There is no ‘one size fits all’ solution to reducing readmissions, says Alicia Goroski, MPH, senior project director for care transitions for the Colorado Foundations of Medical Care (CFMC), the national coordinator for the QIO effort. Instead, it’s important to look at the raw data and determine what is driving readmissions in your community. Here, Goroski describes two care transition interventions developed by the state-based QIOs, one of which was the most widely used throughout the nation and reduced readmissions in one state by more than 50 percent over an 18 month period.
In Harlingen, Texas, when they did their initial root cause analysis, they found that over half of the 30-day readmissions coming back in their community were coming from skilled nursing facilities (SNFs). They realized that that community was ripe for the implementation of the Interact intervention. They went about their project in that community by convening all the nursing homes. There actually became this amazing nursing home coalition where there certainly was a sense of competitiveness, but there was also a sense of coming together with the overall goal of, ‘Let’s reduce this’.
Over the 18 months of their intervention period, the 30-day readmission rate for nursing homes in that Harlingen community went from about 46 percent down to 19 percent. It was an amazing decrease.
On the flipside, here in our Denver community when we lifted our data, we realized that almost 75 percent of our readmissions were occurring among beneficiaries who had been discharged home with no services. No home health, not even a few days’ stay at a nursing home. So based on that, had we gone and implemented Interact, it really wouldn’t have addressed what was driving readmissions in Denver. So we instead hired three full-time coaches and implemented the Care Transitions Intervention (CTI) for those patients who were being discharged directly home.
Rethinking Readmissions: Patient-Centered Collaborations in Care Transition Management examines the data analytics driving the CMS Care Transitions Demonstration Project as well as some home-grown programs that are supporting patients’ seamless transitions back into their communities.