Acute care readmission reduction initiatives: An update on major programs in Michigan

July 30, 2015

A person receiving acute care in a hospital holds the hand of another person.Inpatient hospitalizations account for 32 percent of the total $2.9 trillion spent on health care in the United States. 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. Research has shown that many factors—including a patient’s socioeconomic status, clinical conditions, and their communities’ characteristics—can influence acute care hospital readmissions.

 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). This paper is an update on the HRRP and other programs previously highlighted.

The HRRP has spurred a significant amount of activity to curb acute care 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.