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Facilitating Care Delivery Improvement Across Communities

January 30, 2013
by Mark Hagland
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Medicare Quality Improvement Organization (QIO) leaders showcase results of a study on community-wide care interventions

On Jan. 23, leaders at the American Health Quality Association (Washington, D.C.) held a press briefing to highlight the publication of an article in the Journal of the American Medical Association (JAMA) in which leaders in AHQA documented an impressive decline in hospitalization and rehospitalization among Medicare patients in communities in which Quality Improvement Organizations (QIOs) have coordinated interventions that engaged whole communities in care improvement.

The JAMA article, entitled “Association Between Quality Improvement for Care Transitions in Communities and Rehospitalizations Among Medicare Beneficiaries,” was authored by six healthcare researchers, including lead author Jane Brock, M.D., MSPH, and also co-author Joanne Lynn, M.D., M.A., M.S. , both of whom spoke with reporters during the telephonic press briefing.

As Drs. Brock and Lynn noted during the press briefing, they were involved in a study of 14 communities in which QIOs became involved in community-wide healthcare improvement efforts. The 14 communities participating in the study saw an average 5.7-percent reduction in rehospitalizations, and also a 5.74-percent decrease in initial hospitalizations during the same two-year period. The core innovation involved, Drs. Brock and Lynn, and Mary Ellen Dalton, R.N., Ph.D., noted, was the success of QIOs in working with coalitions of stakeholder groups within individual communities to create consensus-driven interventions to improve care delivery.

The 14 communities involved in the project were: Tuscaloosa, Ala.; Denver, Colo.; Miami, Fla.; Atlanta, Ga.; Evansville, Ind.; Baton Rouge, La.; Lansing, Mich.; Camden, N.J.; Albany, N.Y.; Pittsburgh, Pa.; Providence, R.I.; Harlingen, Tex; and Whatcom County, Wash. Within those communities, the researchers found that quality improvement interventions were associated with about 6,800 hospitalizations and 1,800 rehospitalizations averted per year. In an average community of 50,000 fee-for-service Medicare beneficiaries, the researchers noted, the project would have saved Medicare more than $4 million per year in hospitalization costs, while costing less than $1 million per year to implement.

As Brock, chief medical officer of the Colorado foundation For Medical Care, Colorado’s Medicare QIO organization, noted, “The actual mix of interventions that happened in each community was different. Every community was different, and [the specific combination of care delivery interventions] depended on local knowledge and experience,” she added, noting that, “In Colorado, one thing that proved to be very effective was to intentionally improve the link between hospital discharge and at-home support.”

Brock went on to say that “One of the key things we think is most important about this is showing that convening all the care providers together can be effective and effective fairly quickly.”

Joanne Lynn, M.D., a medical officer in the Office of Clinical Standards and Quality in the federal centers for Medicare and Medicaid Services (CMS), said that “We really must drive down at least the per-capita costs of healthcare, as we get more and more frail and elderly people, so we need to really look for the efficiencies; and reducing hospitalization in this way is very promising. It’s very important to remember,” Lynn added, “that this project happened at a time when there were no financial benefits or penalties for this. But the teams got together and convened, and capitalized around the sense of professionalism and pride in work that led to these sorts of reductions.” Lynn has been a leader in the Community-Based Shared Transitions Program under Medicare, “in which communities for the first time are being paid by Medicare to smooth transitions” of care, she noted.

In response to a question from Healthcare Informatics regarding the IT foundations required to achieve sustained, community-wide care delivery improvement, Brock said that “A number of communities were in the process of setting up health information exchanges and were working with providers setting up EMRs [electronic medical records], during the course of this project. So yes, health IT is very important here. The patient transitions from the hospital bed to the nursing home bed in 20 minutes, but it can take weeks for the information to follow that patient,” she noted.  “And it would be interesting to know how much IT implementation has happened since the beginning of this program,” she added.”

Lynn offered that “I think that it’s very important that we really work this IT angle so much more than we were able to on this project. Remember, this project started back in 2008, and there’s been tremendous EMR development since then. But some of the communities, and some of the hospitals, gave the project access to records; some providers handed patients paper copies of parts of their records,” she noted. “But in the long term, we need records that can move forward with their patients, and also provide a feedback loop with information on what has occurred. We need a way to be able to feed back that particular interventions aren’t working right, and to get it right. And also to note social service interventions, such as Meals on Wheels, and so on.”

In the future, Lynn said, “I’d love to have an app on a  smartphone that the grandchild [of an elderly patient] is sitting there holding, that would download the discharge plan, so the grandchild would have the discharge plan in hand. We need to be thinking much more creatively in the future about this, and really build this into our records.”