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A widespread community in Eastern Washington/North Idaho applies for CCTP funding and forges new connections along the way

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This article was originally published in May 2012.

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Update January 2013: Congratulations to Bridging Care Across the Inland Northwest participants for being awarded CCTP funding!

“We’ve been around 34 years, but we’ve never worked with hospitals like we are now, and we hadn’t collaborated as closely with the Visiting Nurse Association before,” said Anne Whigham, the Case Management Operations Manager for Aging & Long Term Care of Eastern Washington (ALTCEW), which is the local branch of the Area Agency on Aging (AAA). “We were in our own niche. We had plenty of work to do and given funding reductions, we were reluctant to promote our network of aging services in order to get more work,” she continued.

But then Section 3026 of the Affordable Care Act created the Community-based Care Transitions Program (CCTP), and its program administrator, the Centers for Medicare & Medicaid Services’ (CMS), gave preference to communities seeking CCTP funding who were organized under the umbrella of a AAA. Given that opportunity, “ALTCEW forged ahead to form new partnerships with many healthcare providers in Spokane and the surrounding counties, and joined forces with our sister agency in Coeur d’Alene, Idaho who was also organizing its local providers,” said Nick Beamer, Executive Director at ALTCEW.

Eventually, this new collaboration—which includes stakeholders across a large portion of eastern Washington and northern Idaho—took on the name "Bridging Care Across the Inland Northwest."

A few local providers, in particular a team at Providence Sacred Heart Medical Center and members of the Providence Visiting Nurse Association, had already been engaged in implementing care transitions projects. Several years ago, Jeffery Liles, MD FHM, Medical Director of Care Management at Providence Sacred Heart, began a pilot project that used registered nurses to integrate parts of the Coleman model of care transitions into their hospitalist group. “The pilot, in time, led to a collaboration with our home health agency and our outpatient pharmacotherapy clinic. That project laid the foundation for our work with the larger community to apply for the Section 3026 funding,” Liles explained.

Starting in July 2011, a growing group of stakeholders began meeting to explore the idea of applying for the funding. By September, they hosted a large community meeting which included an inspiring speaker who had experienced the perils of fragmented care transitions firsthand. “We all realized that even if we don’t get funded, we’ll figure out what to do about this issue because it’s the right thing to do,” Whigham reported.

The application included input from committed, high-energy partners located in two states, 11 counties, and two universities. “The amount of work was enormous,” Whigham admitted. She thinks that a key to their success in pulling together so many viewpoints was to “be open to any outcome and be committed to the idea of developing a model that works for everyone. If we had come in there with a preconceived notion about ‘First we’ll do this, and then we want this’ it never would have worked,” she said. Qualis Health Quality Improvement Consultant Carol Higgins, OTR (Ret.) CPHQ was particularly adept in shepherding the group. “Carol really helped us along without telling us what to do. She was always asking ‘Have you thought about this?’ or ‘What’s your approach to handling that?’” Whigham reported. “I will sing Carol’s praises forever.”

The process of completing the comprehensive application provided numerous opportunities for organizations to better understand, and begin to collaborate with, each other. For instance:

  • The Washington State University College of Nursing is partnering with the Eastern Washington University’s social work and health policy programs to create joint educational sessions focused on care transitions. “It will be a wonderful opportunity for differing health professions’ students to work together,” said Cindy Corbett, PhD RN, Professor at WSU College of Nursing.
  • Although the Area Agency on Aging of North Idaho had previously worked with Kootenai Health, a Coeur d’Alene hospital, the efforts had not been particularly successful. “We’ve been wanting to strengthen that relationship into one that resulted in positive outcomes for the aging community,” AAA North Idaho Director Pearl Bruno Bouchard, MPA reported. Qualis Health Quality Improvement Consultant Christine Packer, MEd, helped to solidify connections between the two organizations by providing additional contacts and networking opportunities. On its own, “our agency just doesn’t demand the kind of attention Qualis Health can garner,” Bouchard noted.
  • “We learned a great deal from the other members of our team even when working within our [own] large organization! That expanded exponentially when we added other community partners to the group,” said Debbie Rappuchi, MS RN, Director of Providence VNA Home Health. “I doubt we would have learned so much about each organization, each discipline, and the role in transitions of care without [forming the project’s steering committee]. We spent the first several months just getting to know each other and developing an appreciation for what each organization has to offer the community.”
  • Whigham realized “now’s the right time” to make new connections for ALTCEW and its network of services in the community, and to help other organizations discover how each intersects with the same population at different points along their healthcare journey. As a result, Providence Sacred Heart has started connecting their Medicaid-funded patients who are high utilizers of emergency room services to ALTCEW case managers. “This relationship will continue to grow and will have a multiplier effect on the care in our region,” Liles stated. And conversely, ALTCEW is taking advantage of others’ expertise as well. Whigham is anticipating a great response when Liles provides a training session to family caregivers at an upcoming ALTCEW event.

Whigham echoed the comments of many Bridging Care Across the Inland Northwest participants by exclaiming “I’m so excited about this work!”

Learn more about Qualis Health's work through the Communities for Safer Transitions of Care project.