Nine hospitals collaborate to prevent readmissions

Partnership includes Agency on Aging

Nine hospitals in southern Texas have joined with the area's Agency on the Aging and formed the Rio Grande Valley Readmission Coalition to follow at-risk patients after they are discharged from the hospital in an effort to prevent readmissions.

The partnership has received funds through the Centers for Medicare & Medicaid Services' Community-Based Care Transition Project, funded under the Accountable Care Act, which requires hospitals to partner with a community-based organization.

Representatives from the hospitals began meeting with the Agency on the Aging in the summer of 2011 to develop the program, says Robin Jones, RN, quality improvement coordinator at Valley Baptist Medical Center in Brownsville, TX.

They researched readmission reduction programs and chose the Care Transitions program, developed at the University of Colorado, which supports patients as they transition from hospital to home.

The Agency on Aging has contracted with a third-party analytic company to manage the program. All of the hospitals in the program are linked to a data exchange software program administered by a third-party analytic company. Case managers can access the web portal, which includes eligibility criteria, enter their patients' names and charts, and find out if they qualify. "This takes a lot of work off the case managers who don't have to go back to the chart and determine if patients are eligible for the program one at a time," Jones says.

When hospital case managers identify patients who are being discharged to home as being at high risk for readmissions, they refer them to the program. If the patient agrees, a health coach from the Agency on Aging who has been trained on Care Transitions interventions meets the patient before discharge and then follows up after the patient goes home. The coaches are working with 20 to 25 patients at a time.

"Patients may or may not have home health or other services at home to qualify for this program. They may have had experience with a home health agency that does not have a readmission prevention program, but if they choose this agency, our hands are tied and we may feel patients need additional interventions. That's when we refer them to the program," she says.

After the patient is discharged, the coach sees the patient at home within three days and then follows up by telephone at weekly intervals during the 30 days following discharge. "They assist the patient in transitioning to home. They make sure they have their medication and understand how to take it. This program is all about teaching patients to manage their conditions and care for themselves," Jones says.

The coaches teach patients about the disease process, how to keep medication lists and sort pills, and coach them on what to ask the physician during the follow-up visit. They educate patients on when to call the doctor and when to go to the emergency department if their condition worsens.

When patients need help from community agencies, the coaches are able to help them access them through resources from the Agency on Aging's Aging and Disability Resources Center. "Our patients are able to access these resources easier because they're already entered into the Agency on the Aging system," she says. The agency has set aside some funding for Meals on Wheels, transportation and medication assistance for patients in the program who need it.

The program has fostered a close working relationship among the hospitals in South Texas, Jones says.

"Hospitals in this area often have to transfer patients within the region because they need specialty care. By collaborating, we can understand the special services each hospital provides and smooth the transitions between hospitals. We also share information with each other on our successful readmission initiatives," she adds.

By using the contracted analytic company and identifying patients by Medicare numbers, hospitals are able to track their enrolled patients' care as part of the continuum of care, no matter which hospital provides it.

"If we engage them in coaching and the patient shows up at another hospital, our case manager and the Agency on the Aging coach can work together to identify the reason for the admission and if there is something they could do differently to avoid future readmissions," Jones says.