Preventing Hospital Readmissions Takes a Village

Apparently a lot has changed since. After more than a year's delay, federal officials picked the first seven groups last fall, and another 23 last month. These 30 are just getting started this spring.

These CBOs have challenging tasks. They must have already partnered with a hospital, preferably one grappling with readmission rates in the top quartile within each state, to identify the Medicare patients at highest risk for readmissions. That, in itself, has been tough.

The bar for success is high: These projects must achieve a 20% reduction in the number of 30-day readmissions to their partner hospitals within the first two years to be eligible for further funding.

But the CBO can't follow every discharged patient, and only Medicare fee-for-service patients are eligible. So to capture enough reductions, the hospital must direct the CBOs to those patients at highest risk: those who live alone, are elderly or disabled, have been diagnosed with high-risk conditions such as heart attack, pneumonia, or congestive heart failure or multiple co-morbidities.

While each program varies in detail, in general, these CBO workers meet these patients at the hospital bedside, talk with the providers familiar with their care, and earn the patients' and families' trust. After hospital discharge, the CBOs track the patients in their homes or long-term care facilities with face-to-face visits to assess any environmental or cultural barriers that impede their safe recovery.