Adviser LeadingAge New York Summer 2015 July 2015 | Page 33

Selfhelp Community Services, Inc.
Tova Klein, LMSW, assistant vice president, Senior Communities

Q. What were the goals and
objectives of the project?

patients obtaining the services that
were referred.

Tova: To provide patients with

Q. Specifically, what worked?
And what didn’t work?

Selfhelp was awarded three grant
projects through the Balancing
Incentive Program (BIP). They are
Selfhelp Medicaid Care Transition
Program (BIP CT), Selfhelp Medicaid
Safety Net Program (BIP SN)
and Selfhelp Enhanced SHASAM
program (BIP SHASAM).

coaching in order to prevent
hospital readmission, to maintain
a readmission rate of less than 15
percent and to provide community
resources to clients.

Selfhelp Medicaid Care
Transition Program (BIP CT)

Q. Overall, would you say
that you met the goals and
objectives? Please explain.

Q. Please provide a brief
description of your BIP
innovation grant project.
Tova: The Care Transitions program
will provide transition coaching and
short term case management to
Medicaid eligible patients – from
three hospitals in Queens – who
are identified as being at risk of
readmission. Coaching will take place
in the hospital, at home and via
telephone during the first 30-days
post discharge. The goal is to transfer
sk ills and knowledge to patients and
caregivers to maximize understanding
and compliance with discharge plans
as well as enhancing access to health
and social services as needed. The
desired outcomes include improved
transitions between hospital and home,
establishing an effective exchange of
information between the community
and the hospital, increased access to
and use of coordinated health and
social care and a reduction in the rate
of hospital readmissions. Performance
measures will include number of
patients served, readmission rates,
patient satisfaction, tracking of physical
visits within 14 days of discharge
and number and types of community
supports identified and obtained.

Tova: Overall the program has met
the goals and objectives.
The program has maintained a
readmission rate of less than 15
percent because we have connected
patients to their primary care
physicians in the first 14 days post
discharge. Many of the patients were
unaware that they need to follow
up with their primary care physician
and when the coaches visited the
patients, the coaches made calls with
the patients or directed them to make
the call. This ensured that they clients
received necessary follow up care.
The program provided patients with
referrals to community resources at
an average rate of 90 percent to date.
Also, the program has been successful
in meeting the goal of 50 percent of

Tova: Through the program we
have found that providing coaching
to patients within the first weeks of
discharge has helped to ensure that
they follow up with their primary
care physician. Additionally, helping
patients identify red flag indicators of
worsening condition and appropriate
next steps helped the patients avoid
hospital readmission.
The program has had some difficulty in
receiving timely information on patient
discharges and has not been able to
meet the goal of visiting patients within
72 hours. However, even though we
do not visit patients within 72 hours
the program has had a significant
impact on the patients that were seen.

Q. What are your plans for
sustainability of the project?
Tova: The BIP programs will end
September 30th 2015. There are no
plans to sustain the project, though
the lessons learned and the successful
experiences attained will be used to
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