A pilot health care project has helped six Critical Access Hospitals (CAHs) in rural Colorado reduce avoidable readmissions like their big-city hospital cousins – without big-city resources. The results of the two-year project, which concluded on September 18, 2017, may have a national impact, as the Centers for Medicare & Medicaid Services (CMS) rolls out innovations to health care providers who serve the nation's most vulnerable patients. 

The program, called Coordinated-Transitional Care (C-TraC), was funded by CMS through the Telligen Quality Improvement Organization (QIO), the Colorado Rural Health Center and C-TraC developer Amy Kind, MD, PhD, associate professor, Geriatrics and Gerontology. 

The nurse-led program uses follow-up phone calls after hospital discharge to help patients understand their care and avoid being readmitted when possible, which differs from traditional transitional care programs that include home visits. 

C-TraC was initially implemented in 2010 at the William S. Middleton Memorial Veterans Hospital, followed by expansion to University Hospital in 2013.

Tailoring the program to rural hospitals in Colorado required careful planning. "We had to be very mindful of the unique challenges posed by the extreme low resource availability in most of these areas," said Dr. Kind. 

"For example, some of these hospitals relied primarily on locum tenens physicians or were challenged by severe nursing shortages. Others had no available pharmacy services in the region on certain days of the week. Ultimately, we used implementation science techniques to engage stakeholders at each site and to adapt C-TraC work flows to each context."

Participating Colorado hospitals included Melissa Memorial Hospital in Holyoke; Prowers Medical Center in Lamar; Southeast Colorado Hospital District in Springfield; Rio Grande Hospital in Del Norte; Spanish Peaks Regional Health Center in Walsenburg; and Wray Hospital in Wray.

Transitional Care Program for Rural Colorado Hospitals Helped Reduce Readmissions 

Because C-TraC is telephone-based, fewer staff resources are needed to run the program. The Critical Access Hospitals included in the C-TraC pilot only house up to 25 inpatient beds. C-TraC is an evidence-based program designed to reduce avoidable readmissions by encouraging patients to keep their medical appointments after discharge, monitoring for "red flag" symptoms that signal patient decline and catching medication errors before they happen.

Dr. Kind's research shows that C-TraC patients in other states had one-third fewer readmissions to the hospital within 30 days of discharge than patients who did not participate in C-TraC. Among hospitals who participated in this pilot, an analysis of Medicare claims showed that 9.5 percent of patients who participated in C-TraC were readmitted within 30 days versus 14.3 percent of non-participating patients. Moreover, four of the six participating hospitals have chosen to continue C-TraC after the project ends.

Leadership at the two hospitals that will not continue C-TraC said they hope to revive the program if hospital resources improve. 

Nurses and CEOs who participated in the pilot indicated that results were promising for participating hospitals. Participants said C-TraC provided a community benefit previously unmet in rural areas of Colorado. Other important findings from five of the six hospitals included "Red flags" identified in 11 percent to 26 percent of follow-up calls, and medication discrepancies uncovered in 3% to 28% of follow-up calls.

The flexibility with which C-TraC was implemented in these locations was key, said Dr. Kind. "In my opinion, this adaptation was one of the reasons C-TraC proved effective and feasible in these sites," she said. "Our protocolized adaptation process was of great interest to CMS, and we are hopeful that it, and C-TraC, will be the focus of future CMS-funded projects.  Overall, I am thrilled at how successful this dissemination proved to be."

Statistics show that about one in five Medicare patients are readmitted within 30 days of a hospital stay. Older patients with cognitive impairment, multiple chronic illnesses and limited social ties are at increased risk for readmissions. The Telligen QIO works with CMS to help improve care for Medicare patients in Colorado and other states. The pilot program was designed to test if an evidence-based transitional care program could be successfully adapted to the resources of rural Critical Access Hospitals. Risks for readmission are magnified in rural areas of Colorado, with rapidly aging populations and distant health care facilities and other social supports.

"C-TraC was beneficial in dramatically improving the transitions of care for discharged patients at Melissa Memorial Hospital," said Trampas Hutches, CEO of Melissa Memorial Hospital in Holyoke, Colo. "The C-TraC program worked in a lot of ways; most importantly, it improved the health outcomes of our patients."

Dr. Kind and her colleagues continue to develop new variations of the program, and to expand it to additional locations. "We are working with collaborators at the University of Wisconsin and in Boston to develop new surgery and palliative care specific C-TraC protocols. Additionally, we are actively working with UW partners to explore new options for increasing the C-TraC program’s spread, especially within Wisconsin," she said.