Remember the African proverb: "It takes a village to raise a child?" Maybe it takes a village to prevent hospital readmissions, too.
From Rockport to Yakima and from Detroit to El Paso, 30 community-based organizations are joining hands with hospitals, finally, in a communal effort to do just that, all funded by $500 million authorized by the Affordable Care Act for five years.
These CBOs are social support groups and Area Agencies on Aging, the type of quasi-government entities and non-profits historically known for home-delivered meals, transportation services, support, and counseling for seniors and the disabled. Now, these regional collaboratives are embarking on a variety of experiments to pick up the care of patients where hospital discharge planners leave off.
When I first wrote about the Community-Based Care Transitions Program last October, prospects looked grim. Projects were supposed to have started Jan. 1, 2011, but by fall none had been picked and few hospitals seemed interested.
Health and Human Services officials lamented the paucity of applications. Hospital officials complained they didn't even know who their senior services organizations were or what they did because they lived in different worlds. And how could they understand these medically fragile patients?
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.
CBO workers try to anticipate avoidable complications, such as malnutrition, falls, symptom confusion, or medication misuse that can occur if the patient didn't understand their dosage or couldn't get to the doctor.
If problems do arise, there are follow-up calls and referrals to coordinate additional services in a way that hospitals rarely have enough staff to do.
"Sometimes it really does take looking into someone's fridge to see, do they have food when they get home from the hospital?" says Cathie Berger, director of the Atlanta Area Agency on Aging, one of the first seven collaboratives approved. "Somebody needs to be checking back, and following that patient home," if only to see if the patient could easily trip and fall.
"A lot of people don't understand what their needs are until they get home," says Robert Mapes, manager of community and agency relations at AgeOptions, a collaborative approved to work with six Chicago area hospitals. "They may find that their bed at home is a lot lower than their hospital bed and it's tougher to get in and out of and they need help. Or they don't realize how much standing is required to cook your own meal at home."
The Centers for Medicare & Medicaid Services pays the CBOs directly. Rates vary, but one organization indicated the rate was $200 to $300 per discharge, or more depending on the scope of work. CMS officials wouldn't comment, saying it separately negotiates all rates.
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.
The patients may have literacy or language challenges or be living with a spouse who has health issues as well. And Merrimack added mental health outreach, because it found that within its population, depression that produces anxiety and pain can often mean a trip back to the hospital.
Moreover, making sure patients obtain their prescribed medication can present a challenge. Healing@Home and the Area Agency on Aging in Maricopa County, AZ are working with Sunwest Pharmacy and four Phoenix area hospitals to address that issue. Sunwest delivers prescription drugs to program participants unable to obtain their medication themselves.
It's good to see that at least some hospitals recognize some benefits from these partnerships, because that wasn't the case when I inquired about this program last fall. One hospital official suggested she couldn't imagine that a CBO, or Area Agency on Aging in her town could manage the post-discharge needs of a morbidly obese patient with diabetes and congestive heart failure.
Of course, the program will require close monitoring for unintended consequences. We need to be sure patients aren't dying at home because of an overaggressive effort to prevent a readmission, or that groups of patients aren't reappearing at the hospitals' doors on day 31.
But as a policy official familiar with the issue once explained, these hospitals are well aware that community factors provoke a lot of readmissions that hospitals can't begin to address.
It is a grand experiment, but one that just might work. It may indeed take a village to keep a patient from being readmitted.