Hospital organization, insurer collaborate

Program aims to smooth care transitions

Recognizing that hospital readmissions are costly for providers and insurers alike, Blue Cross and Blue Shield of Illinois and the Illinois Hospital Association are collaborating on a quality initiative to reduce the rate of hospital readmissions.

Preventing Readmissions through Effective Partnerships (PREP), which kicked off Feb. 1, 2011, leverages resources of the insurer and the hospital association to improve the quality of patient care and reduce costs at the same time.

"We know that hospital readmissions are a significant problem and that if patients are readmitted, they are as sick if not sicker than they were before discharge. This represents a significant drain on resources from a payer perspective and from a hospital perspective," says Charles Schutz, MD, MPH, medical director with Blue Cross and Blue Shield of Illinois.

Data from the Centers for Medicare and Medicaid Services (CMS) shows that Illinois has a higher rate of Medicare readmissions than many other states, ranking 44th in the nation, Schutz says. The state's rate of 30-day readmissions in 2009 was 20.3%, compared with a 17.5% across all states.

The insurer and the hospital association already were working separately on quality improvement and patient safety initiatives, which led to the formation of the strategic partnership, says Cathy Grossi, RN, JD, vice president of the Illinois Hospital Association. "The synergy was really right for our provider-payer partnership to transform healthcare in our state," Grossi says.

Blue Cross and Blue Shield of Illinois has committed up to $1 million a year over four years to help hospitals acquire the resources and the staff to implement the readmission-reduction initiatives, Schutz says. "Although we deal primarily with a commercial population, we're taking a broad perspective on readmission," he says. "This is a major public health issue, and it has to be implemented across the board. You can't just reduce readmission for Medicare patients or those with commercial insurance. There's got to be systematic change in the way healthcare is provided, regardless of patient's age and payer."

The program involves five key initiatives: redesigning the hospital discharge processes, improving transitions of care, developing and improving palliative care programs, strengthening hospitalist programs, and measuring reductions in readmissions using standardized metrics. Components of the program include a portfolio of programs that focus on transition of care for patients, Grossi says. "This collaboration capitalizes on what we already had in place," she says. "We are taking a multi-disciplinary approach to integrating the family in the discharge process from the day of admission. We are working to improve the educational process and the understanding of patients and families about medications, follow-up care, and clinical components so they can be more active partners in their care."

Schutz says, "PREP's goal is to develop a comprehensive patient-centered discharge process so patients can receive the follow up care they need in their own community."

The program promotes specific case management and discharge planning interventions such as a complete risk assessment of all patient needs after discharge, resulting in patient-centered discharge planning. Case managers and discharge planners use the "teach back" method to ensure that patients and family members understand their medication regimen and discharge instructions and ensure that patients have a follow-up appointment with their primary care provider.

Hospitals are encouraged to develop a standardized plan to communicate information about the patient's stay and discharge instructions to the primary care physician in the community where the patient lives. The readmission reduction initiatives also expect hospitals to call high risk patients within 72 hours of discharge to make sure they have gotten their prescriptions filled and have a timely appointment with their doctor, and to answer any questions or concerns.

"Reducing readmission involves a lot of simple things, such as making sure patients have an appointment to see their primary care physician for follow up and assessing all the diagnoses the patients have and all the medications they take," Schutz adds.

A common scenario is a patient who has received surgery, then in a short time is readmitted for a chronic condition that was not addressed during his previous admission. In other instances, many patients don't understand how to take their medication when they leave the hospital, or they just don't get prescriptions filled, Schultz adds.

Hospitals beef up efforts to reduce readmission

Program provides education, mentoring

The Preventing Readmissions through Effective Partnerships (PREP) quality initiative helps hospitals develop a standardized approach to discharge planning and to take specific actions to reduce readmissions. PREP is a collaboration of the Illinois Hospital Association and Blue Cross and Blue Shield of Illinois.

"We emphasize that once a person is hospitalized, we need to begin to work on a discharge plan to ensure that they get the care they need once they leave the hospital. We want these patients to be able to avoid a trip to the emergency department or a rehospitalization. We recognize that all of this hinges on the discharge planning that takes place while they are in the hospital," says Charles Schutz, MD, MPH, medical director with Blue Cross and Blue Shield of Illinois.

The hospital association and insurer have collaborated on arranging webinars, seminars, educational forums, and site visits to help hospitals implement readmission reduction programs. Cathy Grossi, RN, JD, vice president of the Illinois Hospital Association says,"We are able to capitalize on how the programs are being implemented and tailor them to meet the specific needs of hospitals and their communities across Illinois. The focus is not just on larger hospitals, but also on small and rural critical access hospitals." Programs that are available to the hospitals include:

• Project BOOST (Better Outcomes for Older adults through Safe Transitions) was created by the Society of Hospital Medicine through grant support from the John A. Hartford Foundation. Project BOOST mentors work with hospitals and provide resources that enable the hospitals to identify patients at high risk for readmission and take steps before and after discharge to prevent the readmission. (For more information, visit www.hospitalmedicine.org/BOOST)

• In Project RED (Re-Engineered Discharge), multi-faceted program is designed to educate patients about their post-discharge care plans, ensure that patients receive the recommended follow-up care, and increase communication between the hospital and the patients' primary care physicians. A nurse or case manager called a Discharge Advocate works with patients to educate them during their stay, organize post-discharge services, and expedite the flow of information to caregivers after discharge. (For more information, visit http://www.bu.edu/fammed/projectred)

• Illinois Transitional Care Consortium's Bridge program utilizes social workers for the care management of patients as they transition from the hospital to their homes. The organization is a consortium of community-based organizations, hospitals, a research organization, and a healthcare advocacy organization. (For more information, visit http://www.transitionalcare.org)

• Training on Palliative Care from Northwestern University's Feinberg School of Medicine to help clinicians learn ways to manage the care of patients with chronic pain in a way that keeps them out of the hospital. In addition to holding seminars about palliative care, the program provides physicians who work with the hospital staff on an ongoing basis to organize and implement a palliative care program.

• Hospitals have the option of choosing in any or all of the initiatives and can choose components that meet their needs. For example, hospitals have the opportunity to participate in a webinar about the BOOST program and the option to work with a physician trained by the Society of Hospital Medicine on implementing the program. Schultz adds, "We have engaged with one of the nation's top researchers in this arena, Mark Williams, MD, who is leading our efforts to optimize the transition of care for hospitalized patients." Williams, professor and chief of the division of hospital medicine at Northwestern Memorial Hospital and Northwestern Feinberg School of Medicine is principal investigator for Project BOOST and serves as a mentor to Illinois hospitals.

The palliative care program offer seminars as well as physician staff to work with hospitals on an ongoing basis to set up their programs. Hospitals that want to develop or improve a hospitalists program have the opportunity to participate in a year-long training and mentoring program. PREP will also work with critical access hospitals which serve populations in rural and underserved areas to adapt the programs to meet their needs.

Grossi says, "In Illinois, the urban, suburban, and rural populations may have different needs. People throughout the state may come to a large hospital in Chicago for care but when they go home, are not able to receive follow up care locally," Grossi says. The program will help hospitals implement programs to provide appropriate follow-up care in their community for patients who have complex medical needs.