IPRO: Care Transition Interventions Led to 21% Reductions in Readmissions

NYAPRS Note: Another example of the essential effectiveness of hospital to community transitional assistance programs, an approach best represented in our mental health communities by peer bridger innovations.


Care Transition Interventions Led To 20.8% Reduction In Rehospitalizations, According To Study Done In Three New York Communities

Results from IPRO-led Project Presented at IHI Scientific Symposium


LAKE SUCCESS, N.Y., Dec. 9, 2013 -- Evidence-based interventions to improve transitions of care, as part of community-wide efforts by healthcare providers in three New York communities, led to a 20.8% relative reduction in 30-day hospital readmissions for Medicare Fee-for-Service beneficiaries. These results come from an analysis by IPRO of its ongoing work with hospitals, physician practices, nursing homes, home health agencies and other healthcare providers in the Centers for Medicare & Medicaid Services (CMS) funded Care Transitions project. 


The results were reported December 9 at the 19th Annual Institute for Healthcare Improvement (IHI) Scientific Symposium on Improving the Quality and Value of Health Care, held in Orlando, FL. Results were presented by IPRO pharmacist Anne Myrka, RPh, MAT, BCPS, who helps lead medication management-related aspects of the project.


"These latest results confirm that by working with IPRO in a concerted, collaborative effort, New York's healthcare community can significantly improve care and reduce rehospitalizations," said Clare B. Bradley, MD, MPH, Senior Vice President and Chief Medical Officer, IPRO.


Nationally, almost 20% of Medicare beneficiaries are readmitted to the hospital within 30 days of discharge. It is estimated that up to 76% of these rehospitalizations may be preventable.


IPRO is New York State's Medicare Quality Improvement Organization (QIO), which contracts with CMS to work collaboratively with healthcare providers and professionals in order to help improve care for Medicare beneficiaries.  IPRO leads the Care Transitions project as part of the national CMS Integrating Care for Populations and Communities Aim.  IPRO was also one of 14 QIOs selected by CMS to participate in an earlier care transitions pilot project that showed significant reductions in hospital readmissions in New York's Upper Capital Region, following collaborative efforts to evaluate and improve systems for transitioning care across healthcare settings. In a study published in JAMA earlier this year, communities working with QIOs (including IPRO) in the project showed nearly twice the reduction in hospitalizations and rehospitalizations as those not working with QIOs.


In the current effort, IPRO is working with several healthcare communities across New York State, each consisting of a cohesive group of healthcare providers with existing referral patterns.  IPRO facilitates monthly meetings with each community coalition to identify the most common causes of hospital readmissions and to seek solutions through sharing of ideas and experiences.  IPRO also assists with a community-based root cause analysis of readmission drivers; implementation of evidence-based quality improvement interventions; and intervention effectiveness evaluation. 


The most common causes of unnecessary readmissions identified through the meetings and analyses were related to communication among providers, and between patients and providers, during transitions of care; medication management and reconciliation of differing drug regimens; patient /caregiver education for self-management; and issues related to transfer of information across the various healthcare settings. 


Each community instituted multiple interventions; some interventions varied between communities.  All three communities, for example, instituted uniform procedures for reconciling patients' medications as they moved between settings, and all instituted a procedure for standardizing the information to be transferred at the time of discharge. Two of the communities instituted a system of care transitions coaches.  The coaches encourage patients who are transferring from either a hospital or a short-term skilled nursing facility stay to home to play a more active role in understanding the signs and symptoms of worsening of their chronic illness, importance of medications and their self-care. 


To establish a baseline, IPRO measured rehospitalizations between October 1, 2010 and March 31, 2011.  Interventions started August 1, 2011.  Remeasurement was done between October 1, 2012 and March 31, 2013. 


While the weighted average rehospitalization rate across the three communities was 32.53% at baseline, it dropped to 25.75% at remeasurement, demonstrating a 20.8% relative improvement. 

IPRO is a national organization providing a full spectrum of healthcare assessment and improvement services that foster more efficient use of resources and enhance healthcare quality to achieve better patient outcomes. Founded in 1984, IPRO is highly regarded for the independence of its approach, the depth of its knowledge and experience, and the integrity of its programs. IPRO holds contracts with federal, state and local government agencies, as well as private-sector clients, in more than 33 states and the District of Columbia. A national not-for-profit organization, IPRO is headquartered in Lake Success, NY.  For more information, visit www.IPRO.org.


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.