Key members of the Care Transitions Innovations (C-TraIn) team include, from left, Devan Kansagara, MD, FACP; Stephanie Peña, RN; Jackie Sharpe, PharmD; Char Riley; Nic Granum; Honora Englander, MD, ACP Member; and Leann Michaels.
It started with a single uninsured patient. The middle-aged man — a long-haul truck driver by trade — was admitted to the hospital with pneumonia, depression and a long list of other maladies. Though given a list of low-cost clinics at discharge, he didn’t understand the process for getting care and couldn’t afford his medications.
The man developed other complications and became progressively worse, eventually losing his job and then his housing. He was later readmitted into the intensive care unit and stayed for 19 days, at an un-recouped cost to the hospital of $130,000.
The event led two internists at OHSU, Honora Englander, M.D., and Devan Kansagara, M.D., to convene an academic conference on how to improve the link between hospitalization and follow-up visits to a doctor’s office. Two years and dozens of meetings later, the Care Transitions Innovation (C-TraIn) program was born.
Several elements set the C-TraIn initiative apart from other transition-improvement efforts. For one, OHSU directly pays three community clinics to provide outpatient care and serve as the medical home for low-income patients discharged from the hospital. OHSU also has developed its own collection of low-cost pharmacy medications (also known as a formulary) for these same patients. The hospital pays for 30 days of formulary prescription medications at discharge, after which patients access medications through clinic pharmacies, medication assistance programs and $4 plans.
“Something different about this is that it’s funded by the hospital itself, not a grant. It’s an example of the hospital improving the quality of care for patients, and paying for care upstream in an outpatient setting,” said Englander, who is now an assistant professor of medicine at OHSU and an internist at Old Town Clinic, one of the three outpatient clinics in Portland to which the hospital refers C-TraIn patients.
Initially, the proposed program made enough financial sense to convince administrators to pilot the program. The team did a formal study of its impact on readmissions, patient satisfaction and quality. Today the program continues to operate with a full-time nurse to lead baseline assessments with patients and help with their transitional care needs following hospitalization. The nurse also helps the patient develop self-management goals and serves as the main patient educator and care coordinator throughout the patient’s stay, as well as for 30 days after being discharged.
Rebecca Harrison, M.D., an OHSU hospitalist, says she “can breathe more easily knowing there is a plan in place” for these patients. For her, the only downside to the program is that it’s not in place for all patients, everywhere. “Any hospital, all over the country, could benefit from having a designated individual who works on care transitions,” she said.
There’s truth to that. OHSU’s study has shown that it could work at other hospital systems, and may have particular relevance to academic medical centers, who’s three-part mission of clinical care, research and education make them a natural place for health care reform.
A paper on the pilot study developed by Englander and Kansagara will soon be published in the Journal of Hospital Medicine.
This story contains excerpts from an article in the March 2012 issue of ACP Hospitalist.
Teens and tweens danced and the chatter of video gamers wafted across the room. In another corner, hula-hoops soared. All in all, hundreds of kids were gathered and some were reeling from the effects of alcohol.
It all occurred in Bend’s Pilot Butte Middle School gym. And it wasn’t a party, it was an event sponsored by OHSU and St. Charles Medical Center. The effects of alcohol? They were virtually induced.
Let’s Get Healthy, an OHSU interactive education and research exhibit, made its way to Bend recently for a week-long tour. While there it visited four schools to reach 1,004 students, and an event for the public was held at the end of the week.
The exhibit seeks to educate the public about health in a fun way while linking scientists, students and communities together in collaborative health research. Some of the teaching tools are non-traditional: a video game that blasts the sun’s cancer-causing rays, a Dance-Dance Revolution station and goggles that impair vision to show how dangerous it can be to drink and drive.
Attendees have the choice to contribute to anonymous health information that is fed into a population database. Researchers later can use the information to study the scientific relationships among diet, body composition, genetics and chronic disease. The information also is useful to the communities where the events have been held.
While those communities use the data to develop programs and write grants to support healthy living in their hometowns, the local schools use the information to conduct scientific inquiry lessons, such as having students examine their own energy drink consumption using real, but completely anonymous data.
Overall, Let’s Get Healthy reached 2,018 students in four communities in the past year. The program started in 2007 and has put on two-dozen events with more than 7,000 participants to date.
View a video to learn more about the program or contact the staff.
The recent commitment of $2 billion over the next five years from the federal government puts our state in the spotlight for health care reform. One component of the funding is sure to bring smiles — and access — to recent graduates and communities around Oregon.
Student forgiveness loans for health care providers who consent to practice in rural and other medically underserved parts of the state will be available in 2013. The money — $2 million — should help to deliver the workforce that will be needed as more patients seek care.
The Oregonian’s recent editorial on this subject captures the impact the forgiveness loans should have on the state.
Learn about the focus and work of the OHSU Office of Rural Health.
Read more on the recent federal health reform funding for Oregon.
What is the science behind cooking a great steak? Are dogs affected by music? What is the texting frequency of kids vs. adults?
Students at Robert Gray Middle School are encouraged to learn about the scientific process by applying it to the everyday things they love. Their interests — and their projects — were on display in the spring at the school’s annual science fair. OHSU students had the privilege to judge their work.
One middle-schooler married her love for dragons and all things medieval with scientific methods. Her project, titled the Strongest Sword, led her to test and compare several metals and their strengths. Robert Gray science teacher Kathryn Wagner-West was thrilled with the students’ projects, “What’s the point of doing research on things you don’t want to do? That’s not motivating toward a career.”
Engaging youths to have an interest in careers in health and science is a shared goal with OHSU. The university has dozens of programs and offers experiences to students around the state to inspire youths to learn more as they continue their education. The Robert Gray/OHSU collaboration is a perfect example of a partnership that works. The science fair marked the 10th year for these visits, and both sides are looking forward to future alliances.
Kris Helphinstine, an OHSU physician assistant student who had been a teacher himself before enrolling at OHSU, was humbled by the experience. “It’s great to see the kids who are coming up with good questions and understand the process. Regardless of their competence it gives kids something science-related to be excited about and it gives us a chance to encourage them.”
How did the Robert Gray students feel about their new mentors? West explained it best, “The kids get good feedback from people they respect, and they’re motivated by their professionalism. That and their white coats.”
To learn more about how healing, teaching and discovery come together, visit the OHSU website.