Aging agencies help cut readmissions

Three years ago, eight-hospital Riverside Health System faced looming federal penalties for excess readmissions, often the result of inadequate transitions from the hospital to home.

Thirty-day readmission rates varied widely across the Newport News, Va.-based system, with most above the national average. The system lacked a standardized way of ensuring that discharged patients had adequate supports in place, understood their conditions and saw primary-care physicians for follow-up care.

“We didn't really know what was going on in patients' homes,” said Dr. Kyle Allen, Riverside's vice president for clinical integration and medical director, geriatric medicine and lifelong health. “We missed many of the issues that led them to be readmitted.”

Hospitals such as those belonging to Riverside are under increasing financial pressure to smooth the post-discharge period and address patients' daily-life challenges, both to improve outcomes and protect hospital finances. One underused approach to reducing readmissions involves encouraging patient self-management and collaboration among providers and community-based organizations. Hospitals that forged such collaborations have rapidly reduced readmissions, experts say.

“Much of the time, people get readmitted because of the challenges they have in daily life, not because of their diagnoses,” said Dr. Eric Coleman, director of the Care Transitions Program at the University of Colorado and a national thought leader in the field.

Recognizing it didn't have the tools to prevent readmissions and avoid the penalties, Riverside decided to try the partnership approach.

Beginning with a small pilot program, Riverside forged collaborative relationships with agencies on aging, which are community organizations that help older adults live independently.

“In healthcare, there's a tendency to do things on your own,” said Allen, who began working with such agencies in the 1990s in private practice and later as chief of geriatrics at Akron, Ohio-based Summa Health System.

Under Riverside's program, hospitals enroll Medicare beneficiaries with chronic illnesses. Cases are given to trained transition coaches from community agencies who brief patients and their relatives on how to manage medications, watch for signs of worsening health and set goals to keep them out of the hospital.

A 2012 pilot program with Bay Aging, Urbanna, Va., and three Riverside hospitals led to a 20% drop in all-cause readmissions among 140 patients, and more than $900,000 in estimated savings.

Based on that success, in 2013 the CMS funded the Eastern Virginia Care Transitions Partnership, which expanded the pilot to include five area agencies on aging and 11 hospitals, including five Riverside hospitals. The system has seen its overall readmission rate drop to 16% from 23% in 2012, Allen said. The national readmission rate hovered just below 18% during the first eight months of 2013.

Recently, Allen said, a 56-year-old man with a history of emphysema and pneumonia was discharged from one of Riverside's rural hospitals after a stay for respiratory distress. The transition coach arranged transportation, contacted a food bank, got fuel assistance and helped the patient understand how to manage his condition.

Riverside is performing deep data dives to analyze transitions of care that don't go well. It is measuring criteria such as medication reconciliation and successful transfer of advanced directives, said Pat Russo, vice president of care management.

Partnering with outside agencies and other community-based groups presents challenges, such as confusion over who does what, reimbursement and physician hesitation.

“Riverside's biggest success is creating a trusting environment where people can come together and find solutions,” said the University of Colorado's Coleman. “If you want to be a player, you have to be in the room.”

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