Jan 232013

By Dr. Joanne Lynn

The latest issue of JAMA features our paper describing   an exciting and successful initiative from the Centers for Medicare and Medicaid Services (CMS) and fourteen of its quality improvement organizations (QIOs).  Grounded in quality improvement methodology—plan-do-study-act–this unusual project offers many insights for those aiming to reduce avoidable readmissions.  And its raises a number of important question about how we measure progress in reducing readmissions. (For more on that topic, see our earlier MediCaring blog, https://medicaring.org/2013/01/07/readmissions-count-should-cms-revise-its-calculations/ )

A Medicare patient’s ability to receive successful treatment during care transitions from one setting to another has a crucial effect on the overall cost and efficiency of the Medicare system. Errors in information transfer, care planning or community support can cause hospitalizations, rehospitalizations and unnecessary costs to the Medicare program.

This project involved a three-year, community-based effort to improve the care transition process for fee-for-service Medicare beneficiaries. Participating QIOs facilitated cooperation among providers, health care facilities, and social services programs, such as Area Agencies on Aging. They centered their efforts around each community’s unique needs.   QIOs worked with communities to understand their own particular causes of readmissions, and to implement appropriate, evidence-based models to address them.  Communities analyzed results of the intervention along the way, and changed course to stick with interventions most likely to work.

The results, when compared to 50 comparison communities, showed significant reductions in hospitalizations and rehospitalizations, both by an almost 6% average, saving Medicare $3 million in hospitalization costs per average community per year.

This correlation has already led to new national efforts such as Partnership for Patients and the Community-based Care Transitions Program. In addition, in the 10th Scope of Work, all 53 QIOs are leading community projects nationwide (so far, in more than 400 communities).

This paper may be the first time one of America’s leading medical journals has published a report based on QI methods. Doing so represents a profound change in the openness of American medicine to learn not only what works for a patient, but works for the delivery system, too.

key words: quality improvement, care transitions, CMS, CFMC, Joanne Lynn, readmissions, community coalitions, JAMA

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  One Response to “JAMA Report Finds Community Collaboration Key to Reducing Hospitalizations and Rehospitalizations”

  1. i have organized three nurse practioners who have all done subacute work and are familar with home visits: our idea is to set it up as a private company and i work as a medical director: we are doing it privately and feel that we can adapt faster to the market forces compared to larger hospitals or powerful nursing home chains. the bottom line is the nps and myself have equal partnership and my feeling is that we all have to work from a motivated private practioner paradigm and create the primary care model that i have seen evaporate over the last 10 years as a geriatrician. it seems the the hired persons at various places do not have the same motivation as private practioners and i feel reformulating the idea of a homecare provider, and integrating a family approach makes it more real for the community. i feel that this team should have some components of a multidisplinary team mixed that works like a hybrid nursing home and hospice team: maybe more pallitive care but this too is ill defined (just passed my boards on this)

    I guess i found the whole hospitalist trend troubling, as the whole snfist trend troubling: i dont see the transition care team working if its not a care coordination team that places the primary care provider at the center: i fear the concept will collapse if there is no sense of community as the old family docs had about 40 years ago. i just dont see large institutions pulling it off

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