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Colorado Care Transitions Project Featured in JAMA Article

Hospitalizations and rehospitalizations among Medicare patients declined nearly twice as much in communities where Quality Improvement Organizations (QIOs), like the Colorado Foundation for Medical Care (CFMC), coordinated interventions that engaged whole communities to improve care than in comparison communities, according to a study in the January 23 issue of the Journal of the American Medical Association (JAMA). The results show that interventions aimed at improving care transitions—when patients move from one care setting to another, such as from a hospital to their home—reduced rehospitalizations for Medicare patients by almost six percent in 14 select communities nationwide, including northwest Denver. CFMC is one of the 14 state-based QIOs that received funding from the Centers for Medicare & Medicaid Services (CMS) to participate in the project. CFMC also directed the 14 QIOs as a national support contractor.

Readmitting Medicare patients to the hospital within a month of discharge is a frequent—and costly—occurrence and in many instances, can be avoided. Almost 25 percent of heart failure patients on Medicare, for example, 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.

The study appearing in JAMA shows how state-based QIOs, funded by the Medicare program, systematically coordinated community-based efforts with hospitals and other medical and social service providers to improve the quality of care transitions and avoid costly readmissions. The 14 communities in the study averaged a 5.7 percent reduction in rehospitalizations. A less expected result was that Medicare beneficiaries in these communities also experienced a 5.74 percent reduction in hospitalizations over the two-year period. Communities of comparable size, demographics and hospitalization utilization—but where there were no concerted efforts to improve care transitions—averaged considerably more modest reductions, just a 2.05 percent drop in rehospitalizations and a 3.17 percent decline in hospitalizations.

In northwest Denver, there was a 10.78 percent reduction in rehospitalizations of Medicare patients and an 8.37 reduction in hospitalizations.

“While many communities are working to reduce readmission rates, the communities supported by QIO efforts experienced double the rate of reduction as others,” said Jane Brock, MD, MSPH, lead study author and chief medical officer at CFMC. “This study shows that a coordinated approach involving diverse stakeholders in a community—organized and spearheaded by a quality improvement expert—is a promising strategy.”

“Over the last several years, we have taken a hard look at how medical and social service providers communicate and collaborate with each other and their patients in Colorado,” said Arja P. Adair, Jr., president and CEO of CFMC. “Today, we're sharing what we learned in northwest Denver and spreading what works across many more communities in Colorado to support local collaborations and community-based approaches to help keep our seniors from returning to the hospital after discharge for issues that could have been safely avoided.”

The community-based approach coordinated by CFMC and other QIOs in the study focused on resources available in the community and used the patient and family as a partner, which was markedly different from commonly used hospital-based approaches to improve care transitions.

From 2008 to 2011, a group of hospitals, skilled nursing facilities, home health care agencies, nursing homes, physicians and other medical and social service providers in northwest Denver participated in a project – supported by CFMC – to improve the quality of care transitions between care settings and reduce expensive, preventable hospital readmissions for Medicare beneficiaries in the community through patient engagement and activation.

CFMC helped the community form a steering committee comprised of representatives from acute and non-acute medical settings, local employers, and patients/caregivers, who were tasked with reviewing data and selecting appropriate community interventions. Based on the local needs of northwest Denver, one of the evidence-based interventions implemented was Dr. Eric Coleman’s Care Transitions Intervention combined with Dr. Judith Hibbard’s Patient Activation Measure. In this model, transitions coaches work with patients to build the knowledge, skills and beliefs to self-manage and ensure their needs are met during their transition from the hospital. For example, coaches help patients and their family members become actively engaged in their transitions by keeping a personal health record, knowing the ‘red flags’ for trouble, ensuring they receive the right medications, and follow-through on appropriate follow-up care with a primary care physician.

“This innovative work based in Colorado has proven that we can make smarter health care decisions and prevent seniors from taking needless trips back and forth to the hospital,” said Colorado U.S. Senator Michael Bennet. “Investing in successful community-based care transition programs will provide higher quality to our nation’s seniors, and ease the burden on our health care system so that our doctors and nurses don’t get bogged down treating preventable problems. These type of collaboration benefits everyone while reducing health care costs.”

Within the 14 communities, researchers found that quality improvement interventions prevented about 6,800 hospitalizations and 1,800 rehospitalizations per year. In an average community of 50,000 fee-for-service Medicare beneficiaries, the project would have saved Medicare more than $4 million per year in hospitalization costs, while costing less than $1 million per community per year to implement.

The U.S. Department of Health & Human Services has also 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. CFMC is currently working with five communities throughout Colorado to foster coalition-based approaches to reducing rehospitalizations.

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