Creating Care Transitions That Reduce Readmissions and Improve the Health of Communities

No, they were the most successful; they looked at utilization and readmissions. And the QIO provided them with the care transitions information and training. All that happened in 2006-2008; and Joanne spearheaded the effort to turn it into this 14-community effort. So the target was a community; and CMS didn’t mandate which interventions should be performed. So we in the QIO sat down and did root cause analysis: what causes readmissions in our communities? And then we decided who should be at the table in each of the 14 communities. And when we took a population health approach, it changed everything. Because in the past, the focus had been on developments within hospitals. But this project involved looking at population health across communities. So we entered the claims data and realized that we needed to work with particular hospitals and nursing homes, and then we brought the leaders of those organizations together, and asked them, well, what do you think causes readmissions?

And what did everyone learn?

At the beginning, the providers started out saying things like, ‘Yeah, we have a problem with our heart failure patients, so let’s look at discharge instructions to them.’ And that’s a reasonable approach; but you realize that the real roots of this are perhaps not heart failure as such, but the challenges inherent in home-based patient management. They go home from the hospital and eat a pizza; and why do they go home and eat a pizza, which is incredibly high in sodium, when you’ve just spent days educating them while in the hospital? It turns out to be very pedestrian reasons like, ‘Well, I was tired and all I had in my fridge was a pizza, because I had been in the hospital for seven days.’ So they might be old, confused, tired, without transportation, etc.

So we came to the realization that disease as such doesn’t matter so much; instead what matters is the level of community support. And that is exactly the premise of the coaching intervention: that people need to be prepared to take on the burden of self-management, and need resources to help them, and sometimes it might be Meals on Wheels or something like that. The constellation of support varies by community.  And increasingly, the area agencies on aging might begin to bridge the gap between community services and patients’ ability to manage their own situations.

The Pennsylvania group was amazing; they got involved in this work in just that way, and made fantastic drops in readmissions. I’m not saying that disease is not important, or that the activities of providers are not important, because they’re extremely important. But a readmission occurs when the burden of a patient creates a situation that can’t support their staying out of the hospital. If someone is homeless and demented, it’s going to be challenging. And look at heart failure; there’s no real, easy way to change a person’s diet overnight, especially at the point of discharge.

So we give people a lot of instructions; but when they get home, they often lack the capacity to function on their own. Do they live with family members? Do they have neighbors? What is their economic situation? A lot of the articles in the JAMA package talk about risk adjustment for various factors involved in this. But that gets very complicated. We’d have to know whether they live alone, whether they live in a safe enough neighborhood for community services to come into patients’ homes or not, factors like those. So it was easier for us just to throw out that risk adjustment and work on these interventions.

What types of IT and health information exchange (HIE) foundations will be required to replicate this kind of work elsewhere?

Several of these community-based organizations have Section 3026 awards. Section 3026 of the Affordable Care Act allows area agencies on aging to partner with hospitals to deliver interventions like coaches, and to build Medicare. And that means that the Hospital Insurance Trust Fund for the first time has funding to provide services in people’s homes after discharge. It’s one of the demonstration projects under the ACA. Through that section of the ACA, 75 sites have received awards, including Denver. So Medicare is now paying for community support under very specific conditions and contracts. And one area in which the community-based organizations are making faster progress, one thing that seems to make a difference, is if the community-based organization has access to the discharge planning record from the hospital, and if it becomes part of the medical record. Usually, the electronic medical record is often completely separate from the discharge planning record. And so physicians can’t directly see what the discharge planner is doing.

So when the discharge planning record is easily linked with the EMR and is viewable by the community support agency that is serving recently discharged patients, things get better faster. The other thing, and this is my opinion—I have felt that in some ways, the perfect has been the enemy of the good enough for some time in terms of linking physicians and hospitals. I’ve got to tell you that tremendous progress could be made if you could just notify the primary care physician about a patient’s discharge the moment it happens, even if you can’t do it in a robust, HIPAA-compliant way; because the physicians are technically taking responsibility.