Louisiana QIO Reduces Readmissions Rates by 80 Percent with Care Transition Coaches

In an effort to improve coordination across the continuum of care, Louisiana Health Care Review (LHCR), the Medicare QIO for Louisiana, has set an unprecedented standard for change. LHCR is one of 14 QIOs performing the sub-national Care Transitions Theme, which aims to improve health care processes at and after hospital discharge to reduce unnecessary rehospitalization among Medicare beneficiaries. Within six months of the program’s inception, LHCR lowered the readmission rate in the Baton Rouge area from about 19 percent to about 5 percent, far exceeding its original 2 percent goal.

Need for Change

In 2007, Louisiana had the highest rate of Medicare 30-day readmissions in the country. Shorter hospital stays and fragmented care programs were among the problems associated with 2 out of every 10 chronically ill elderly patients coming back to the hospital within a month of their release.

“Patients were receiving the proper care they needed while in the hospital,” said Laurie Robinson, LHCR quality improvement director and a registered nurse. “Yet, once patients left the medical facility, they did not have a full understanding of next steps – whether it was what medicines to take and their proper dosage, or when to make a follow-up doctor’s appointment. It’s become an issue with the continuum of care.”

A Caring Solution with Stunning Results

In Louisiana, five hospitals - Baton Rouge General Medical Center, Lane Regional Medical Center, Ochsner Medical Center- Baton Rouge, Our Lady of the Lake Regional Medical Center and St. Elizabeth Hospital – were selected for participation in the Care Transitions program. More than 10 Baton Rouge-area home health agencies are also participating.

The program works by pairing older patients with a “transition coach.” The patient agrees to meet with the coach within 48 hours of discharge and the coach helps the individual put together a list of questions for their primary care physician. Transition coach and patient teams also discuss questions about medications and devise a self-care plan after leaving the hospital, among other collaborative measures.

During the first six months, the program worked with 93 patients who had diagnoses including pneumonia, chronic obstructive pulmonary disease, congestive heart failure and acute myocardial infraction. Only 4 of the patients were readmitted to hospitals. Normally, 17 of those patients would have returned to the hospital, because of the inability to manage their condition in the outpatient setting.

“Essentially by preparing these patients for life post-hospitalization, we’ve empowered them to take control of their own health care,” said Robinson. “And we’ve seen improvements across the board.”

According to the Medicare Payment Advisory Committee’s (MedPAC) June 2005 report, “A Path to Bundled Payment Around a Rehospitalization,” Medicare could potentially save $12 billion a year if these results can be replicated nationwide.

The next phase of LHCR’s project involves expanding the role of coaches from helping patients with self-management to include coordination with doctors and treatment teams. Through the remainder of the 9^th SOW, LHCR will work toward keeping readmission rates to single digits by assigning each coach 20-25 patients with the goal of reaching 500 patients total.