Bringing Together the Community for Sustainable Reductions in Hospital Readmissions

By Jane Brock, M.D., MSPH, chief medical officer, Colorado Foundation for Medical Care (CFMC) Alicia Goroski, MPH, national project director, Care Transitions Theme Support Center, CFMC Risa Hayes, CPC, NW Denver project manager, CFMC

The Quality Improvement Organization (QIO) Care Transitions Theme emphasizes the importance of community engagement and collaboration as a primary strategy for improving health care quality and efficiency.  The 14 QIOs that are participating in the Theme are using evidence-based interventions and tools to reduce hospital readmissions in a targeted regional health care market. The Centers for Medicare & Medicaid Services (CMS) created a flexible foundation for the Theme to foster learning opportunities; QIOs were not mandated to use specific interventions but were instead provided with a variety of evidence-based interventions and tools and expected to adapt their strategies to best meet local needs.  The Colorado Foundation for Medical Care (CFMC), the Medicare QIO for Colorado, focused its Care Transitions efforts on a community in northwest Denver. Our QIO adopted a community-based approach to achieve a remarkable reduction in readmission rates and to assist patients in making a safe transition from hospital to home. According to preliminary data, CFMC’s Care Transitions project reduced both readmission and admission rates for hospitals in northwest Denver. 

Identifying the Problem

The CFMC team began its work by examining medical records of patients readmitted and existing provider processes likely to affect the transfer of patient care to identify the key factors that were contributing to hospital readmissions. Our findings suggest that most of the root causes of readmissions can be generally categorized into the following: medication mismanagement, patient disengagement, and/or lack of established standard and known processes to support ideal transfer activities.  Our findings are similar to those found in the other Care Transitions communities and suggest that the problem of hospital readmissions for Medicare beneficiaries requires a multidimensional approach to system-wide change. 

Building a Community-based Approach

To kick off the project, our team formed a steering committee composed of representatives from acute and non-acute medical settings, local employers, and patients/caregivers, whose task was to review data and select the most appropriate community interventions. Based on our local needs, one of the evidence-based interventions we decided to implement was Dr. Eric Coleman’s Care Transitions Intervention^(SM). In this model, transitions coaches work with patients to build self-management skills to ensure their needs are met during their transition from the hospital.

Empowering the Community

Participating medical service providers embraced the coaching model and sent staff through Dr. Coleman’s training program to become transitions coaches.  It was increasingly apparent as our project unfolded, however, that the complexity of care needs for our elderly population depends on a wide array of non-medical services in addition to high quality medical care.  We subsequently developed five community action teams of provider and non-provider stakeholders who volunteered to solve specific problems related to the root causes listed above.  These action teams have developed a number of solutions, including a standard personal health record, a post-acute care educational tool and a logo and website for the community effort.

Achieving Sustainability

Looking ahead, CFMC is embarking on a sustainability plan so that community efforts can endure beyond the duration of our funding.  We are framing our efforts as a community organizing campaign, exploring the use of social network analysis, and aiming to support a distributive leadership model within the community.   The primary lessons we have learned from our Care Transitions project are that 1) interventions to improve patient engagement are crucial for reducing hospital readmissions, and 2) local community ownership of improvement efforts is essential. Lasting transformational change in health care outcomes can be fostered by collective community action and building a care continuum that rests on existing local social networks.