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Acute Care Readmission Reduction Initiatives: An Update on Major Programs in Michigan

Cover Page Acute Care Readmission Reduction Initiatives 2015 Update_For Review_Revised 7-24Inpatient hospitalizations account for 32 percent of the total $2.9 trillion spent on health care in the United States.(1)U.S. Centers for Medicare & Medicaid Services. 2013. National Health Expenditures. In the majority of cases, it is necessary and appropriate to admit a patient to the hospital. However, patients returning to the hospital soon (e.g., within 30 days) after their previous stay account for a substantial percentage of admissions. For example, nearly 18 percent of Medicare patients were readmitted in 2013.(2)U.S. Centers for Medicare & Medicaid Services, The CMS Blog. Dec. 6, 2013. New Data Shows Affordable Care Act Reforms Are Leading to Lower Hospital Readmission Rates for Medicare Beneficiaries. (accessed 6/26/15).,(3)[1] J. Rau. Oct. 2, 2014. Medicare Fines 2,610 Hospitals In Third Round Of Readmission Penalties. Kaiser Health News. (accessed 6/26/15). Research has shown that many factors—including a patient’s socioeconomic status, clinical conditions and their communities’ characteristics—can influence hospital readmissions.(4)J. Hu, M.D. Gonsahn, D.R. Nerenz. 2014. Socioeconomic Status and Readmissions: Evidence from an Urban Teaching Hospital. Health Affairs, 33(5):778-785 Readmissions are costly, potentially harmful, and often preventable.(5)D.C. Goodman, E.S. Fisher, C. Chang. 2013. After Hospitalization: A Dartmouth Atlas Report on Readmissions Among Medicare Beneficiaries. (Hanover, NH: Dartmouth Institute for Health Policy & Clinical Practice). http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf404178 (accessed 6/26/15).

In 2013, CHRT published an issue brief on the major programs aimed at reducing hospital readmissions, including the Hospital Readmissions Reduction Program (HRRP) established under the Affordable Care Act (ACA).(6)L. Russell and P. Eller. May 2013. Acute Care Readmission Reduction Initiatives: Major Program Highlights (Ann Arbor, MI: CHRT). The following is an update on the HRRP and other programs previously highlighted.

CMS Hospital Readmissions Reduction Program (HRRP)

Under the HRRP, acute care hospitals with high readmissions rates for certain conditions could have lost up to 1 percent of their total Medicare inpatient reimbursement payments in fiscal year 2013 (FY2013), up to 2 percent in FY2014, and up to 3 percent in FY2015. The penalties are calculated based on a hospital’s readmission rates over a three-year period.(7)CMS uses a three-year measurement period to increase the number of cases per hospital used for measure calculation, which improves the precision of each hospital’s readmission estimate.

Beginning in FY2013, the U.S. Centers for Medicare & Medicaid Services (CMS) began reducing Medicare payments to hospitals with high readmission rates for heart attack (AMI), heart failure (HF), and pneumonia.(8)CMS defines a hospital’s excess readmission ratio as a measure of a hospital’s readmission performance compared to the national average for the hospital’s set of patients with that applicable condition. ,(9)Medicare uses an “all-cause” definition for hospital readmissions, meaning a hospital stay at any hospital within 30 days of an initial hospitalization (for the selected conditions) counts as a readmission. As of 2014, planned readmissions related to heart attack, heart failure, and pneumonia within the 30 day window are no longer counted.,(10)According to CMS, HRRP focuses on AMI, HF, and pneumonia because they are common conditions with substantial mortality and morbidity and hospitals already report on them for CMS’ Hospital Compare website. In FY2015, CMS added two readmission measures: chronic obstructive pulmonary disease (COPD) and elective hip or knee replacement. CMS plans to add another measure, coronary artery bypass graft (CABG), in FY2017.(11)C. Boccuti and G. Casillas. Jan. 2015. Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program (Washington, DC: Kaiser Family Foundation). (accessed 6/15/2015). Over the HRRP’s first three years, hospitals nationwide have been penalized an estimated $945 million in total (see Figure 1).

Figure 1: CMS Hospital Readmission Reduction Program: 3-year Implementation Period, U.S

Year penalty appliedFY2013FY2014FY2015
Performance (measurement) periodJune 2008-July 2011June 2009-July 2012June 2010-July 2013
Diagnoses of initial hospitalizationHeart attack
Heart failure
Pneumonia
Heart attack
Heart failure
Pneumonia
Heart attack
Heart failure
Pneumonia
COPD
Hip or knee replacement
Maximum penalty1%2%3%
CMS estimate of total penalties$290 million$227 million$428 million

Source: Kaiser Family Foundation

Some studies indicate that the HRRP is showing initial success in reducing readmission rates. A recent study of New York hospitals found that readmission rates for the first three conditions targeted by the HRRP—AMI, HF, and pneumonia—fell between 2008 and 2012.(12)K. Carey and M-Y. Lin. June 2015. Readmissions to New York Hospitals Fell For Three Target Conditions From 2008 to 2012, Consistent With Medicare Goals. Health Affairs, 34(6):978-985. An analysis of CMS’ Hospital Compare database, which publishes hospital readmission rates, shows readmissions rates for AMI, HF, and pneumonia fell nationwide between 1 and 2 percent by mid-2013.(13)Boccuti and Casillas, 2015. A 2013 MedPAC analysis showed that reductions in readmission rates for these conditions were greater than the reduction in overall readmission rates.(14)Medicare Payment Advisory Commission. June 2013. Report to the Congress: Medicare and the Health Care Delivery System (Washington, DC). (accessed 6/15/2015).

While the HRRP may be having an effect on readmission rates for the target conditions, Medicare payment reductions nearly doubled from FY2014 to FY2015. The increase in total penalties could be due, in part, to the addition of new conditions in FY2015, and the fact that the maximum penalty increased from 2 to 3 percent per hospital stay.

Some hospital executives have expressed concern about the HRRP’s method for determining improvement in readmission rates. That is, a hospital with high readmission rates could reduce its rates from one year to the next, but still lose Medicare reimbursement because penalties are assessed based on a hospital’s readmissions rate compared to the national average which hospitals say unfairly penalizes them even if some improvement is made.(15)Boccuti and Casillas, 2015 For example, Beaumont Health System in Royal Oak, Mich., says it has reduced its readmissions rates in recent years, but could lose a projected $3.86 million in Medicare reimbursement in FY2015 because the system’s rates were higher than the national average.(16)J. Greene. May 17, 2015. Michigan hospitals cut readmission rates but continue to pay stiff penalties. Crain’s Detroit Business. (accessed 6/15/15).

HRRP Implementation in Michigan

Fifty-four Michigan hospitals were penalized 0.42 percent on average in FY2013, while 55 hospitals were penalized an average of 0.39 percent in FY2014 (Figure 2). In FY2015, when CMS added two measures to the HRRP, 71 Michigan hospitals, three-quarters of the state’s eligible hospitals,(17)Psychiatric, rehabilitation, long term care, children’s, cancer, and critical access hospitals are exempt from the HRRP were penalized an average of 0.64 percent.

In each of the program’s first three years, Michigan’s average penalty was equal to or higher than the national average (Figure 2). According to Kaiser Health News, only 20 states had higher average penalty rates than Michigan in FY2015.(18)J. Rau. Oct. 2, 2014. Readmission Penalties By State: Year 3, Kaiser Health News. (accessed 6/15/15).

Figure 2: Michigan Hospital Penalties, FY2013 - FY2015

 # of MI Hospitals PenalizedAverage Penalty(19)The average penalties were calculated for penalized hospitals only, excluding non-penalized hospitals.
% of Eligible Hospitals Penalized
 
MIUSMIUS
FY2015
71
0.64%0.63%75%77%
FY2014
55
0.39%0.38%58%64%
FY2013
54
0.42%0.42%57%63%

Source: CHRT analysis of data from the Centers for Medicare & Medicaid Services, accessed through Kaiser Health News(20)KHN dataset is available here: http://khn.org/news/medicare-readmissions-penalties-by-state/

According to MPRO, Southeast Michigan hospitals have higher readmission rates than the rest of the state.(21)J. Greene. May 17, 2015. Medicare hospital readmission rate higher in metro Detroit than rest of state. Crain’s Detroit Business. (accessed 6/15/2015). In total, Michigan hospitals are being penalized an estimated $25 million in FY2015, but those penalties are regionally concentrated: hospitals in Southeast Michigan will lose $21 million (84 percent of Michigan’s total penalties) in Medicare reimbursement, according to an MPRO analysis.(22)J. Greene. May 17, 2015. Michigan hospitals cut readmission rates but continue to pay stiff penalties. Crain’s Detroit Business. MPRO reported that the average FY2015 penalty for hospitals in Southeast Michigan is 0.72 percent, up from 0.42 percent in FY2014.

Key Readmission Reduction Initiatives in Michigan

The HRRP has spurred a significant amount of activity to curb hospital readmissions. In 2013, CHRT identified 10 readmissions initiatives used by hospitals and health plans nationally. Six of these initiatives have been implemented in Michigan (Appendix A provides an update on the other four programs). Those programs implemented in Michigan included:

  • Care Transitions Intervention® (CTI): Transitions Coaches® (e.g. advance practice nurses, registered nurses, and social workers), trained through the CTI program, review a patient’s discharge plans at the hospital, visit the patient at home within 48 to 72 hours of discharge, and call the patient three times within the first 28 days after discharge.
  • Project Re-Engineered Discharge (RED): Nurses coordinate patients’ transitions home, while pharmacists call patients after discharge to review medications and communicate any problems to the primary care provider.
  • Transitional Care Model (TCM): Advanced practice nurses provide home visits to high-risk elderly patients for three months, and are available by phone seven days a week.
    Hospital to Home (H2H): A central clearinghouse provides hospitals and cardiovascular care providers with information and tools for improving care transitions and reducing readmission rates among patients who experienced heart failure or a heart attack.
  • Project BOOST (Better Outcomes for Older adults through Safe Transitions): A toolkit that offers hospitals and primary care providers evidence-based clinical intervention tools for improving care transitions.
  • STate Action on Avoidable Readmissions (STAAR): A pilot program that focuses on building community-based and state-based partnerships to improve care transitions.

Each of the six initiatives target one of three levels for intervention—patient, system, and community levels—and are supported by varying degrees of evidence. The following is a summary of their implementation in Michigan, and an introduction to BCBSM’s new initiative to help reduce hospital readmissions in the state.

Patient-level Intervention

To date, the initiatives that have been most successful in reducing hospital readmissions—CTI, Project RED, and TCM—focus on transitioning patients from the hospital to the home setting. In randomized controlled trials for each of the three initiatives, data showed reductions in readmissions and overall health care costs.(23)E. Coleman et al. Sept. 2006. The Care Transitions Intervention: Results of a Randomized Controlled Trial. Archives of Internal Medicine, 150(3):178-188. ,(24)M.D. Naylor et al. May 2004. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized Controlled Trial. Journal of the American Geriatrics Society, 52:675-684.,(25)B.W. Jack et al. Feb. 2009. A Reengineered Hospital Discharge Program to Decrease Rehospitalizations: A Randomized Trial, Annals of Internal Medicine, 150(3):178-188.

Each model is used by payers, hospitals and other providers in Michigan, but CTI appears to be the most used and serves as the model for BCBSM’s Care Transitions to Home and Care Transitions to Skilled Nursing Facility programs. In these BCBSM care management programs, nurses call or visit high-risk BCBSM members and their clinicians to provide the following services post-discharge:(26)Blue Cross Blue Shield of Michigan. May 14, 2015. Personal interview

  • Medication reconciliation
  • Access to services such as home care and durable medical equipment
  • Coaching on signs of worsening symptoms
  • Assistance making follow-up primary care appointments
  • Triage for referral to other programs
  • Assessment of caregiver support

System-level Intervention

Two of the six initiatives, H2H and Project BOOST, have developed tools, such as standardized forms and methods for transmitting patient information from a hospital to primary care and specialty providers, to help providers implement evidence-based practices for improving the hospital discharge process. Many of these tools are based on principles found in the more-widely used initiatives CTI, Project RED, and TCM.

H2H, an initiative of the American College of Cardiology, helps hospitals and cardiac providers achieve attainable quality improvement goals within their organization by helping to develop goal statements for projects, define measures of success, and assess their progress.(27)B.W. Jack et al. 2009. An example of H2H’s quality improvement projects is See You In 7, which focuses on helping providers develop a process for scheduling follow-up appointments within seven days of discharging patients. However, no data has demonstrated that the program is associated with reducing hospital readmissions. Approximately 600 hospitals nationwide have implemented H2H, including hospitals in Michigan.(28)American College of Cardiology. N.d. Hospital to Home. http://cvquality.acc.org/Initiatives/H2H.aspx (accessed 6/15/15).

In comparison, Project BOOST offers evidence-based clinical interventions for a wide array of conditions, including risk assessment tools and risk-specific discharge preparations. Data has shown that the program is helping hospital units reduce readmissions.(29)LO Hansen et al. Aug. 2013. Project BOOST: Effectiveness of a Multihospital Effort to Reduce Rehospitalization, Journal of Hospital Medicine, 8(8):421-427. As of June 2015, the program is only implemented in 196 hospitals nationwide.(30)Society of Hospital Medicine. N.d. Project BOOST. http://www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/Overview.aspx (accessed 6/15/15).

In 2013, Project BOOST was implemented in 24 hospitals and provider organizations in the Michigan, the majority of which implemented the program through the Michigan Transitions of Care Collaborative (M-TC2). The M-TC2, a collaborative quality initiative (CQI) of Blue Cross Blue Shield of Michigan (BCBSM), was based on Project BOOST and rewarded physician organizations for taking steps to improve care transitions and reduce readmissions. At the end of 2014, BCBSM retired the M-TC2, reducing Project BOOST’s presence in the state. The project coordinators for the CQI found it had limited impact because it only provided financial incentives for physician organizations and not hospitals.(31)Blue Cross Blue Shield of Michigan. May 14, 2015. Personal interview.

Community-level Intervention

STAAR, which concluded in 2013, aimed to reduce hospital readmissions by improving care transitions but not at the patient level. Launched in 2009 by the Institute for Healthcare Improvement (IHI), the goal of the four-year pilot program (2009-2013) was to form relationships among providers and other stakeholders to effectively coordinate patient care across settings. IHI selected Michigan and three other states—Massachusetts, Ohio, and Washington—to participate. Michigan’s program, led by the Michigan Health and Hospital Association’s Keystone Center for Patient Safety and Quality and the Michigan Peer Review Organization (MPRO), was required to implement two interventions:

  1. Cross-continuum teams: Community-based teams of hospitals, providers, support services, and patients worked together to align policies and practices across settings to improve the hospital discharge process.
  2. State-level steering committee: A multi-stakeholder, state-level committee charged with (1) coordinating and aligning complementary programs across the state, (2) identifying and mitigating systemic barriers, and (3) promoting a common framing of the issues through provider and stakeholder networks.

STAAR concluded in 2013 due to a lack of continued funding from the Commonwealth Fund. Data is not yet available on the program’s impact in the state.(32)A.E. Boutwell, M.B. Johnson, P. Rutherford et al. July 2011. An Early Look At A Four-State Initiative To Reduce Avoidable Hospital Readmissions. Health Affairs, 30(7):1272-1280.

New Intervention

In February 2015, BCBSM introduced a new CQI, the Integrated Michigan Patient-centered Alliance on Care Transitions (I-MPACT), to reduce avoidable readmissions and post-discharge ED utilization rates. I-MPACT replaces BCBSM’s M-TC2 CQI, which BCBSM retired at the end of 2014.(33)Blue Cross Blue Shield of Michigan. Feb. 2015. Blue Cross and BCN will make an I-MPACT with new transitions of care program. Value Partnerships Update. (accessed 6/15/15). BCBSM found that M-TC2 was implemented in fewer than expected hospital units largely because it did not provide incentives for hospitals, and the staff capacity at participating physician organizations and hospitals to extract data for the CQI was limited.

I-MPACT, which is based at the University of Michigan Health System, develops care coordination partnerships between hospitals, physician organizations, other post-acute care providers and community organizations. Unlike M-TC2, I-MPACT is a hybrid CQI (includes incentives for hospitals in addition to physician organizations) and does not standardize interventions statewide, but is organized regionally (based on 16 hospital referral regions in Michigan),(34)The hospital referral regions were defined using the Dartmouth Atlas method. See: http://www.dartmouthatlas.org/tools/faq/researchmethods.aspx allowing providers to tailor care transition interventions to the community and patient population that they serve.(35)Blue Cross Blue Shield of Michigan. May 14, 2015. Personal interview.

Participants for the first cohort will be finalized in Fall 2015 and will include three to four regional provider teams. The target population will include adult members (18-64 years), with an emphasis on certain conditions (e.g., health failure). The CQI is expected to launch in 2016.(36)Ibid.

Conclusion

Providers and payers in Michigan are increasingly investing in initiatives to reduce hospital readmissions, due in part to the HRRP established under the ACA. Many readmission reduction initiatives have reacted to the HRRP by tailoring much of their focus to conditions targeted by HRRP (e.g., heart failure). Future changes to the HRRP could impact where hospitals choose to focus their resources and the strategies they use to reduce readmissions.

One such change that could impact the program is the inclusion of patients’ socioeconomic status (SES), which CMS does not currently adjust for when calculating penalties. For example, Congress has introduced bi-partisan legislation to require the program to risk adjust for SES, but it has yet to pass. This concept is also being explored by the National Quality Forum. In 2015, the organization launched a two-year trial to study the implications of considering patient-level adjustments factors, including SES, in the HRRP and other pay-for-performance programs.(37)The Establishing Beneficiary Equity in the Hospital Readmission Program Act 0f 2015 (S. 288, H.R. 1343).is being considered by Congress. ,(38)National Quality Forum, July 23, 2014. NQF Board Approves Trial Period to Test Impact of Risk Adjustment of Performance Measures for Sociodemographic Factors. (accessed 6/15/2015).,(39)National Quality Forum. N.d. Risk Adjusting Measures for Socioeconomic Status. (accessed 6/15/2015). This change would be particularly relevant for safety-net hospitals, such as those located in Southeast Michigan, that are caring for large low-income populations, and are more than twice as likely to be penalized as hospitals caring for higher-income patients.(40)K.E. Joynt, A.K. Jha. March 2013. A Path Forward on Medicare Readmissions. New England Journal of Medicine, 368:1175-1177,(41)K.L. Graham, E.H. Wilker, M.D. Howell et al. June 2015. Differences Between Early and Late Readmissions Among Patients: A Cohort Study. Annals of Internal Medicine, 162(11):741-749.

APPENDIX A

Update on key readmission reduction programs not implemented in Michigan

The following is an update on the four out-of-state programs that CHRT highlighted in a 2013 publication on readmission reduction initiatives. Although these programs are not currently implemented in Michigan, they may serve as a resource as providers and health plans explore opportunities for improving patient care.

1. Collaborative on Reducing Readmissions in Florida (http://collab.fha.org)
The Collaborative on Reducing Readmissions in Florida initiative, staffed by the Florida Hospital Association, provides 75 participating hospitals with a shared learning environment for reducing readmissions.

In August 2015, the collaborative will launch its second phase and begin working with hospitals to develop and implement quality improvement initiatives.(42)Florida Hospital Association. Jun. 11, 2015. Personal interview.

2. Optum CarePlus (www.optum.com/landing/care-management)
Developed in 1987, the CarePlus model (initially known as EverCare) uses advanced practice nurses and care managers to provide individuals in long-term care facilities with in-facility clinical and case management services. The model has been shown to reduce health care spending, hospitalizations, and emergency department visits.(43)[1] R.L. Kane et al. Oct. 2003. The effect of Evercare on Hospital Use. Journal of the American Geriatrics Society, 51(10): 1427-1434.,(44)R.L. Kane et al. 2002. Evaluation of the EverCare Demonstration Project, Final Report. (Minneapolis, MN: University of Minnesota).

Today, CarePlus is owned by Optum, a health care services platform under UnitedHealth Group. The vendor provides a broad range of Medicare, Medicaid, and private long-term care delivery and coordination programs to payers based on the CarePlus model.(45)R.J. Shumacher. 20015. Optum™ CarePlus: In-Place Clinical Delivery for Nursing Home Residents. In M.L. Malone, E.A. Capezuti, R.M. Palmer. (Eds.), Geriatrics Models of Care: Brining ‘Best Practice’ to an Aging America, pp. 249-255 (Switzerland: Springer International). ,(46)Optum. 2013. The impact of Optum CarePlus on nursing home and residents. (accessed 6/15/15)

3. Guided Care® (www.johnshopkinssolutions.com/solution/guided-care-2/)
Guided Care is a chronic care management program that places nurses in primary care offices. The nurses supplement care to elderly patients with chronic illnesses by providing in-home assessments, coordinating care, and educating patients and their caregivers about self-management skills.

A 2013 study evaluating the program’s effectiveness showed mixed results.(47)C. Boult et al. Mar. 2011. The Effect of Guided Care Teams on the Use of Health Services: Results from a Cluster-Randomized Controlled Trial. Archives of Internal Medicine, 171(5):460-466. A 32-month randomized control trial found the model reduced utilization of home health care by 29 percent for high-risk older patients, but did not significantly improve patients’ health status.(48)C. Boult et al., Jan. 2013. A matched-pair Cluster-Randomized Trail of Guided Care for High-Risk Older Patients. Journal of General Internal Medicine, 28(5):612-621.

4. Preventing Readmissions through Effective Partnerships (www.ihatoday.org/IHA-Institute/PREP.aspx)
Preventing Readmissions through Effective Partnerships (PREP) is a program used by hospitals in Illinois in partnership with Blue Cross Blue Shield of Illinois and the Illinois Hospital Association. The program aims to improve the aggregate statewide 30-day readmission rate in Illinois from 20.3 percent to below 17.5 percent. Through PREP, hospitals receive technical assistance and access to resources from a number of sources, including Project RED and Project BOOST.(49)Illinois Hospital Association. N.d. Preventing Readmissions through Effective Partnerships. http://www.ihatoday.org/IHA-Institute/PREP.aspx (accessed 6/15/15).

The program concluded at the end of 2014, but an evaluation has not yet been published.

 

 

 

 

 

 

 

 

 

 

References   [ + ]

1. U.S. Centers for Medicare & Medicaid Services. 2013. National Health Expenditures.
2. U.S. Centers for Medicare & Medicaid Services, The CMS Blog. Dec. 6, 2013. New Data Shows Affordable Care Act Reforms Are Leading to Lower Hospital Readmission Rates for Medicare Beneficiaries. (accessed 6/26/15).
3. [1] J. Rau. Oct. 2, 2014. Medicare Fines 2,610 Hospitals In Third Round Of Readmission Penalties. Kaiser Health News. (accessed 6/26/15).
4. J. Hu, M.D. Gonsahn, D.R. Nerenz. 2014. Socioeconomic Status and Readmissions: Evidence from an Urban Teaching Hospital. Health Affairs, 33(5):778-785
5. D.C. Goodman, E.S. Fisher, C. Chang. 2013. After Hospitalization: A Dartmouth Atlas Report on Readmissions Among Medicare Beneficiaries. (Hanover, NH: Dartmouth Institute for Health Policy & Clinical Practice). http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf404178 (accessed 6/26/15).
6. L. Russell and P. Eller. May 2013. Acute Care Readmission Reduction Initiatives: Major Program Highlights (Ann Arbor, MI: CHRT).
7. CMS uses a three-year measurement period to increase the number of cases per hospital used for measure calculation, which improves the precision of each hospital’s readmission estimate.
8. CMS defines a hospital’s excess readmission ratio as a measure of a hospital’s readmission performance compared to the national average for the hospital’s set of patients with that applicable condition.
9. Medicare uses an “all-cause” definition for hospital readmissions, meaning a hospital stay at any hospital within 30 days of an initial hospitalization (for the selected conditions) counts as a readmission. As of 2014, planned readmissions related to heart attack, heart failure, and pneumonia within the 30 day window are no longer counted.
10. According to CMS, HRRP focuses on AMI, HF, and pneumonia because they are common conditions with substantial mortality and morbidity and hospitals already report on them for CMS’ Hospital Compare website.
11. C. Boccuti and G. Casillas. Jan. 2015. Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program (Washington, DC: Kaiser Family Foundation). (accessed 6/15/2015).
12. K. Carey and M-Y. Lin. June 2015. Readmissions to New York Hospitals Fell For Three Target Conditions From 2008 to 2012, Consistent With Medicare Goals. Health Affairs, 34(6):978-985.
13. Boccuti and Casillas, 2015.
14. Medicare Payment Advisory Commission. June 2013. Report to the Congress: Medicare and the Health Care Delivery System (Washington, DC). (accessed 6/15/2015).
15. Boccuti and Casillas, 2015
16. J. Greene. May 17, 2015. Michigan hospitals cut readmission rates but continue to pay stiff penalties. Crain’s Detroit Business. (accessed 6/15/15).
17. Psychiatric, rehabilitation, long term care, children’s, cancer, and critical access hospitals are exempt from the HRRP
18. J. Rau. Oct. 2, 2014. Readmission Penalties By State: Year 3, Kaiser Health News. (accessed 6/15/15).
19. The average penalties were calculated for penalized hospitals only, excluding non-penalized hospitals.
20. KHN dataset is available here: http://khn.org/news/medicare-readmissions-penalties-by-state/
21. J. Greene. May 17, 2015. Medicare hospital readmission rate higher in metro Detroit than rest of state. Crain’s Detroit Business. (accessed 6/15/2015).
22. J. Greene. May 17, 2015. Michigan hospitals cut readmission rates but continue to pay stiff penalties. Crain’s Detroit Business.
23. E. Coleman et al. Sept. 2006. The Care Transitions Intervention: Results of a Randomized Controlled Trial. Archives of Internal Medicine, 150(3):178-188.
24. M.D. Naylor et al. May 2004. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized Controlled Trial. Journal of the American Geriatrics Society, 52:675-684.
25. B.W. Jack et al. Feb. 2009. A Reengineered Hospital Discharge Program to Decrease Rehospitalizations: A Randomized Trial, Annals of Internal Medicine, 150(3):178-188.
26. Blue Cross Blue Shield of Michigan. May 14, 2015. Personal interview
27. B.W. Jack et al. 2009.
28. American College of Cardiology. N.d. Hospital to Home. http://cvquality.acc.org/Initiatives/H2H.aspx (accessed 6/15/15).
29. LO Hansen et al. Aug. 2013. Project BOOST: Effectiveness of a Multihospital Effort to Reduce Rehospitalization, Journal of Hospital Medicine, 8(8):421-427.
30. Society of Hospital Medicine. N.d. Project BOOST. http://www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/Overview.aspx (accessed 6/15/15).
31, 35. Blue Cross Blue Shield of Michigan. May 14, 2015. Personal interview.
32. A.E. Boutwell, M.B. Johnson, P. Rutherford et al. July 2011. An Early Look At A Four-State Initiative To Reduce Avoidable Hospital Readmissions. Health Affairs, 30(7):1272-1280.
33. Blue Cross Blue Shield of Michigan. Feb. 2015. Blue Cross and BCN will make an I-MPACT with new transitions of care program. Value Partnerships Update. (accessed 6/15/15).
34. The hospital referral regions were defined using the Dartmouth Atlas method. See: http://www.dartmouthatlas.org/tools/faq/researchmethods.aspx
36. Ibid.
37. The Establishing Beneficiary Equity in the Hospital Readmission Program Act 0f 2015 (S. 288, H.R. 1343).is being considered by Congress.
38. National Quality Forum, July 23, 2014. NQF Board Approves Trial Period to Test Impact of Risk Adjustment of Performance Measures for Sociodemographic Factors. (accessed 6/15/2015).
39. National Quality Forum. N.d. Risk Adjusting Measures for Socioeconomic Status. (accessed 6/15/2015).
40. K.E. Joynt, A.K. Jha. March 2013. A Path Forward on Medicare Readmissions. New England Journal of Medicine, 368:1175-1177
41. K.L. Graham, E.H. Wilker, M.D. Howell et al. June 2015. Differences Between Early and Late Readmissions Among Patients: A Cohort Study. Annals of Internal Medicine, 162(11):741-749.
42. Florida Hospital Association. Jun. 11, 2015. Personal interview.
43. [1] R.L. Kane et al. Oct. 2003. The effect of Evercare on Hospital Use. Journal of the American Geriatrics Society, 51(10): 1427-1434.
44. R.L. Kane et al. 2002. Evaluation of the EverCare Demonstration Project, Final Report. (Minneapolis, MN: University of Minnesota).
45. R.J. Shumacher. 20015. Optum™ CarePlus: In-Place Clinical Delivery for Nursing Home Residents. In M.L. Malone, E.A. Capezuti, R.M. Palmer. (Eds.), Geriatrics Models of Care: Brining ‘Best Practice’ to an Aging America, pp. 249-255 (Switzerland: Springer International).
46. Optum. 2013. The impact of Optum CarePlus on nursing home and residents. (accessed 6/15/15)
47. C. Boult et al. Mar. 2011. The Effect of Guided Care Teams on the Use of Health Services: Results from a Cluster-Randomized Controlled Trial. Archives of Internal Medicine, 171(5):460-466.
48. C. Boult et al., Jan. 2013. A matched-pair Cluster-Randomized Trail of Guided Care for High-Risk Older Patients. Journal of General Internal Medicine, 28(5):612-621.
49. Illinois Hospital Association. N.d. Preventing Readmissions through Effective Partnerships. http://www.ihatoday.org/IHA-Institute/PREP.aspx (accessed 6/15/15).

Care Transitions: Best Practices and Evidence-based Programs

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Poorly coordinated care transitions from the hospital to other care settings cost an estimated $12 billion to $44 billion per year.(1)L.O. Hansen, R.S. Young, K. Hinami, et al. 2011. Interventions to Reduce 30-Day Rehospitalization: A Systematic Review. Annals of Internal Medicine 155: 520–8. Poor transitions also often result in poor health outcomes. The most common adverse effects associated with poor transitions are injuries due to medication errors, complications from procedures, infections, and falls.(2) S. Kim and S.A. Flanders. 2013. Transitions of Care. Annals of Internal Medicine 58(5 Part 1): ITC3-1.

Many providers are focused on improving transitions, due in part to reimbursement changes under the Affordable Care Act.

In October 2012, the Centers for Medicare and Medicaid Services (CMS) instituted penalties for facilities with high readmission rates within 30 days of discharge for three conditions: myocardial infarction (heart attack), heart failure, and pneumonia.(3)R. Burton. September 13, 2012. Health Policy Brief: Improving Care Transitions. Health Affairs. (Issue Brief). http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=76 (accessed 10/3/13). Hospitals face reimbursement reductions of up to one percent of annual Medicare payments.(4)R. Burton. September 13, 2012. Health Policy Brief: Improving Care Transitions. Health Affairs. (Issue Brief). http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=76 (accessed 10/3/13).

New payment models, including bundled payments and shared savings programs for Accountable Care Organizations, also create incentives to coordinate transitions and provide care in less intensive settings.(5)R. Burton. September 13, 2012. Health Policy Brief: Improving Care Transitions. Health Affairs. (Issue Brief). http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=76 (accessed 10/3/13). CMS is also encouraging outpatient providers to focus on safe transitions through new reimbursement codes issued in 2013. Providers may bill for care transitions services if they see patients within 14 days of discharge from a hospital, skilled nursing facility (SNF), or rehabilitation facility.(6) A.B. Bindman, J.D. Blum, and R. Kronick. 2013. Medicare’s Transitional Care Payment—A Step toward the Medical Home. New England Journal of Medicine 368(8): 692–4. http://www.nejm.org/doi/full/10.1056/NEJMp1214122 (accessed 10/1/13).

Improving care transitions for complex patients moving from hospitals to SNFs, to their own home, or to another setting can result in significant savings while improving patient safety.(7)R. Burton. September 13, 2012. Health Policy Brief: Improving Care Transitions. Health Affairs. (Issue Brief). http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=76 (accessed 10/3/13). This paper summarizes best practices in care transitions and describes successful programs that reduced readmissions and overall costs.

This paper also includes an annotated bibliography detailing the research on care transitions and describes the care transitions programs offered by the University of Michigan Health System and Blue Cross Blue Shield of Michigan. The program descriptions were developed through interviews with key informants in each program, providing greater detail than was available on care transitions programs at other organizations.

Best Practices in Care Transitions

Best practices in care transitions are based on effective programs focusing on transitions from the hospital to home. There is very little research on transitions from the hospital to settings other than the home (such as emergency departments, nursing homes, or home health).(8) M.D. Naylor, L.H Aiken, E.T. Kurtzman, et al. 2011. The Importance of Transitional Care in Achieving Health Reform. Health Affairs 30(4): 746–54. Therefore, to date, providers must depend on these best practices in hospital-to-home transitions to inform care transition programs for transitions to SNFs and other post-acute care settings.(9) S. Kim and S.A. Flanders. 2013. Transitions of Care. Annals of Internal Medicine 58(5 Part 1): ITC3-1. (10) 6. M.D. Naylor, E. T. Kurtzman, M.V. Pauly. 2009. Transitions of Elders between Long-Term Care and Hospitals. Policy, Politics, & Nursing Practice, 10(3): 187–94. The following program elements are described as best practices in the academic literature:

  • Comprehensive discharge planning. Prior to discharge, hospital staff organize follow-up services and address patients’ financial and psychosocial barriers to receiving needed care, drawing on community resources as needed. Hospital staff call patients one to three days after discharge to address patients’ questions, assess symptoms and medications, and reinforce patient/caregiver education. Discharge planning can be conducted by physicians, care managers, nurses, or pharmacists.(11) S. Kim and S.A. Flanders. 2013. Transitions of Care. Annals of Internal Medicine 58(5 Part 1): ITC3-1. (12) R.E. Burke and E.A. Coleman. 2013. Interventions to Decrease Hospital Readmissions: Keys for Cost-Effectiveness. JAMA Internal Medicine. Published online ahead of print on March 25, 2013. (13) J.L. Greenwald, C.R. Denham, B.W. Jack. 2007. The Hospital Discharge: A Review of a High Risk Care Transition with Highlights of a Reengineered Discharge Process. Journal of Patient Safety 3(2): 97–106. http://www.bu.edu/fammed/ projectred/publications/greenwald.pdf (accessed 10/3/13). (14) S. Kripalani, A.T. Jackson, J.L. Schnipper, E.A. Coleman. 2007. Promoting Effective Transitions of Care at Hospital Discharge: A Review of Key Issues for Hospitalists. Journal of Hospital Medicine 2(5): 314–23. http://onlinelibrary. wiley.com/doi/10.1002/jhm.228/full (accessed 10/3/13). (15) 10. P.E. Sokol and M.K. Wynia, writing for the AMA Expert Panel on Care Transitions. 2013. There and Home Again, Safely: 5 Responsibilities of Ambulatory Care Practices in High Quality Care Transitions (Chicago, IL: American Medical Association). http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf (accessed 10/3/13). (16) M.D. Naylor, D.A. Brooten, R.L. Campbell, et al. 2004. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. Journal of the American Geriatrics Society 52: 675–84. http://www.cha.com/pdfs/ Quality%5CReducing%20Hospital%20Readmissions/Related%20Articles/Transitional%20Care%20of%20Older%20Adul ts.pdf (accessed 10/3/13).
  • Complete and timely communication of information. Clinicians in the hospital send discharge summaries to outpatient providers one to two days after discharge, using standardized formats. Essential information includes diagnoses, test and procedure results, pending tests, medication lists, rationale for medication changes, advance directives, caregiver status, contact information for the discharging physician, and recommended follow-up care. (17) S. Kim and S.A. Flanders. 2013. Transitions of Care. Annals of Internal Medicine 58(5 Part 1): ITC3-1. (18) R.E. Burke and E.A. Coleman. 2013. Interventions to Decrease Hospital Readmissions: Keys for Cost-Effectiveness. JAMA Internal Medicine. Published online ahead of print on March 25, 2013. (19) J.L. Greenwald, C.R. Denham, B.W. Jack. 2007. The Hospital Discharge: A Review of a High Risk Care Transition with Highlights of a Reengineered Discharge Process. Journal of Patient Safety 3(2): 97–106. http://www.bu.edu/fammed/ projectred/publications/greenwald.pdf (accessed 10/3/13). (20) S. Kripalani, A.T. Jackson, J.L. Schnipper, E.A. Coleman. 2007. Promoting Effective Transitions of Care at Hospital Discharge: A Review of Key Issues for Hospitalists. Journal of Hospital Medicine 2(5): 314–23. http://onlinelibrary. wiley.com/doi/10.1002/jhm.228/full (accessed 10/3/13). (21) V. Snow, D. Beck, T. Budnitz, et al. 2009. Transitions of Care Consensus Policy Statement, American College of Physicians: Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, Society of Academic Emergency Medicine. Journal of General Internal Medicine 24(8): 971–6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2710485/ (accessed 10/3/13).
  • Medication reconciliation. Clinicians reconcile medications at each transition (for example, to inpatient, outpatient, or post-acute care). Clinicians check the accuracy of medication lists and dosages, and look for contraindications. Clinicians also assess financial barriers to filling prescriptions and provide medication lists to outpatient providers. Medications can be reconciled by physicians, pharmacists, nurses, or care managers.(22) S. Kim and S.A. Flanders. 2013. Transitions of Care. Annals of Internal Medicine 58(5 Part 1): ITC3-1. (23) R.E. Burke and E.A. Coleman. 2013. Interventions to Decrease Hospital Readmissions: Keys for Cost-Effectiveness. JAMA Internal Medicine. Published online ahead of print on March 25, 2013. (24) J.L. Greenwald, C.R. Denham, B.W. Jack. 2007. The Hospital Discharge: A Review of a High Risk Care Transition with Highlights of a Reengineered Discharge Process. Journal of Patient Safety 3(2): 97–106. http://www.bu.edu/fammed/ projectred/publications/greenwald.pdf (accessed 10/3/13). (25) S. Kripalani, A.T. Jackson, J.L. Schnipper, E.A. Coleman. 2007. Promoting Effective Transitions of Care at Hospital Discharge: A Review of Key Issues for Hospitalists. Journal of Hospital Medicine 2(5): 314–23. http://onlinelibrary. wiley.com/doi/10.1002/jhm.228/full (accessed 10/3/13). (26) 10. P.E. Sokol and M.K. Wynia, writing for the AMA Expert Panel on Care Transitions. 2013. There and Home Again, Safely: 5 Responsibilities of Ambulatory Care Practices in High Quality Care Transitions (Chicago, IL: American Medical Association). http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf (accessed 10/3/13). (27) M.D. Naylor, D.A. Brooten, R.L. Campbell, et al. 2004. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. Journal of the American Geriatrics Society 52: 675–84. http://www.cha.com/pdfs/ Quality%5CReducing%20Hospital%20Readmissions/Related%20Articles/Transitional%20Care%20of%20Older%20Adul ts.pdf (accessed 10/3/13). (28) V. Snow, D. Beck, T. Budnitz, et al. 2009. Transitions of Care Consensus Policy Statement, American College of Physicians: Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, Society of Academic Emergency Medicine. Journal of General Internal Medicine 24(8): 971–6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2710485/ (accessed 10/3/13). (29) E.A. Coleman, C. Parr, S. Chalmers, S. Min. 2006. The Care Transitions Intervention: Results of a Randomized Controlled Trial. Archives of Internal Medicine 166: 1823–28. http://www.caretransitions.org/documents/ The%20CTI%20RCT%20-%20AIM.pdf (accessed 10/3/13).
  • Patient/caregiver education using the “teach back” method. In this method, patients are asked to restate instructions or concepts in their own words. Education can be supplemented by illustrations and written materials at appropriate reading levels. Education focuses on major diagnoses, medication changes, time of follow-up appointments, self-care, warning signs, and what to do if problems arise. Physicians, nurses, care managers, or discharge planners provide education before and after discharge.(30) R.E. Burke and E.A. Coleman. 2013. Interventions to Decrease Hospital Readmissions: Keys for Cost-Effectiveness. JAMA Internal Medicine. Published online ahead of print on March 25, 2013. (31) J.L. Greenwald, C.R. Denham, B.W. Jack. 2007. The Hospital Discharge: A Review of a High Risk Care Transition with Highlights of a Reengineered Discharge Process. Journal of Patient Safety 3(2): 97–106. http://www.bu.edu/fammed/ projectred/publications/greenwald.pdf (accessed 10/3/13). (32) 10. P.E. Sokol and M.K. Wynia, writing for the AMA Expert Panel on Care Transitions. 2013. There and Home Again, Safely: 5 Responsibilities of Ambulatory Care Practices in High Quality Care Transitions (Chicago, IL: American Medical Association). http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf (accessed 10/3/13). (33) M.D. Naylor, D.A. Brooten, R.L. Campbell, et al. 2004. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. Journal of the American Geriatrics Society 52: 675–84. http://www.cha.com/pdfs/ Quality%5CReducing%20Hospital%20Readmissions/Related%20Articles/Transitional%20Care%20of%20Older%20Adul ts.pdf (accessed 10/3/13). (34) V. Snow, D. Beck, T. Budnitz, et al. 2009. Transitions of Care Consensus Policy Statement, American College of Physicians: Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, Society of Academic Emergency Medicine. Journal of General Internal Medicine 24(8): 971–6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2710485/ (accessed 10/3/13). (35) E.A. Coleman, C. Parr, S. Chalmers, S. Min. 2006. The Care Transitions Intervention: Results of a Randomized Controlled Trial. Archives of Internal Medicine 166: 1823–28. http://www.caretransitions.org/documents/ The%20CTI%20RCT%20-%20AIM.pdf (accessed 10/3/13).
  • Open communication between providers. Communication occurs between care settings and among multidisciplinary teams within each setting. Responsibilities are clearly defined for the discharging provider and the subsequent provider. The discharging provider confirms that the subsequent provider received the discharge summary and pertinent test results, and responds to questions promptly. Information transfer involves physicians, nurses, care managers, office personnel, and information technology staff.(36) R.E. Burke and E.A. Coleman. 2013. Interventions to Decrease Hospital Readmissions: Keys for Cost-Effectiveness. JAMA Internal Medicine. Published online ahead of print on March 25, 2013. (37) J.L. Greenwald, C.R. Denham, B.W. Jack. 2007. The Hospital Discharge: A Review of a High Risk Care Transition with Highlights of a Reengineered Discharge Process. Journal of Patient Safety 3(2): 97–106. http://www.bu.edu/fammed/ projectred/publications/greenwald.pdf (accessed 10/3/13). (38) 10. P.E. Sokol and M.K. Wynia, writing for the AMA Expert Panel on Care Transitions. 2013. There and Home Again, Safely: 5 Responsibilities of Ambulatory Care Practices in High Quality Care Transitions (Chicago, IL: American Medical Association). http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf (accessed 10/3/13). (39) M.D. Naylor, D.A. Brooten, R.L. Campbell, et al. 2004. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. Journal of the American Geriatrics Society 52: 675–84. http://www.cha.com/pdfs/ Quality%5CReducing%20Hospital%20Readmissions/Related%20Articles/Transitional%20Care%20of%20Older%20Adul ts.pdf (accessed 10/3/13). (40) V. Snow, D. Beck, T. Budnitz, et al. 2009. Transitions of Care Consensus Policy Statement, American College of Physicians: Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, Society of Academic Emergency Medicine. Journal of General Internal Medicine 24(8): 971–6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2710485/ (accessed 10/3/13). (41) E.A. Coleman, C. Parr, S. Chalmers, S. Min. 2006. The Care Transitions Intervention: Results of a Randomized Controlled Trial. Archives of Internal Medicine 166: 1823–28. http://www.caretransitions.org/documents/ The%20CTI%20RCT%20-%20AIM.pdf (accessed 10/3/13).
  • Prompt follow-up visit with an outpatient provider after discharge. Hospital staff schedule follow-up visits prior to discharge. Such visits are generally recommended within seven days of discharge. Providers offer follow-up care, ongoing symptom and medication management, and 24/7 phone access. Physicians, nurses, pharmacists, and/or care managers follow up with patients during office visits, home visits, or by phone. (42) S. Kim and S.A. Flanders. 2013. Transitions of Care. Annals of Internal Medicine 58(5 Part 1): ITC3-1. (43) R.E. Burke and E.A. Coleman. 2013. Interventions to Decrease Hospital Readmissions: Keys for Cost-Effectiveness. JAMA Internal Medicine. Published online ahead of print on March 25, 2013. (44) 11. M.D. Naylor, D.A. Brooten, R.L. Campbell, et al. 2004. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. Journal of the American Geriatrics Society 52: 675–84. http://www.cha.com/pdfs/Quality%5CReducing%20Hospital%20Readmissions/Related%20Articles/Transitional%20Care%20of%20Older%20Adul ts.pdf (accessed 10/3/13).

The research strongly suggests that these best practices create a strong foundation for high-quality, cost-saving care transitions from the hospital to home. Multiple providers can share responsibility for completing each best practice, as long as each provider’s role is clearly defined. A 2009 consensus guideline on care transitions, which was jointly published by six medical professional societies, also indicates that programs should be evaluated using measures that address gaps in care and directly affect quality.(45) V. Snow, D. Beck, T. Budnitz, et al. 2009. Transitions of Care Consensus Policy Statement, American College of Physicians: Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, Society of Academic Emergency Medicine. Journal of General Internal Medicine 24(8): 971–6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2710485/ (accessed 10/3/13).

Successful Programs in the Academic Literature

Most successful care transitions programs have focused on transitions from the hospital to home, as have almost all of the transitions programs that were evaluated in randomized controlled trials (RCTs)—the gold standard of research. Three of the effective hospital-to-home programs not only reduced readmissions or poor outcomes, but also reduced costs. Each of these programs incorporated most of the best practices in care transitions, and each has been implemented by providers nationwide.

  • The Care Transitions Intervention. This intervention was conducted in a large integrated delivery system in Colorado from 2002 to 2003. Advanced practice nurses met with high-risk elderly patients prior to discharge, then conducted one home visit and three phone calls over four weeks following discharge. The intervention reduced readmissions within 30 days by 30 percent and readmissions within 180 days by 17 percent, and had an estimated 15 percent net savings ($390 per patient) in total hospitalization costs six months after the intervention. Program costs were factored in to the net savings estimate.(46) E.A. Coleman, C. Parr, S. Chalmers, S. Min. 2006. The Care Transitions Intervention: Results of a Randomized Controlled Trial. Archives of Internal Medicine 166: 1823–28. http://www.caretransitions.org/documents/ The%20CTI%20RCT%20-%20AIM.pdf (accessed 10/3/13).
  • The Transitional Care Model. This intervention was conducted in six academic and community hospitals in Philadelphia from 1997 to 2001. Advanced practice nurses provided a minimum of eight home visits to high-risk elderly patients for three months, and were available by phone seven days a week. The intervention reduced the readmission rate after one year by 36 percent, and net costs fell by 38 percent ($4,845 per patient) in the year after discharge. Program costs were factored into the net savings estimate.(47) M.D. Naylor, D.A. Brooten, R.L. Campbell, et al. 2004. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. Journal of the American Geriatrics Society 52: 675–84. http://www.cha.com/pdfs/ Quality%5CReducing%20Hospital%20Readmissions/Related%20Articles/Transitional%20Care%20of%20Older%20Adul ts.pdf (accessed 10/3/13).
  • Project RED (Re-engineered Discharge). This intervention was conducted at the Boston Medical Center from 2003 to 2004. Nurse discharge advocates met in-person with patients before their discharge, made follow-up appointments with primary care physicians (PCPs), and sent discharge summaries to PCPs. Pharmacists called patients two to four days after discharge to review medications and communicated problems to PCPs. The intervention reduced the combined rate of 30-day readmissions and emergency department (ED) visits by 30 percent. Total health care spending in the 30 days after discharge dropped by 34 percent ($412 per patient) before deducting the cost of the intervention. The authors do not estimate net savings, but estimate the staff time required for the intervention as a half-time nursing position and a 0.15-time pharmacist position.(48) B.W. Jack, V.K. Chetty, D. Anthony, et al. 2009. A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial. Annals of Internal Medicine 150(3):178–88. http://www.bu.edu/fammed/ projectred/publications/AnnalsArtcile2-09.pdf (accessed 10/3/13).

These three programs are widely considered to be best practices because they are the only programs that reduced both readmissions and total costs in RCTs.(49) S. Kim and S.A. Flanders. 2013. Transitions of Care. Annals of Internal Medicine 58(5 Part 1): ITC3-1. (50)R. Burton. September 13, 2012. Health Policy Brief: Improving Care Transitions. Health Affairs. (Issue Brief). http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=76 (accessed 10/3/13). (51) M.D. Naylor, E. T. Kurtzman, M.V. Pauly. 2009. Transitions of Elders between Long-Term Care and Hospitals. Policy, Politics, & Nursing Practice, 10(3): 187–94. (52)G. Hesselink, L. Schoonhoven, P. Barach, et al. 2012. Improving Patient Handovers from Hospital to Primary Care: A Systematic Review. Annals of Internal Medicine 57(6): 417–28. Additional hospital-to-home transition programs improved patients’ outcomes, but did not evaluate costs.(53)G. Hesselink, L. Schoonhoven, P. Barach, et al. 2012. Improving Patient Handovers from Hospital to Primary Care: A Systematic Review. Annals of Internal Medicine 57(6): 417–28. In a 2012 systematic review of RCTs focused on transitions from the hospital to home, at least one outcome measure showed improvement in 26 of the 35 RCTs.(54)G. Hesselink, L. Schoonhoven, P. Barach, et al. 2012. Improving Patient Handovers from Hospital to Primary Care: A Systematic Review. Annals of Internal Medicine 57(6): 417–28.

There is little high-quality research on care transitions between settings other than the hospital to home. Only one RCT evaluated a program focused on transitions from the hospital to long-term care (LTC) facilities. There are no RCTs evaluating other types of care transitions from hospitals to alternative post-acute care settings, such as nursing homes, rehabilitation facilities, or home care. In the program that addressed transitions to long-term care, a pharmacist coordinated care and reconciled medications for patients entering a LTC facility for the first time. The program improved patients’ pain management during the eight weeks of follow-up, but had no impact on patients’ use of hospital services.(55) M. Crotty, D. Rowett, L. Spurling, et al. 2004. Does the Addition of a Pharmacist Transition Coordinator Improve Evidence-Based Medication Management and Health Outcomes in Older Adults Moving from the Hospital to a Long- Term Care Facility? Results of a Randomized, Controlled Trial. The American Journal of Geriatric Pharmacotherapy 2(4): 257–64.

No research to date explicitly evaluates care transitions for patients eligible for both Medicare and Medicaid (known as dual eligibles).(56) M.D. Naylor, L.H Aiken, E.T. Kurtzman, et al. 2011. The Importance of Transitional Care in Achieving Health Reform.Health Affairs 30(4): 746–54 Because many dual eligibles live in LTC facilities, the one RCT addressing long-term care provides the best available evidence for this population. Care management programs for patients living in nursing homes may also suggest effective care transition strategies for dual eligibles. One such program is Evercare, an enhanced primary care initiative staffed by nurse practitioners. By providing additional primary care visits to patients at risk of admission or readmission, the program reduced the hospitalization rate of Evercare enrollees by 50 percent compared to two control groups. The program’s estimated annual savings was $103,000 per nurse practitioner.(57) M.D. Naylor, E. T. Kurtzman, M.V. Pauly. 2009. Transitions of Elders between Long-Term Care and Hospitals. Policy, Politics, & Nursing Practice, 10(3): 187–94. (58) R.L. Kane, G. Keckhafer, S. Flood, et al. 2003. The Effects of Evercare on Hospital Use. Journal of the American Geriatrics Society 51: 1427–1434.

Several successful programs used technology to improve health outcomes. In the 2012 systematic review of RCTs focused on hospital-to-home transitions, five RCTs were based on computer-generated communication between providers in different settings. The programs generally used electronic health records to share discharge summaries or used health information exchanges to provide real-time discharge notifications.(59)G. Hesselink, L. Schoonhoven, P. Barach, et al. 2012. Improving Patient Handovers from Hospital to Primary Care: A Systematic Review. Annals of Internal Medicine 57(6): 417–28. One of the effective RCTs used telemonitoring to reduce the combined rate of readmissions and ED visits in the year after discharge. (60)G. Hesselink, L. Schoonhoven, P. Barach, et al. 2012. Improving Patient Handovers from Hospital to Primary Care: A Systematic Review. Annals of Internal Medicine 57(6): 417–28. (61) 18. A. Giordano, S. Scalvini, E. Zanelli, et al. 2009. Multicenter randomised trial on home-based telemanagement to prevent hospital readmission of patients with chronic heart failure. International Journal of Cardiology 131: 192–199.

Telemonitoring involves patients’ regular use of devices like scales or blood pressure cuffs that send the results electronically to health care providers, allowing for quick intervention if the results raise red flags. However, telemonitoring and phone-based interventions generally did not reduce readmissions for high-risk elderly patients, particularly when implemented alone.(62)M.D. Naylor, L.H Aiken, E.T. Kurtzman, et al. 2011. The Importance of Transitional Care in Achieving Health Reform.
Health Affairs 30(4): 746–54.
(63) R.E. Burke and E.A. Coleman. 2013. Interventions to Decrease Hospital Readmissions: Keys for Cost-Effectiveness. JAMA Internal Medicine. Published online ahead of print on March 25, 2013. (64) G. Paré, M. Jaana, C. Sicotte. 2007. Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base. Journal of the American Medical Informatics Association 14(3): 269–77. http://jamia.bmj.com/content/14/3/ 269.full.pdf+html (accessed 10/3/13). (65) P.Y. Takahashi, J.L. Pecina, B. Upatising, et al. 2012. A Randomized Controlled Trial of Telemonitoring in Older Adults with Multiple Health Issues to Prevent Hospitalizations and Emergency Department Visits. Archive of Internal Medicine 172(10): 773–9. http://archinte.jamanetwork.com/article.aspx?articleid=1149633 (accessed 10/3/13). (66) S.I. Chaudhry, J.A. Mattera, J.P. Curtis, et al. 2010. Telemonitoring in Patients with Heart Failure. New England Journal of Medicine 363: 2301–9. http://www.nejm.org/doi/full/10.1056/NEJMoa1010029#t=article (accessed 10/3/13). This research suggests that enhancing electronic records and information exchanges can facilitate safe transitions, but the impact of telemonitoring is less clear.

Care transitions interventions have the greatest impact on high-risk patients, especially those with modifiable risks like diabetes and obesity.7 It is difficult to accurately identify high-risk patients using current risk stratification software and methodologies.(67) S. Kim and S.A. Flanders. 2013. Transitions of Care. Annals of Internal Medicine 58(5 Part 1): ITC3-1. However, two tools are recommended in the academic literature: the LACE model (length of stay, acuity of admission, comorbidities, and ED use) and the 8Ps Risk Assessment Tool.(68) S. Kim and S.A. Flanders. 2013. Transitions of Care. Annals of Internal Medicine 58(5 Part 1): ITC3-1. The LACE model was validated for inpatient care,(69) C. van Walraven, I.A. Dhalla, C. Bell, et al. 2010. Derivation and Validation of an Index to Predict Early Death or Unplanned Readmission after Discharge from Hospital to the Community. Canadian Medical Association Journal 182(6): 551–7. http://www.cmaj.ca/content/182/6/551.full.pdf+html (accessed 10/3/13). and was adapted for outpatient providers in 2013 by the Michigan Primary Care Transformation Demonstration.(70) Marie Beisel, RN, MSN, CPHQ, Project Manager at the Michigan Care Management Resource Center. May 13, 2013. Personal communication. The 8Ps model was developed by Project BOOST, a care transitions model piloted in hospitals nationwide. This tool includes both clinical and psychosocial variables.(71) Society of Hospital Medicine. 2008. Risk Assessment Tool: the 8Ps. http://www.hospitalmedicine.org/ResourceRoom Redesign/RR_CareTransitions/html_CC/06Boost/03_Assessment.cfm (accessed 7/29/13)

 

Conclusion

Safe care transitions from the hospital to other settings are essential to providing high-quality patient care and reducing avoidable readmissions. Providers and payers are increasingly investing in care transition programs, due in part to reimbursement changes under the Affordable Care Act that reward high-quality care. Best practices in hospital-to-home transitions can inform current and future initiatives, and health systems can also implement one of the three care transitions programs shown to reduce readmissions and costs. More research is needed on care transitions between hospitals and other settings, such as SNFs and home health care, which present further opportunities to increase both quality and savings.

 

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