Improved Care Transitions Can Reduce Costs
Medicare spent $118 million in 2009 on readmissions in the Nashville area, including more than $17 million on just 447 high-needs Nashville-area patients with four or more hospital readmissions. Mounting pressure to reduce healthcare costs is a focus of health reform, and over the past several years, geographic analyses of healthcare claims data have demonstrated significant variations in utilization, cost and quality of hospital services. (See related story below.)
As purchasers and payers call for better integration of healthcare delivery, these analyses represent an opportunity to develop a systems-based approach to more coordinated, effective, and affordable healthcare service provision.
Qsource conducted a study analyzing geographic healthcare claims data as the Medicare Quality Improvement Organization (QIO) for Tennessee and is now engaging community stakeholders to share innovative approaches for improving care coordination and to identify root causes of the variations found in the readmissions data. Communities are responding by forming partnerships across Tennessee to improve transitions of care in their areas. Functioning as a community, stakeholders are better able to deliver high-value healthcare to residents, improving the health of the workforce and reducing costs to existing and potential employers.
The breakdowns in healthcare delivery that occur during transition from hospital to home, or another source of care, have major implications for health outcomes, costs and patient experiences. Targets for improving transitions of care include:
- decreasing the deterioration of health conditions that can occur following discharge for all patients receiving hospital care,
- making sure that care delivery is responsive to the clinical and social needs of all patients in a hospital service area, and
- reducing unnecessary readmissions.
The problem of readmissions is not solely hospital-based. It involves multiple providers across settings — primary care physicians and specialists, nursing home and home health staff, and non-clinical providers of supportive services. To understand this complex problem, focus needs to be directed not only at what is going on within hospital walls, but also what is going on after the patient re-enters the community.
In a typical measure of readmission, the hospital is the unit of analysis where methodologies use complex statistical procedures to attribute a readmission to the hospital in which it occurs and that geographic community. The Qsource study examined readmission data in Tennessee by attributing readmissions to the ZIP code in which the beneficiary resides. These data were then aggregated to the hospital service area (HSA) and subsequent health referral region (HRR) based on the Dartmouth Atlas of Health Care Project and reflective of natural Medicare beneficiary utilization patterns.
There are 297,961 Medicare beneficiaries age 65 and older residing within the Nashville HRR, of whom 48,005 were admitted to the hospital during 2009. Approximately 20 percent (9,284) of the beneficiaries receiving inpatient care experienced one or more readmissions and accounted for 13,924 readmissions. Within the Nashville HRR, $118 million was spent by Medicare on readmissions in 2009 alone.
Qsource looked at community rates of readmissions for five Tennessee metropolitan areas (Memphis, Nashville, Chattanooga, Knoxville and the TriCities). Community rates adjust readmissions by the size of the Medicare population in each region. The lowest community rate of readmissions in Tennessee occurs in the Chattanooga area; the highest, in Nashville. In the Nashville HRR, there are approximately 47 readmission events per 1,000 Medicare beneficiaries, heart failure being the leading cause. Of all the discharge events in the Nashville HRR, 23 percent involve subsequent admissions within 30 days to a different hospital than that in which the first admission occurred, underscoring the need to examine data by beneficiary rather than hospital. Fifty percent of patients readmitted were originally discharged to self-care/home, approximately 21 percent to skilled nursing facilities, 17 percent to home with home health services and 12 percent to some other care facility (such as hospice, psychiatric hospital).
All Medicare readmission expenditures are from just 20 percent of beneficiary patients and 15 percent of this spending (about $17.2 million) is on 447 individuals. One way to reduce this spending is to combine system-level interventions that improve all patients’ care transitions with resource allocation targeted toward those who account for a disproportionate share of the spending.
While significant, the Qsource study data presented here merely approaches the tip of the iceberg in terms of understanding this multifaceted, complex problem. Further exploration of the local healthcare delivery system and patient needs is warranted.
Community stakeholders with multiple perspectives of the readmission problem are uniquely positioned to identify opportunities for improvement that respond to local needs for healthcare delivery change. As a crucial part of the community, the value of the patient perspective on breakdowns in care should not be underestimated.
Dawn M. FitzGerald is CEO of Qsource, a nonprofit, healthcare quality improvement and information technology consultancy headquartered in Tennessee. She recently served on the Institute of Medicine’s Committee on Future Directions for the National Healthcare Quality and Disparities Reports. FitzGerald is currently a member of the NQF Healthcare Disparities and Cultural Competency Consensus Standards Committee. She has coauthored more than a dozen articles on quality improvement efforts and analysis of Medicare data and received numerous awards including the James Q. Cannon Endowment for Healthcare Quality Improvement’s Outstanding Leader in Operations Management Award.
New Care Transitions Network Launches November 8th in Nashville
National Expert Dr. Eric A. Coleman to Deliver Keynote Address
Representatives from hospitals, nursing homes, patient advocacy organizations and other stakeholders in Tennessee are invited to Nashville on Nov. 8 as Qsource convenes to build capacity for improving care transitions. The free event will be held from 10 am-2 pm at Cheekwood to explore how communities can better support patients and reduce hospital readmissions.
National expert, Eric A. Coleman, MD, MPH, will deliver the keynote address. In addition, there will be a panel of local physicians from across Tennessee who advocate for seamless transitions between healthcare settings.
Qsource supports communities seeking grant funding through the community-based care transitions program (CCTP) authorized in Section 3026 of the Patient Protection and Affordable Care Act of 2010. Communities formally accepted in the CCTP will receive federal money to reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measureable savings to the Medicare program.
The event will introduce the statewide learning and action network called “STAT: Safe Transitions across Tennessee.” The network’s focus is to rapidly spread best practices about care transitions. Future STAT initiatives, which will be open to all communities that do not receive the special grant funding, will include collaborative projects, online interaction and peer-to-peer education. For a copy of the Qsource study data analyses, details on our quality improvement efforts to integrate care or to register for the event, go to www.qsource.org.