Many Hospital Readmissions May Be Prevented Through Improved Care Transitions

A study published in the New England Journal of Medicine last year found that nearly one fifth of Medicare beneficiaries discharged from a hospital were rehospitalized within 30 days, and 34 percent were rehospitalized within 90 days. A 2005 analysis by the federal Medicare Payment Advisory Commission (MedPAC) concluded that as many as three out of four 30-day readmissions may be preventable.

Improving transitions of care, as patients move between health care settings or go home, has been identified as a key way to reduce rehospitalizations. One of the opportunities to improve transitions involves streamlining communication and care coordination between acute care hospitalists and the community primary care physicians and specialists involved in the care management of the chronic, comorbid patient population. Coordination of post acute follow-up care with primary care physicians within seven days of discharge, medication reconciliation and support of patient/caregiver selfmanagement skills all impact prevention of avoidable acute care hospitalizations. All of these causes can be addressed through care transition improvement.

The Centers for Medicare & Medicaid Services (CMS) is now funding the Care Transitions Theme, an initiative with 14 state-based Quality Improvement Organizations (QIOs) to test approaches to improving the quality of care for Medicare beneficiaries as they transition between health care provider settings.

IPRO, the QIO for New York, is among those selected for this project. Working within the counties of Rensselaer, Saratoga, Schenectady, Warren and Washington, our effort reaches across all provider settings. Our work began in August 2008 and will run through July 2011.

In support of cross-setting partnerships and collaboration we have been meeting onsite in physician practices in the region, interviewing physicians, nurses, practice managers and support staff, to gain insight on the challenges they encounter assisting their patients during transitional care. Likewise, we have sought feedback from other providers, as well as from the Medicare beneficiaries themselves. A number of issues have come up repeatedly.

We have found that there are opportunities to improve communication between hospitalists, primary care physicians and specialists working in the community. These opportunities occur around patient admission to acute care, and care management and medication changes during the hospital stay. Primary care physician access to a comprehensive discharge summary on the same day or within 24 hours of discharge is one important area for focused improvement. We are working to share potential strategies to improve the process both in physician practices and in acute care settings. In addition, we are encouraging patients to bring all medications, as well as their discharge instructions, to their first postdischarge physician appointment.

It is also key that patients make and keep appointments with their primary care physician within seven days of discharge. Seniors may not understand the urgency of follow up, and may not convey this urgency when they call a busy medical practice. For patients with conditions like heart failure or pneumonia, this seven days is a critical window of opportunity to avoid rehospitalization.

As a physician practicing in New York, there are many things you can do to address these issues. Putting systems in place for speedy post-discharge appointments and educating your office staff on the importance of getting these appointments are among the most critical. Encouraging patients, especially seniors with chronic health conditions, to use Personal Health Records, is another. A number of tools for care transition management, including a Personal Health Record, are available for free on our Web site,

I look forward to keeping you informed as we move forward with this project and learn more about the optimal interventions for improving transitions of care.

This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 9SOW-NY-THM7.2-10-10.