JAMA paper on reducing readmissions

EAST BRUNSWICK, N.J., Jan. 23, 2013—Community-wide quality improvement efforts, facilitated by state-based Quality Improvement Organizations (QIOs), correlate to almost 6 percent average declines in rehospitalizations and hospitalizations according to a study in the January 23 issue of the Journal of the American Medical Association (JAMA). In the study—by Jane Brock, MD, MSPH et al—14 QIOs, including Healthcare Quality Strategies, Inc., (HQSI), the Medicare-designated QIO for New Jersey, systematically coordinated community-based interventions with hospitals to improve the quality of care transitions—when patients move from one care setting to another, such as from a hospital to their home—and avoid harmful and costly readmissions.

Readmitting Medicare patients to the hospital within a month of discharge is a frequent and costly occurrence. Nationally, almost 25 percent of heart failure patients on Medicare are readmitted to the hospital within 30 days of discharge. The federal government says avoidable hospital readmissions cost the Medicare program billions of dollars a year.

In New Jersey, which historically has high hospitalization and rehospitalization rates, this Medicare-funded pilot has led to development of additional HQSI-supported health care coalitions throughout the state. In its first 15 months, HQSI’s Medicare supported QIO initiatives in New Jersey have helped reduce the number of rehospitalizations among Medicare beneficiaries statewide by 9.4 percent by mid-2012, from 67.42 per thousand beneficiaries in September 2011. On an annual basis this reduction is estimated to have saved Medicare approximately $72 million.

HQSI currently supports four community coalitions that cross nine counties (Atlantic, Burlington, Cape May, Cumberland, Mercer, Middlesex, Monmouth, Salem and Union). One hundred and seven health care providers, including hospitals, nursing homes, home health agencies, hospices, physicians and community and government organizations such as county offices on aging, actively partner to improve care for the approximately 234,045 Medicare beneficiaries who live in these communities combined.

“The good news for New Jersey is not just that patient care and collaboration improved during the project period, but that the state’s health care community continues to work together to care for their shared patients and reduce avoidable readmissions,” said Andrew Miller, M.D., MPH, HQSI’s medical director and care integration program manager. “When the project began in 2009, collaboration among health care providers was rare. Now it’s becoming the norm in many parts of the state.”

As the study in JAMA shows, the rehospitalization rate for the Southwest New Jersey community included in the project bounced up and down during the study period (2006-2010), as did state rates. However, the interventions put in place by this community have continued with good results.

According to Virtua Chief Medical Officer James Dwyer, D.O., “The most successful intervention was demonstrated through Virtua’s Home Care Agencies. Working with HQSI, Virtua developed a hybrid model of Mary Naylor of the University of Pennsylvania’s evidence-based care model that used nurse practitioners, working with frail elderly patients with chronic conditions living at home, to decrease the number of hospital readmissions. Virtua’s rate of readmission for the frail elderly patients was 30 percent or almost one in three patients returning to a hospital within 30 days of discharge from the hospital. At the end of the project the rate of readmission had decreased to 11 percent or approximately one in 10 patients requiring readmission to the hospital. The project was so successful that Virtua has expanded the training to include more home care nurses trained as ‘transition nurses’. Virtua is very proud of these results and the continuing success of this initiative.”

Robert Remstein, D.O., president of the Trenton Health Team, vice president for accountable care at Capital Health and a leader of one of HQSI’s current communities, agrees. “This study supports the work we are doing in the greater Trenton area to assure that our most vulnerable Medicare patients receive the right care in the best location.”

Hospitals throughout the nation are doubling down on efforts to improve care transitions and avoid readmissions, due to both the growing awareness of the burdens placed on patients and families through poor transitional care, and the new penalties assessed by the federal government on hospitals with high rates of readmission for Medicare patients.

“As our region’s largest healthcare provider, we have long recognized that preventable hospital readmissions and improved healthcare transitions are community issues,” said Joan Brennan, DNP, RN, vice president of quality and performance excellence, AtlantiCare, a 2009 Baldrige Award winner. “Working with the QIO has given us the opportunity to bring key stakeholders, including hospitals, sub-acute providers, nursing homes and others providers together to develop and implement ways to make care transitions better for those we serve.”

In addition to its four coalitions, HQSI facilitates and promotes the spread of best practices through its statewide care integrations advisory committee, provides assistance to readmission projects underwritten by foundations such as Robert Wood Johnson Foundation (RWJF) and the Grotta Fund for Senior Care, and works in close collaboration with organizations such as the New Jersey Hospital Association.

“We are direct beneficiaries of HQSI’s work on this pilot study,” said Gretchen Hartling, co-director of New Jersey Health Initiatives of the Robert Wood Johnson Foundation that funds projects throughout New Jersey. “Through our NJ Health Initiatives program, we are funding nine grantees, each of which is implementing interventions designed to reduce avoidable hospital readmissions. We invited HQSI’s Care Integration leaders, Dr. Miller and Dr. Ya-ping Su, Director of Research and Analytic Services, to serve as project consultants to the grantees. This has provided us with an extraordinary opportunity to learn and share with each other, and most importantly, to improve the quality of care in the state.”

“We’re pleased to be the catalyst for bringing all these great organizations and providers together,” Miller said. “Coordinated and person-centered care is the key to keeping people healthy.”

Mary Ellen Dalton, president of the American Health Quality Association (AHQA), the national association representing QIOs working to improve the quality of health care in communities, agrees. “Millions of older patients across the nation know what happens when their health care is not well coordinated—they end up back in the hospital. Hospital readmissions are not just a hospital problem, or a patient problem. They are a community problem, and ensuring that all sectors of a community work together to make care transitions effective is vitally important.”

The U.S. Department of Health & Human Services has established a goal of 20 percent reduction in avoidable readmissions, and CMS is now funding all QIOs nationally to continue community-based readmissions reduction initiatives through July 2014. For more information about Healthcare Quality Strategies and its efforts to improve patient quality of care visit www.hqsi.org.