Through a new initiative aimed at reducing rehospitalizations among patients, hospitals in three states are taking on an issue that regulators and quality advocates are increasingly targeting as they explore the connection between financial incentives and coordination of care.
IHI program targets three states' readmission rates
Hospitals in Massachusetts, Michigan and Washington state will collaborate through an Institute for Healthcare Improvement program dubbed the State Action on Avoidable Rehospitalizations Initiative, or STAAR, to reduce readmission rates by 30% in their facilities. Through the four-year program the providers will collaborate on best practices, evidence-based research, data and building business cases for developing transitions of care.
The initiative comes just as congressional leaders turn their attention to the matter. Provisions on limiting readmission have been part of the discussion on health reform and the subject of a bill introduced last month by Sen. Michael Bennet (D-Colo.). Some of those reforms have the goal of withholding payments for readmissions that might have been avoided or penalizing a hospital if a patient has to return, even if it chooses a different hospital, according to Debbie Welle-Powell, vice president of payer strategies and government affairs for Exempla Healthcare, Denver, which participates in state and federal care transition projects. “I think that’s going to create some alignment.”
The STAAR program focuses on patients who were in the hospital, but returned—to the same or a different facility—within 30 days of discharge for a condition related to the original stay. The 30-day readmission rate is one of the care transition measures in development through the National Quality Forum, and the CMS is conducting a pilot project that seeks to determine whether bundled payments align providers in every step of the care process and improve patient outcomes.
Beyond the goal of reducing readmission rates, the STAAR initiative starts to take on characteristics of a medical home project. According to a description of the program from the IHI, STAAR participants will work with all types of care settings, including skilled-nursing facilities, home health agencies, ambulatory practices and family caregivers, in an effort to ensure a smooth and effective discharge process as well as all post-discharge needs. Cross-setting coordination is just as critical, according to the IHI.
The STAAR program is about removing silos of care, so that different types of facilities work together in ensuring patients receive the proper treatments, follow-up visits and enough information to help them through the healing process, according to Robert Yellan, president and CEO of MPRO, the Medicare quality-improvement organization for Michigan. Reducing readmissions “is a community challenge,” he said. MPRO, along with the Michigan Hospitals and Health Systems Association and several other groups in the state, are partnering for the initiative.
The IHI developed its initiative through a nine-month planning grant from the Commonwealth Fund earlier this year, and has conducted other care transition projects in the past, said Pat Rutherford, a vice president at the IHI. Commonwealth is hoping that the IHI can build on its experience of bringing practices to scale.
“They really were interested in an initiative that took a region and made dramatic improvements,” she said.
The states that have been selected to participate were chosen because they were already focused on those types of improvements, according to Rutherford.
Washington has 11 hospitals participating in the first phase of STAAR, said Carol Wagner, vice president for patient safety at the Washington State Hospital Association. Those initial facilities will be responsible for piloting several strategies and best practices, and helping to implement what works in other hospitals throughout the state, Wagner said. “This will be putting things into place that might not have existed before.”
This is a voluntary initiative. Participating hospitals will pay for the work they conduct within their facilities and other partners, like the hospital association, will help fund implementation strategies. The Washington association expects to spend about $20,000 in the first year to help its hospitals, Wagner said.
Hospitals in Michigan also have been focused readmissions in various projects, but the STAAR initiative will be a way for providers to share information and address issues across state lines, according to Sam Watson, senior vice president of patient safety and quality for the Michigan Health and Hospital Association. Each of the three states will conduct their research as they decide, but collaborations through four IHI work groups will ensure the best information out of that research is disseminated, he said.
He declined to estimate how much hospitals might have to spend but added there was a “sizeable” amount of time that would be required.
It’s time worth spending, the Commonwealth Fund believes. The New England Journal of Medicine published in its April 2 issue a Commonwealth Fund study showing that rehospitalization was a problem among Medicare beneficiaries. About 20% of 11,855,702 patients were readmitted within 30 days of their discharge, and patients who came back had longer lengths of stay. Among patients readmitted after a surgical discharge, 70% came back because of a medical condition, and of patients given a medical discharge, they returned to the hospital without indication that they had gone to a follow-up visit with a primary-care physician, according to the report.
Mark Williams, professor and chief of the division of hospital medicine at the Northwestern University Feinberg School of Medicine and a co-author of that report, said cutting readmissions will play a role in payment reform, public reporting mandates and budget scrutiny at the federal level. Williams also is involved with the IHI in the STAAR initiative. That hospitals actively work to reduce their rates and demonstrate that payments should be aligned with performance “becomes incredibly important,” he said.
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