“Fast Track Home fills a big gap in transitional care – one that is not filled by Medicare or traditional insurance plans.” – Forrest Pettit, Manager, Transitional Care Programs
No one wants to stay in the hospital but coming home has its own challenges, particularly for the elderly. While the focus is supposed to be on recovery, the burden of making meals and managing necessary household tasks, along with getting to therapy and follow up appointments can be overwhelming. For those who cannot manage, the result is usually a stay at a skilled nursing facility. For those who try and fail, it could mean they’re back in the hospital with complications.
“For someone who has been in the hospital, getting back home quickly is very important,” said Forrest Pettit, manager of Council on Aging of Southwestern Ohio’s (COA) Transitional Care programs. “But going straight home from the hospital is a real challenge for someone who needs help with everyday things like cooking, personal care and transportation to follow up appointments. Fast Track Home fills a big gap in transitional care – one that is not filled by Medicare or traditional insurance plans.”
Change where it’s needed most
The traditional Elderly Services Programs (ESP) employed by COA provide meals, housekeeping, personal care, transportation, and more to eligible seniors on an ongoing basis. Enrollment rules require the senior be living in their home, or a caregiver’s home, at the time of the eligibility assessment. That makes the program a poor fit for seniors who normally manage these tasks independently, but need temporary help in-place in order to be discharged home after a hospital stay. That’s where “Fast Track Home” comes in.
The Fast Track Home initiative brings the assessment to the hospital bedside. This proactive approach uses trained COA coaches who are credentialed at participating hospitals to identify and reach out to patients who may benefit from the program. In some cases, this bedside intervention can be the difference between a stop at a skilled nursing facility or a smooth transition from hospital to home.
The Health Collaborative is pleased to select the Fast Track Home project as a finalist for 2017 Richard M. Smith MD Leadership in Quality Improvement Award. The award is presented by The Health Collaborative, a Cincinnati healthcare improvement nonprofit, at its annual dinner and awards ceremony known as Inspire Healthcare – set this year for November 1 at the downtown Renaissance Hotel.
Fast Track Home began as a pilot project at Clinton Memorial Hospital in June 2016. In May 2017, the program expanded to three additional hospitals in Hamilton County. In the program’s first full year (June 1, 2016 – July 1, 2017), 126 older adults enrolled. The current national average for hospital readmission is 17.5%. For Fast Track Home patients, the average was closer to 11%. Of those enrolled, 47 percent transitioned to ongoing ESP after the temporary service period ended. Of those who transitioned to independence, the average length of stay on the program was 39 days, enough benefit to ease their recovery and help prevent a return trip to the hospital or nursing home admission.
Supporting aging in place
Via Fast Track Home, elderly patients are connected to an ESP care manager who monitors their care and makes arrangements for services that will support the patient in their recovery at home. All services are provided free of charge for up to 60 days. The care manager continually monitors the patient’s care and adjusts services as needed. Near the end of the 60-day enrollment period, the care manager conducts a full eligibility assessment to determine if the senior would qualify for ongoing support.
“Bridgette [COA Coach] was a tremendous help in easing my 84-year-old mother’s transition back to her home following a mild stroke. She knew what resources were available and how to access them,” said Valerie Wren, whose mother enrolled in Fast Track Home. “Bridgette relieved so much of the stress and anxiety caused by not knowing how to cope with new limitations. Thanks to Bridgette, my mom had the resources she needed to regain strength and independence, and be able to stay in her own home.”
Fast Track Home improves the patient’s care experience while helping to reduce hospital readmission rates and prevent unnecessary stays in skilled care facilities. Fast Track Home is an innovative, cost-effective approach to providing care when and where it is needed most – to hospitalized older adults, intent on returning home but in need of extra support to make a safe, smooth transition. No comparable program exists in our region – or the country.
About the award
First presented in 2003 in memory of Dr. Richard Smith, a tireless leader and proponent of the safety of all patients, the Richard M. Smith MD Leadership in Quality Improvement Award recognizes an individual or team who exemplifies commitment to quality improvement, makes it an organizational priority, and serves as a role model for those working to enhance the quality of care within their organization and throughout the community.
Meet the team
- Nakiya Averhart, Fast Track Home Hospital Coach
- Nicole Baker, Business Intelligence Analyst
- Bridgette Davis, Fast Track Home Hospital Coach
- Jenny Gibson, Fast Track Home Hospital Coach
- Sam Lapiana, Care Transitions Field Coach
- Forrest Pettit, Elderly Services Program Manager
- Lisa Prewitt, Fast Track Home Hospital Coach
- Stephanie Seyfried, Manager of ADRC and Assessment
- Ken Wilson, Vice President, Program Operations
Please join The Health Collaborative in congratulating Quality Improvement Finalist Fast Track Home, for helping patients recover safely at home, where they are most comfortable and where they most want to be.
About Inspire | Healthcare:
Inspire | Healthcare is the Greater Cincinnati and Northern Kentucky region’s premier annual healthcare event and awards celebration. The awards seek to recognize innovations by individuals, teams, and/or organizations in the areas of informatics, quality improvement, and population health. Other awards given annually include the Inspire Champion Award and the Hoxworth Blood Drive Awards, with separate nomination and judging processes. For more information about Inspire | Healthcare, visit healthcollab.org/inspire.
About The Health Collaborative:
The Health Collaborative strives to lead data-driven improvement initiatives that result in healthier people, better care, and smarter spending. Based in Cincinnati, we work with those who provide care, pay for care, and receive care, to find mutual solutions to healthcare’s most challenging problems. For more information about The Health Collaborative, visit healthcollab.org.