Within 30 days of being discharged from the hospital, about one in five Medicare beneficiaries are re-hospitalized, and as many as three in four of those readmissions could have been prevented. The process by which patients move from hospitals to other care settings is increasingly problematic as hospitals shorten lengths of stay and as care becomes more fragmented. To improve care transitions and quality of care, Quality Improvement Organizations (QIOs) across the country are working to build multi-stakeholder coalitions, identify the root causes of readmissions, select interventions and put them into action.
In August 2011, the Centers for Medicare & Medicaid Services tasked QIOs with assisting communities with improving quality of care for Medicare beneficiaries transitioning across health care settings and reducing 30-day readmissions by 20 percent over three years.
Mountain-Pacific Quality Health-Wyoming (MPQH-Wyoming), the QIO for Wyoming, has been bringing together hospitals, nursing homes, patient advocacy organizations, public health groups, physicians and other stakeholders to form community coalitions in support of this task. Currently, Mountain-Pacific assists and supports five community coalitions in their efforts to adopt widespread improved practices to reduce hospital readmissions. The coalitions convene in Rock Springs, Gillette, Douglas, Casper and Jackson, Wyo.
The QIO began its work by recruiting potential coalition members using a bottom-up approach. Hospitals are key stakeholders in the coalitions, but in rural states like Wyoming, there may only be one hospital within a particular community. Public awareness helped get these major players interested.
“We started at the bottom with community-level stakeholders that wanted to work with us and their health care peers,” said Kevin Franke, Mountain-Pacific’s Care Transitions Project Manager. “After that, we approached the hospitals about what we were already doing with our coalition members, and they were immediately more inclined to get involved.”
Use of the health care system and hospital readmission rates often vary among geographic locations. For rural states, access to quality care is not always near, and Wyoming is no exception. While 60 percent of Wyoming’s population lives within the state’s five metropolitan areas, the remaining population is scattered throughout small towns – often miles from one of the bigger cities – making access to health care difficult. This is perhaps the largest hurdle faced by the coalitions.
Another challenge is that coalition members have unique past experiences and partners, and therefore approach things differently. For example, during one community coalition meeting, a local primary care provider shared a patient story with the group. The provider intended to send a 77-year-old patient to the emergency room (ER) and refer her to hospice once she was stable. However, within 28 days of her initial hospital stay she was sent to the ER four times and admitted as an inpatient twice. At the conclusion of the story, the initial reaction among coalition members was to blame each other for the patient’s repeated trips to the hospital. In the end, public health providers, a hospice, a home health agency, a skilled nursing facility and 12 different physicians all played a role in providing the patient with much-needed coordinated care.
“It’s a great example of what happens when no one knows what’s going on with the other health care stakeholders,” Franke said. “I preach a lot about how we’re not going to make it through this work by competing with each other – we have to collaborate.”
After completing a root cause analysis and overall evaluation of its system, each community adopted interventions that best fit its situation or problem. “None of the communities adopted just one of the evidence-based models but instead took pieces from all of them to implement in their communities,” Franke said.
Each of the communities has strong core players, but members tend to come and go. Franke encourages participants to keep coming back. “[Franke] is great at coaching and acting as a third party in disputes,” said Katie Evenson, Mountain-Pacific’s Communications Coordinator. “He takes situations involving blame and turns them into positive learning examples.”
Each coalition has monthly meetings for peer-to-peer sharing and progress updates. “You can’t expect to do this over email. It takes a lot of face-to-face meetings,” Franke said.
In addition to monthly meetings, Mountain-Pacific hosts an annual quality conference to help share community best practices and collaborate on how to improve care statewide. The conference encourages participants to take action based on what they learn and is open to all health care professionals and beneficiaries.
“Sustainability is about relationship building between the QIO and its constituents, but also within the community itself,” Franke said. “I feel like my job is to make the community coalitions successful, whether that means I get really involved or am motivating them from the background.”
Mountain-Pacific focuses on process measures to determine success. They ask providers questions like:
- Is that particular intervention that you implemented working?
- Have you been able to reach all heart failure patients who were discharged?
- Are you getting through to them?”
“These process measures are more important to me than outcome measures. You don’t have control of outcomes, but you do with processes,” Franke said. “In Wyoming, one or two people can really affect rates. That’s why process is so important. If we can get a process in place, it will help the overall sustainability within the state.”
To date, Wyoming has decreased overall readmission rates in all five communities and will continue to support the current coalitions and actively recruit new members through July 2014. “We want these coalitions to continue to thrive long after the QIO contract period is over,” Franke said.