When you consider that about a fifth of hospital readmissions are preventable, the findings in a March 2009 Mathematica Policy Research report are particularly noteworthy. The report identifies three types of interventions with potential for reducing hospitalizations for Medicare beneficiaries with multiple chronic conditions — a group accounting for the lion's share of Medicare spending. Of special note are transitional care interventions — in which patients are first engaged while in the hospital and then followed intensively over the four to six weeks after discharge from the hospital; self-management education interventions that engage patients for four to seven weeks in community-based programs designed to “activate” them in the management of their chronic conditions; and coordinated care interventions that identify patients with chronic conditions at high risk of hospitalization in the coming year.
While the report notes that no single program has yet combined all three types of interventions, it mentions two approaches that show great promise: the patient-centered medical home (PCMH) model of care and the Guided Care model developed by Dr. Chad Boult and colleagues at the Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health. We recently spoke to Dr. Boult about the Guided Care Model, in which the Guided Care Nurse administers a patient care plan developed by the physician and nurse with data from the EHR. Listen to the interview.