to help the patient manage their recuperation and maintain their health after they leave the hospital. It's clearly working. "We've seen some real success with this program. Patients are improving their health, their life status, and their well-being simply by receiving the support necessary to remain healthy and stay out of the hospital," says Donald Denmark, M.D., Carondelet Health Network's Chief Medical Officer.

The program is an outgrowth of the Affordable Care Act. The federal government reached out to healthcare providers in 2011, challenging them to design programs that provide high quality care and cut costs to the overall healthcare system. Carondelet took up the charge, and in doing so, recognized that medical care is only part of what patients need after they leave the hospital. Carondelet partnered with Pima Council on Aging, a well-respected organization providing important in-home and community-based services and social support to older adults and family caregivers. "The Care Transitions Program works because of the unique partnership of Carondelet nurses and PCOA coaches and navigators," says W. Mark Clark, president and CEO of the Pima Council on Aging. "Each of us brings our medical and social service skills to the focused care of these patients in their homes, providing medical follow-up and specific social suppots that can improve the health outcome for the patient," adds Clark.

"Between our two medical and social services organizations, we are able to provide clients the best quality of care at home once they are discharged from the hospital setting and ensure they don't need to be readmitted," says Angie Sytsma, PCOA's Director of Community Services.

Carondelet nurses and PCOA care coordinators follow the patient for up to 60 days after discharge from the hospital at no cost to the individual. These specialists initiate home visits to provide both medical and social needs and regular phone calls to check on the needs of the patient.

According to Donna Zazworsky, Carondelet's Vice President for Community Health and Continuum Services, the people who have utilized the program are grateful. She says many believe they can manage after discharge, but quickly learn it's more difficult than they thought. "Having a nurse and care coordinator come out to your home helps people learn how to better manage their chronic illness," says Zazworsky. "The nurse will actually go along with the patient on their first doctor's visit after discharge and help them to understand what is needed to maintain their health long-term."

The cost savings can be dramatic. Denmark says the cost of this program is just 5 percent of the costs of inpatient care per patient. "The hospital is an acute care setting where a person is receiving very aggressive management for their disease. This post-hospitalization person-centered care program is a model of care that, if expanded to a larger population, can truly make a difference in the long-term health and well-being of our community."

"This effort truly emulates the mission, vision and values of Carondelet," adds Zazworsky. "Caring for those who are vulnerable has long been one of our guiding principles. What's outstanding about our current initiative is the support and enthusiasm our work has received from CMS. National healthcare leaders are realizing it's the right thing to do. At Carondelet, we've always known this is the right thing to do, and now we have the infrastructure to make it happen."

Carondelet Health Network

Located in Tucson, Arizona, Carondelet Health Network is a Catholic, nonprofit healthcare system dedicated to responding to the health, education, and wellness needs of Southern Arizonans. Carondelet was founded by the Sisters of St. Joseph of Carondelet in 1880. Carondelet's facilities include St. Mary's Hospital, St. Joseph's Hospital, Carondelet Heart & Vascular Institute at St. Mary's Hospital, Carondelet Neurological Institute at St. Joseph's Hospital, and Carondelet Holy Cross Hospital in Nogales, Arizona. Carondelet's family of services also include primary and specialty care offices, an ambulatory surgery center, several imaging centers, Hospice and Palliative Care, and a variety of other outpatient services. In Fiscal Year 2014, Carondelet provided $72 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

Pima Council on Aging

PCOA is a membership-supported non-profit 501(c)(3) organization accessible to any individual or group seeking assistance or sharing our mission to promote dignity and respect for aging, and to advocate for independence in the lives of Pima County's older adults and their families now and for generations to come. Pima Council on Aging (PCOA) is the designated Area Agency on Aging serving older adults and their families living in Pima County, Arizona. PCOA advocates, plans, coordinates, develops and delivers home-and-community-based aging services for older adults and provides supportive assistance, accurate information, and local resource connections for family caregivers.

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