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Project demonstrates community coalitions can improve care
e-Reports, March 4, 2013
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Medicare Quality Improvement Organizations’ (QIOs) project shows community networks can reduce 30-day rehospitalizations, help the sickest and most vulnerable Untitled document

With the spotlight on preventing hospital readmissions, the Centers for Medicare & Medicaid Services (CMS) completed a project that clearly demonstrates the value of community-based approaches to improve care transitions. The result in the Evansville area, including Vincennes, was a 14.74 percent reduction in 30-day rehospitalizations, using a process that can be duplicated in your community.

Health Care Excel (HCE), Indiana’s Quality Improvement Organization (QIO), was among 14 QIOs to participate in the three-year effort to build community coalitions with local providers and stakeholders to care for shared patient populations.

More specifically, the QIO helped bring together representatives from hospitals, skilled nursing facilities, home health care agencies, nursing homes, hospice, as well as social services providers like Area Agencies on Aging. The entities collaborated to improve the quality of transitions between care settings and reduce preventable hospital readmissions for Medicare beneficiaries.

As many as 20 percent of Medicare patients need readmission to a hospital within 30 days of discharge, and often these readmissions can be prevented.

More about the Evansville experience
St. Mary’s leaders talked to HCE about the CMS project on readmissions and chose to participate.

“We had been looking at the full continuum of care, as well as what to do about readmissions,” said ISMA member John Gallagher, M.D., senior vice president and chief medical officer at St. Mary’s Health System.

He explained that readmission is just one helpful metric St. Mary’s uses in examining how to improve care for patients in the hospital and beyond – when patients return home.

“The greatest number of errors is in handoff of care,” Dr. Gallagher said. “The first several days after a patient leaves the hospital are a critical time. Medications, diet and follow up are huge, but it’s not complicated stuff.” Examine how you interact with patients and bridge the gap to help patients do the right things. Then, if problems occur, intervene quickly.

For physicians, Dr. Gallagher noted three important areas needing attention:

  1. Medication reconciliation, making sure what the physician intends for the patient leaving the hospital is actually what happens when the patient gets home
  2. Follow up, doing what is needed to have a patient visit the follow-up physician as soon as possible after discharge
  3. Communication between hospitalist and the physician in the community who will deliver follow-up outpatient care

He noted readmission should be a metric to follow, not the chief concern. “It’s not all about numbers and metrics; it’s about people. Caring for the patient, making sure lives are improved – that goal should not get lost. Attention to quality, efficiency of care and emotional connectedness are most important.”

QIOs in every state are now working with local communities to foster coalition-based approaches to the challenge to reduce readmissions. The nationwide project is discussed in the Jan. 23, 2013, issue of JAMA; obtain the article here or call (312) 464-5262.

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