Preventing Hospital Readmissions Takes a Village
Funds Bypass Hospitals
One of the sore points for hospitals, however, is that they are precluded from receiving any of the $500 million for helping with the discharge planning, since that's within their normal scope of patient work. "These functions are already required by discharge planners; now they just have an additional resource for referral," says Juliana Tiongson, CMS' social science research analyst familiar with the program.
Tiongson says now, more CBOs have applied and she expects to announce more agreements soon. "We've reached a little over 50% capacity for the program, based on the $500 million over five years," she says.
But Tiongson doesn't know which programs will pay off in the long run. "It's a little bit early to tell what ultimately is going to work," she says. The programs are encouraged to join learning collaboratives "to rapidly disseminate what's working in some of the communities, to help others that are struggling to identify best practices."
One particularly ambitious effort is the Merrimack Valley Care Transitions project, which intends to track 8,000 to 10,000 patients discharged from five suburban Boston and southern New Hampshire hospitals in its first year. Merrimack's executive director, Rosanne DiStefano, says a root cause analysis identified environmental factors—not the patients' illnesses—as the greatest reason for readmissions in their region.
"Say they're being discharged to home, but they have a third-floor walkup, and they're in no shape to do that. Or they suffer from cardiovascular problems or COPD, and their apartment has no ventilation. These are problems waiting to happen," DiStefano says.
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