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Reducing Readmissions: Interventions, Incentives and Infrastructure
Reducing Readmissions: Interventions, Incentives and Infrastructure
Reducing Readmissions: Interventions, Incentives and Infrastructure
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When healthcare organizations cut even a minority of avoidable readmissions, the cost savings can be considerable and the quality impact even greater.

Reducing Readmissions: Interventions, Incentives and Infrastructure presents case studies from three healthcare organizations whose efforts have significantly reduced avoidable hospital readmissions in high-risk populations and include the alignment of financial incentives to readmission rates.

This 50-page special report provides details on:

  • The robust initiative behind Priority Health's significantly lower rates of unnecessary hospitalizations among its PriorityMedicare(SM) members as compared to those for traditional fee-for-service Medicare ó 6.94 percent compared to the 18.6 percent readmission rate for traditional Medicare. Mary Cooley, manager of case and disease management at Priority Health, details the Care Transition Program Priority Health uses to help patients at high risk for complications or rehospitalization bridge the transition from hospital to home — initially in its Medicare Advantage product line and recently rolled out across its entire book of business with success across all populations.

    Priority Health's multi-faceted care transitions effort for patients with cardiovascular conditions starts in-hospital and follows the patient through discharge and follow-up physician visits, empowering the patient to be an active participant and consumer in their healthcare.

  • An intensive intervention developed by Aetna based on the Transitional Care Model in which advanced practice nurses work extensively with patients after discharge. Dr. Randall Krakauer, national medical director, Medicare at Aetna, provides details on a pilot initiative with a focus on home care that reduced hospital readmissions in the three months post-discharge by 25 percent.

    The Aetna program links transitional care with case management, using targeted interventions aimed at promoting effective hand-offs as well as comprehensive interventions designed to address the root causes of avoidable acute care service use. Aetna is planning a large-scale implementation of this program throughout its Medicare population.

  • A statewide program from the Maryland Health Services Cost Review Commission (HSCRC) that compares actual versus expected rates of performance for hospital readmission rates that is risk-adjusted. Dianne Feeney, BSN, MS, associate director of quality initiatives for the HSCRC, explains the strategic planning, analytics and infrastructure behind Maryland's initiative to incent hospitals to improve readmission rates on a risk-adjusted basis.

Table of Contents

  • Readmission Avoidance: Care Transitions Program from Priority Health
    • The IHI Triple Aim Model
    • Pilot for Population with Cardiovascular Conditions
    • In-Hospital Process Heads off Readmissions
    • Outpatient Case Management
    • Value of Follow-Up Visit
    • The Post-Discharge Process
    • Outcomes of Cardiovascular Initiative
    • Expanding the Care Transitions Program
    • A Priority Success Story
    • Hope from the Patient-Centered Medical Home
  • Aetna's Infrastructure for Reducing Avoidable Hospital Admissions
    • APNs Tackle Transitional Care
    • Real-World Application of Research-Based Model
    • Linking Transitional Care Effort with Case Management
    • Improvements and Outcomes
  • Maryland Employs Pay for Performance to Reduce Potentially Preventable Readmissions
    • Causes of Potentially Preventable Readmissions
    • Marylandís Pay for Performance Methodology
    • Identifying the Readmission Spike
    • Actual vs Expected Readmissions Based on Patient Mix
    • Sizing the Incentive for Hospitals
  • Q&A: Ask the Experts
    • Determining a High-Risk Patient
    • Case Management Collaborations between Payors, Providers
    • Unintended Consequences from Care Transition Efforts
    • Follow-Up Protocols and Populations
    • Red Flag Education Tools
    • Hospitalsí Response to Reimbursement for Quality
    • Funding for Care Transitions
    • Tying Readmission Reduction to Pay for Performance
    • Correlating Readmission Rates with Clinical Results
    • In-Hospital Aspect of Transitional Care
    • Home Visits vs Telephonic Monitoring
    • An Effective Hospital Discharge
    • Role of the EHR in Readmission Reduction
    • More on Maryland Hospital Program
    • Engaging Providers in Readmission Reduction Efforts
    • Moving Patients from Transitional Care to Case Management
    • Provider Partnerships
    • Value of Home Visits
    • Structuring Pay for Performance for Hospitals
  • Glossary
  • For More Information
  • About the Presenters
Publication Date: February 2010
Number of Pages: 50
ISBN 10: 1-936186-07-1 (Print version); 1-936186-08-X (PDF version)
ISBN 13: 978-1-936186-07-5 (Print version); 978-1-936186-08-2 (PDF version)
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