What They Are
"Readmission" occurs when patients who have had a recent stay in the hospital go back into a hospital again. Patients may have been readmitted back to the same hospital or to a different hospital or acute care facility. They may have been readmitted for the same condition as their recent hospital stay, or for a different reason. Often referred to as "rehospitalization."
Who's At Risk
Patients in transition - those moving from one care setting to another - are at increased risk for hospital readmission. Unanswered questions including the following, can increase patient risk for readmission: who is in charge of the patient transition, what is the plan, whether the plan and follow-up instructions are understood, and knowledge of whom to call with questions once they are home or in their new care setting.
What's At Stake
Patients move from one setting of care to another or to one set of care providers to another during an episode of illness. As patients and families navigate across new care settings and among different care providers, they often encounter communication challenges and confusion around who is clearly accountable for their care. This can lead to medical errors, duplication, increased costs and may also lead to higher rates of hospitalization.
What Providers Are Doing to Prevent Readmissions
Massachusetts is currently participating in many projects to address and improve hospital readmission issues. These efforts are largely coordinated state-wide by the Massachusetts Care Transitions Forum, and a list of these projects follows.
- Re-Engineered Discharge (RED) Toolkit from AHRQ
- Potentially Preventable Readmissions (PPR) Project with 3-M
- STAAR Initiative: STate Action on Avoidable Rehospitalizations
- Interventions to Reduce Acute Care Transfers (INTERACT-II) Initiative
- MOLST Demonstration Project: Medical Orders for Life-Sustaining Treatment
- Project RED (Re-Engineered Discharge)
- Project BOOST (Better Outcomes for Older Adults through Safe Transitions)
- Home Care Projects: Masspro Collaborative Project
- Business-led Projects: Dovetail Health's Pharmacist-Led Transition Services to Avoid Costly Readmissions
Community-based Care Transition 3026 Grants Awarded to Massachusetts Partnering Organizations
In August 8th 2012 the Center for Medicare and Medicaid Services (CMS) announced the third round of site selections under the Community-based Care Transition Program (CCTP), 3026 grant offered through the Affordable Care Act (ACA), which provides funding from the Innovation Center to community-based organizations partnering with eligible hospitals for care transition services. Awardees of this grant will be charged with improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries. The 3026 grant is part of the Partnership for Patients and is charged with reducing hospital-acquired conditions by 40% and hospital readmissions by 20% by 2013. Community-based organizations will use care transition services to effectively manage Medicare patients' transitions and improve their quality of care. Up to $500 million in total funding is available for 2011 through 2015. Learn more about CCTP.
Under the ACA there were 17 national sites awarded a grant in August 2012, and joined the already 30 national sites announced in November 2011 and March 2012. Massachusetts to date has been awarded 4 of the grants for our partnering organizations which are located throughout the state. The partnering organizations will be working with CMS and local hospitals to provide support for high-risk Medicare patients following a hospital discharge as they move to new settings, including skilled nursing facilities and home health services. The Massachusetts CCTP grand awardees for Massachusetts are listed below:
August 2012 recipient:
1. Somerville-Cambridge Elder Services, a Massachusetts-designated Aging Services Access Point (ASAP) and an Area Agency on Aging (AAA), will partner with Mystic Valley Elder Services, Cambridge Health Alliance, Hallmark Health System and dozens of community-based health and social service providers to provide care transitions services in Middlesex County.
March 2012 recipients:
1. Elder Services of Berkshire County, a Massachusetts-designated (ASAP) and federally-designated AAA in rural western Massachusetts, that has partnered with Berkshire Medical Center and the Berkshire Visiting Nurse Association to improve care transition services for Medicare beneficiaries.
2. Elder Services of Worcester, Massachusetts, a Massachusetts-designated ASAP and federally-designated AAA, that has partnered with Bay Path Elder Services. They will provide care transitions services in partnership with seven hospitals, including: MetroWest Medical Center; St. Vincent Hospital; UMass Memorial Medical Center; Wing Memorial Hospital; Marlborough Hospital; Clinton Hospital, and HealthAlliance Hospital.
November 2011 recipient:
1. Elder Services of the Merrimack Valley, Inc., in partnership with Anna Jacques Hospital, Saints Medical Center, Holy Family Hospital, Lawrence General Hospital, and Merrimack Valley Hospital, and serving 23 cities/towns in the Merrimack Valley of Massachusetts and ten bordering cities/towns in southern New Hampshire where patients using these hospitals also reside.
WORKING HARD TO REDUCE PREVENTABLE READMISSIONS:
A Gatefold Publication You Can Use
One of MHA's Strategic Performance Improvement Priorities - reducing preventable readmissions - is garnering great attention in 2011. Hospital Boards of Trustees throughout Massachusetts are signing on to the three-part improvement initiative in which they pledge to address
the issues of readmissions, mortality, and central line-associated bloodstream infections at their regular meetings; to advocate
for healthcare policies that reduce incidences of the three issues; and to measure
improvements in the three areas.
In February 2011, nearly 400 caregivers attended a two-day STAAR conference - or State Action on Avoidable Readmissions. STAAR is focused on improving care transitions to reduce readmissions. Twenty-two cross-continuum teams have been part of the STAAR project since September 2009, and 27 new teams came to the event to learn from their colleagues and begin their own work.
On the state and federal level, Medicaid and Medicare are, or are about to, institute penalties for excessive readmissions.
Now, Hospitals & Health Networks, the flagship publication of the American Hospital Association has produced this "Gatefold" publication on the readmissions issue. It lays out the numbers, key aspects of the Affordable Care Act relating to readmissions, the top seven hospital readmissions, and a checklist that STAAR states, such as Massachusetts, use to assess and remedy the problem.