By Melinda Young
Care transitions across organizations and the community require better collaboration and communication among providers and social service organizations, according to recent research.1
Patients benefited from improved collaboration. They reported feeling better supported and cared for by providers involved in a care transition project.
The new study is part of the five-year ACHIEVE (Achieving Patient-Centered Care and Optimized Health in Care Transitions by Evaluating the Value of Evidence) study. The investigators are addressing care and transition gaps by evaluating hospitals’ implementation of tactics for care transitions and determining which best address patients’ goals and outcomes.2
“At the patient level, what matters to them is they feel cared about and supported at all levels,” says Brianna Gass, MPH, a senior manager of health management at Telligen in West Des Moines.
Patients want to believe their health and well-being are supported by providers, and they want to trust their providers care about that as well. “Also, as part of our interviews, we discovered that trust is very important to providers who are working together in these coalitions,” Gass explains.
Trust is an issue, especially when it comes to communication between providers in different organizations. For example, a coalition of different providers and organizations working to identify the major causes of hospital readmissions need to share data with one another. If they refused to share readmission rates with possible competitors, it is a barrier to finding solutions.
“To establish some level of trust helped to break down those barriers,” Gass says.
These were the ACHIEVE study’s aims:
- Identify outcomes that matter to patients regarding their experiences with transitional care;
- Determine which evidence-based care transition tactics were most effective for patients and family caregivers;
- Identify barriers and facilitators to implementing transitional care tactics;
- Develop recommendations for implementing and disseminating the best evidence on optimal transitional care services and outcomes.
“Once we understood those outcomes, we looked at defining different strategies to address deficiencies in transitional care,” Gass explains. “We looked at those strategies in comparison to one another.”
Gass and colleagues contacted organizations involved in the CMS Quality Improvement Organization (QIO) program. The goal was to identify community coalitions. It involved providers in all states and three territories. The goal was for communities to form multidisciplinary, multisetting transitional care teams with a variety of expertise, including physicians, nurses, administrators, case managers, social workers, care navigators, and ancillary service providers of transportation, housing, nutrition support, and others.
“The QIO acted as a convener, and they employed community organizing practices to get all stakeholders who agreed to participate on the same page,” Gass explains. “They helped them understand that readmissions is a problem.”
The QIO created a mutual understanding of how addressing care transitions is something best handled by a coalition. Post-acute providers also can help prevent readmissions because hospitals are not solely responsible for it.
“We were interested in what the communities decided to do about readmissions and what was their process for implementing interventions,” Gass says. “We wanted to know what barriers they encountered and what they did about them.”
A common change the coalitions made was to improve communication, which was recognized as a top issue. “One of the things we uncovered as part of our interviews was that there were different perceptions between the settings,” Gass says. “The hospital had its perception about what post-acute skilled nursing facilities [need to do], and skilled nursing facilities would say the hospital didn’t do this and this, and that’s why the patient deteriorated, and they had to send the patient back to the hospital.”
There also were misconceptions about social workers and community-based organizations. “These coalitions helped to facilitate — and it was an unintended consequence — a mutual respect and understanding of the role of these various organizations, and how that role is important,” Gass notes. “There is this perception among physicians that when they are asked to better coordinate care, we are just adding to this burden they already have. It helps to create an understanding that there are other resources to share in the responsibility to keep patients safe once they leave the hospital.” This framework is important as patients are handed off.
As part of its quality improvement mission, programs worked to reduce readmissions by collecting data from various stakeholders and finding the root cause of patients’ medical crises. They met regularly and took ownership in the coalition. When education was needed, they could attend learning sessions to build their skills.
The ACHIEVE Study ended in 2019, shortly before the COVID-19 pandemic. This timing was important for outcomes.
“I feel that right before the pandemic, we were at a point where we were starting to have conversations about whether there was a floor for readmission reduction,” Gass says. “Did we want readmissions to reduce to zero, or was there an expected level of readmissions that were not preventable?”
There had been a steady drop in readmissions since the programs were put in place. This decrease also could be observed nationally.3 “But then the pandemic hit, and everything kind of fizzled,” Gass says. “We had a two-year period where these efforts were not happening at the same degree they were, the coalitions were not meeting in person, and the organizations were not offering what they normally did because they were not allowed, or they were overwhelmed and dealing with COVID.”
The quality improvement efforts stalled, and readmission rates began to creep back up.
“There is a renewed need for these types of efforts to take place. They’re starting to come back together, but a lot of ground was probably lost,” Gass explains. “There is a role for collaborative community improvement efforts to address other issues in healthcare as well. Health equity is one issue.”
Collaborative teams could help communities and providers eliminate disparities in their areas. Like readmissions, this is an issue that cannot be handled by a single entity. It takes a team and a community-based approach.
“There is something to be learned in how these coalitions worked together and how they were successful in achieving their goals,” Gass adds.
REFERENCES
- Gass B, McFall L, Brock J, et al. Perspectives of acute, post-acute, physician and community support providers on community collaborative efforts to improve transitions of care. Healthc (Amst) 2022;11:100673.
- Li J, Stromberg A, Clouser JM, et al. Comparing groups of care transition strategies to improve care — The ACHIEVE Study. 2021.
- Brock J, Mitchell J, Irby K, et al. Association between quality improvement for care transitions in communities and rehospitalizations among Medicare beneficiaries. JAMA 2013;309:381-391.
Care transitions across organizations and the community require better collaboration and communication among providers and social service organizations, according to recent research. Patients benefited from improved collaboration. They reported feeling better supported and cared for by providers involved in a care transition project.
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