Report Drop in Hospitalizations and Rehospitalizations among Medicare Beneficiaries

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A new report suggests that communities where hospitals, other health care providers,
and community services work together to coordinate evidence-based hospital
discharges and provide better support in the community, can see a 6 percent
drop in hospitalizations and rehospitalizations, per 1,000 beneficiaries, in
just the first two years. This project relied upon Medicare’s Quality
Improvement Organizations (QIOs) to anchor and guide the work, and the average
community netted about $3 million dollars in annual savings for Medicare.

These findings were released today by the Journal of the American Medical Association
(JAMA) in “Associations between quality improvement for care transitions in
communities and rehospitalizations among Medicare beneficiaries.”

For this project, 14 QIOs, led by the Colorado Foundation for
Medical Care (CFMC) as a national coordinator, participated in a three-year
project in which the QIOs convened medical, community, and social service
providers and facilitated community-wide quality improvement activities to
implement evidence-based improvements in patient care transitions. The QIOs’ efforts
included community organizing, technical assistance in implementing best
practices, and monitoring of participation, implementation, effectiveness, and
adverse effects.

QIOs in each state and territory, funded by the Centers for
Medicare & Medicaid Services (CMS),  help achieve national quality
goals through focused efforts at the community and provider level. The QIO Program
focuses on three aims: better patient care, better population health, and lower
health care costs through improvement.

“This project took an unusual, yet ultimately effective,
approach to improving care transitions,” said Dr. Jane Brock, chief medical
officer at CFMC and lead author for the JAMA article. “Rather than focus on one
hospital ward, or one hundred patients, it engaged whole communities to improve
care for large geographically-defined populations, and it worked!”

Care transitions—when patients move from one care setting to
another—mark perilous points in patient care. As many as 20 percent of Medicare
beneficiaries need to be readmitted to the hospital within 30 days of
discharge, often due to complications associated with transitions or support in
the community. With health care reform, hospitals that do not reduce avoidable
30-day readmissions face Medicare financial penalties. In addition, physicians
and certain community-based organizations are incentivized to improve

“This work focused on every aspect of hospital discharges for
all Medicare beneficiaries in a geographic area, and brought providers together
to confront their problems and offer evidence-based care transition support,”
said Dr. Joanne Lynn, director of Altarum Institute’s Center for Elder Care and
Advanced Illness, and corresponding author for the JAMA article. “Care
transition professionals confronted the often-unnoticed effects of errors
between settings and were motivated by the unnecessary suffering of their
patients, clients, and families to improve overall care.”

In addition to the statistics revealing better community
care, this paper also marks what may be the first time that JAMA has published
a project using quality improvement (QI) methods to measure and report
outcomes, including process control charts. This approach is a substantial
difference from the formality and context-blind nature of a randomized clinical
trial. With the QI approach, participants focus on the system and aim for
improvements with ongoing monitoring, rather than setting up a research project
to test whether a particular intervention is effective. Publishing QI work
represents a profound change in the openness of American medicine to learn not
only what works for a patient but what works for the delivery system.

Efforts to build on this work are already underway, such as
the Partnership for Patients, the Community-based Care Transitions Program, and
coalition-based care transitions work led by QIOs in every state. New federal
rules allow physicians to bill Medicare for certain care coordination
activities, and hospital penalties for high readmissions rates will escalate
over the next two years. The community-based approach to addressing
readmissions offers a new way of thinking about how to affect positive change.

“This has far reaching implications for the future of health
care at any level,” said Dr. Brock. “When a community works together to improve
care at the system level, everyone involved will see the positive effects.”

For additional information on this project, or to speak with
the authors, QIO project managers in the 14 communities, or leading care
transition experts, please visit or

Posted in: Medicare

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