Readmissions and Community-Based Support
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"The fundamental flaw in this model is that hospitals are the only entity eligible to be penalized for readmissions, yet hospitals are not eligible to directly receive any of the technical assistance funds available," Lisa Grabert, senior associate director for policy with the American Hospital Association, told HealthLeaders Media last fall.
After a slow start, and as readmission penalties loomed closer, more hospitals got on board and by August, more than half of the $500 million had been allocated to CBO collaborations involving 47 organizations, some with multiple hospital sites, across 23 states.
A close relationship between the CBO and the hospital teams is essential.
The hospitals must pick the right patients at highest risk, because the program must produce a 20% reduction of a hospital's baseline 30-day all-cause readmission rate among Medicare patients in the first two years. If that's not achieved, CMS can reject funding for the rest of the five-year program. The CBO can't provide these services for all discharged patients, so hospitals must refer just those high-risk patients most likely to be readmitted.
The rules also say the CBO must assure that its costs to keep patients from unnecessarily returning to the hospital within 30 days are less than the cost of an average hospital readmission, or about $9,600.
The programs are structured in a variety of ways. But in general the federally funded CBO may hire care managers to work inside the hospital with physicians and nurses to assess high-risk patients at the point of their index admission. Hospital and CBO teams develop a structured, formal protocol for how they will address each issue the patient might have after discharge and get the patient's consent.
At discharge, the patient's needs are reassessed, and care transition coaches, such as those trained under the Coleman model, are assigned to each patient. That may mean one or more home visits, making sure the patient sees a physician within the first two weeks and has the means to get to the appointment, and instructions and teach-backs to ensure the patient understands his or her medications and care plan. Cultural and language issues must be addressed with multilingual personnel.
It's still too early to tell whether the programs are working. But success stories are starting to come in.
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