Transition focus results in large readmit drop
Project builds on success
One path that leads to better care transitions and reductions in hospital readmissions is to break down the silos where care traditionally is delivered.
"We know from research that any time you have a patient hand-off, there is an opportunity for less quality and increased costs," says Julie Schilz, BSN, MBA, director of community collaborative and practice transformation at Colorado Beacon Consortium in Grand Junction, CO. The consortium consists of leaders from four not-for-profit, Western Colorado-based organizations, including the Mesa County Physicians Independent Practice Association, Quality Health Network, Rocky Mountain Health Plans, and St. Mary's Regional Medical Center.
The Colorado Beacon Consortium received an $11.8 million federal grant to participate in a three-year demonstration project that will improve care transitions, care coordination, and efficiency among providers across the care continuum.
"We are at the outset of our project, and we're very intentionally working to improve the strength of processes and the level of integration in primary care and hospitals, in particular," says Patrick Gordon, executive director of the Colorado Beacon Consortium and the director of government programs at Rocky Mountain Health Plan, also headquartered in Grand Junction.
"We are investing in health information exchange to support those processes," he adds. "Going forward with health information technology will enhance the level of communication between those points."
Rocky Mountain Health Plan already has electronic data collection and care transition processes in place to help reduce hospital readmissions and health care costs. The health plan's adult and disabled members have lower readmission rates than the state's benchmarks.
For instance, the readmission rate benchmark for adults in Colorado is 2.400. The Rocky Mountain Health Plan members' readmission rate within 90 days in 2009 was 1.348. Among the disabled population, the comparison is even more striking: The Colorado readmission rate benchmark is 6.420, while the health plan members' readmission rate within 90 days for 2009 was 2.907.
"We continue to have some of the lowest Medicare hospital readmission rates in the country," Gordon says. "That is related to the transitions of care both pre- and post-hospital stay that we're able to do in a sustained manner."
With the federal grant, the consortium could extend this type of success to reach even more people.
"By focusing on readmissions, we're focusing on care transitions," Schilz says. "The best way to stop a readmission is to have a place where the patient feels well and care is coordinated."
The consortium will begin the work to improve transitions by first rebuilding relationships with hospital systems, Schilz says.
"When you get a group of hospitals and primary care providers together, you realize everyone wants to deliver effective patient care," she explains.
Then, the next step is to improve or replace the existing systems that are not successful in delivering the best patient care.
"If you have a hospital system that has a care transition program, then the goal is to build those links to the primary care practice," Schilz says. "What we have with the Beacon community grant and others is the opportunity to maximize technology as a tool."
Here's how the care transition project will work:
Improve transition communication: Hospitals and others involved in the consortium grant project will commit to working with each other, discussing, and clarifying patient care information, Schilz says.
"They'll have healthy hand-offs that will house the information that talks about patients," she explains. "Everyone will be working toward the same goal."
Transition communication will be patient-centered, asking these questions:
How does the patient live?
How do we engage the patient in a way that encourages the patient to participate in information-gathering?
How will privacy be maintained?
"What are potential unintended consequences?
Providers will meet to discuss how to improve care transitions.
For instance, if a patient shows up in the emergency department (ED), how will the patient's illness and hospital care be communicated to the patient's community providers?
"They'll develop common communication and messaging for patients and make a commitment to share information from the ER to the primary care practice," Schilz explains.
This communication could include the use of tools, such as giving patients' wallet cards with their medical information or educating them in primary care settings with brochures that talk about the consortium's work to improve care transitions, she says.
These could say: "We want to make sure our hand-off with you is effective. Here's what you can do for us: When you go into the ER, make sure your primary care physician knows about it," she adds.
Assess improvements: Each time a new process is initiated, providers in the group will collect data on its outcomes.
"We see who did what and how it worked from your end and my end," Schilz says. "We use quality improvement principles to continuously work on that process."
The assessment phase is crucial to maintaining efficiencies and best use of resources.
"The idea is, if you don't measure it, you don't know if you're improving it," Schilz says.
For instance, the Rocky Mountain Health Plan's success with reducing readmission rates provides tangible evidence that its processes are succeeding.
"One example of where we have a tangible outcome of this type of integration is our Medicaid program," Gordon says. "We've cut in half the readmission rate of some of our most complex cases, the people who need extensive support, and those who are the most costly group of patients."
Address clinical process and outcomes: "Look at the clinical process and, more importantly, clinical outcomes," Schilz advises. "We need systems in place where we're looking at measures every month."
The systems and processes help health care providers deliver on evidence-based care. These systems might include electronic primary care dashboards, financial data collection, customer service improvements, and care models, such as the medical home care model.
"You set up practice tests for the systems and then use data to see if you were successful in your goals," Schilz says.
The most effective way to measure outcomes is to use electronic data collected across a care continuum.
"Rather than manually collecting data through very basic and simple processes, we now can collect and aggregate data through a much more robust exchange solution," Gordon says.
"We make sure we're not just working with islands of data and very intensive data sets we've sown together manually," he explains. "But, rather, we have a systematic solution for collecting data at practice level and sharing it."
The Rocky Mountain Health Plan's experience with data collection will serve as a leadership model as the consortium's seven-county care transition work begins.
"We'll work with leaders in each community to allow them to own and drive this process," Gordon says. "We bring technical assistance, expert resources, technological tools, data collection tools, and a financial incentive that will incentivize participation at the outset."
Also, the health plan is working on interfacing the electronic platforms that are created at the practice level with a health information exchange, he adds.
"Most of the funding we receive from the government will go into the development of electronic, real-time interfaces between the health information exchange and a very disparate and diverse array of platforms being used at the clinical practice level," Gordon says.
This work has encouraging potential for the Colorado community and for other regions that may use it as a model.
"We have a multifaceted approach to care delivery, and now we have an opportunity to maximize that work and add health information exchange as a tool to take the work and amazing results to improve quality of care across all patient populations," Schilz says.
One path that leads to better care transitions and reductions in hospital readmissions is to break down the silos where care traditionally is delivered.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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