Reducing Readmissions: Leveraging Care Networks to Achieve Safe Patient Transitions

Purpose:
Avoidable hospital re-admissions are now tied to value-based purchasing and reimbursement reform. We sought to improve readmission rates across the MaineHealth care continuum by implementing best practices that strategically strengthened relationships between hospitals and post-acute providers.

Significance:
In 2007, almost one-fifth of Medicare beneficiaries were readmitted within 30 days (Jenks). Fiscal incentives and publicly reported quality measures are energizing concern and deepening commitment to patient centered care transitions across the healthcare system and community agencies.

Strategy and Implementation:
To lower readmission rates, we sought to establish and strengthen relationships among providers and organizations across our full care continuum, and to engage their commitment to implement and operationalize the Transitions of Care (TOC) Bundle: standardized risk stratification for readmission, use of transition checklist, medication reconciliation and management, patient/family health education, timely communication among hospital & post-hospital providers, and timely patient follow-up post discharge (Project Boost, Project RED). We sought to standardize these transition practices for all patients to intentionally add value by improving the patient's experience of care. Concepts from social network and diffusion of innovation theories were applied to explicitly capitalize on existing formal and informal relationships between champions in our system, to strategically guide stages of program implementation, and strengthen collaborative learning to share quick wins and best practices.

Evaluation:
Adherence to TOC Bundle increased 11% over the last year. Readmission rates decreased by 11% since start of the intervention (CMS PEPPER Reports). Emerging cross continuum professional networks emerged as a valuable vehicle where increased discussion across settings added value to safe transitions.

Implications for Practice:
Team skills and engagement contribute to intervention success (Burke). Our model strengthened cross-continuum relationships, achieved mission critical outcomes and embraced patient centered care. This resulted in fewer hospital re-admissions. Similar findings are reflected in the literature(Cortes).