Wither or Bloom: Reducing Hospital Readmissions Using Community Interventions
Jane Brock, MD, MSPH
Colorado Foundation for Medical Care
www.cfmc.org/caretransitions
This material was prepared by CFMC, the Medicare Quality Improvement Organization for Colorado, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
Why?
• Clinical
– Huge numbers of involved providers
– But local
• Social
– SES and readmissions
– Social support infrastructure
• Economic
– Common‐pool resource management theory
• Consistent with what we are learning in the Theme
The Care Transitions Theme:
• Define a community
• Recruit and convene providers
• To identify important service gaps leading to readmissions
• To reduce unplanned 30d hospital readmissions for the community
• Using evidence based tools
Defining a Community: The ‘Zip Code Overlap’
FFS Medicare beneficiaries living in zip codes of interest
Target Population
FFS beneficiaries discharged from hospitals of interest
Community identity supports both social and economic sustainability
Interventions
• TNTC
– Care Transitions Intervention
– RED
– Transitional Care Nursing Model
– InterAct
LESSONS LEARNED
Why are people readmitted?
Poor Provider‐Patient interface
medication management, no effective patient engagement strategies, unreliable f/u
Drivers of Readmission
Poor Provider‐Patient interface
medication management, no effective patient engagement strategies, unreliable f/u
Unreliable system support
Lack of standard and known processes
Unreliable information transfer
Unsupported patient activation during transfers
Drivers of Readmission
Poor Provider‐Patient interface
medication management, no effective patient engagement strategies, unreliable f/u
Unreliable system support
Lack of standard and known processes
Unreliable information transfer
Unsupported patient activation during transfers
No Community infrastructure for achieving common goals
Leading a population‐focused project
• Nobody needs to invent more ‘2nd why’
interventions
• Make community (visible)
• Work with receivers
• Facilitate community involvement
Methods of Convening
•
•
•
•
Multi‐representative steering committee
Aggregate vertically in clusters then merge
Aggregate by setting then vertically integrate
Individual improvement projects with data and information broker
Measuring improvement is harder than you think..
• Reducing 30day readmissions reduces ‘admissions’
• Monitoring Measures
# of 30‐day readmissions
Population at risk of admission
# of admissions
Population at risk of admission
INTERIM RESULTS
2007 compared to 2009 (January‐June)
• 10/14 with reductions in readmissions/pop’n
• High performer with 11% relative reduction
• Loose correlation among readmissions % and other monitoring measures
Interim Conclusions
• Remarkable successes
• Community perspective helpful for enthusiasm and participation
• High overlap associated with success
• Work proceeds project by project
Next Steps
• Sustainability pending..
• Qualitative assessments underway
• Social network analysis to guide projects
A Case Report
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Grand Junction, Colorado
Total Mcare Spending Year
Spending($) Rank
1992
3209
304
2006
5873
301
The Power of Groupness...
CPR Arrangements
• An alternative to regulation or privatization
– Defined boundaries
– Local adaptation of rules possible
– Appropriators participate in setting use limits
– Appropriators monitor each other
– Graduated sanctions for appropriators who do not respect the rules
– Have accessible conflict resolution mechanisms
– Large systems are a set of nested smaller systems
Common‐Pool Resource Management
CPR Management
Clearly defined borders
Geographic isolation
Local adaptation of access ‘rules’
Local payer serving community needs
Participation of ‘appropriators’ in decision‐making process
Longstanding culture of collective action
Effective monitoring by appropriators
Physician utilization comparison ranking
Graduated sanctions for those not respecting community rules
Payment incentives, pride in ranking
Conflict resolution mechanisms that are cheap and accessible
IPA culture, payment incentives, social networks – ‘the grocery store factor’
http://en.wikipedia.org/wiki/Common‐pool_resource
Real Conclusion
• “It’s clear that somebody has to do something, and it’s just pathetic that it has to be us”
Jerry Garcia