Hospitals, physicians and health-care advocate groups have worked separately for years on plans to reduce hospital readmissions. On Monday, a Colorado nonprofit group launched an initiative to bring those efforts together to find the best solution.
Healthy Transitions Colorado, which will be managed by the Center for Improving Value in Health Care (CIVHC), is seeking input from thousands of health-care and social-services providers — ranging from the state’s largest hospitals to organizations that provide transportation for poorer residents — to improve the critical process of transitioning patients from hospital care to health at home.
Avoidable readmissions that occur within 30 days of a patient leaving the hospital, often due to a lack of understanding of their own prescription-medication and follow-up care needs, are one of the biggest reasons for the spiraling costs of health care nationwide.
Many hospitals especially have undertaken efforts to stem the tide of readmissions. The Colorado Hospital Association, for example, has offered grants through its “Project Red,” and a number of health care systems have hired workers to coordinate the follow-up care of each departing patient or to partner with pharmacies to deliver prescription medication to those patients.
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But some of the statewide and nationwide efforts that have been most successful at reducing readmissions within 30 days have gone beyond health-care providers working just with other health-care providers and have involved working with local social-services groups, said Dr. Jane Brock, chief medical officer for the Colorado Foundation for Medical Care (CFMC).
And that wider swath is at the heart of the Healthy Transitions initiative.
Health-care and social-services organizations are being asked to register on the initiative’s website, http://healthy-transitions-colorado.org/, and to provide information about what efforts they are undertaking to reduce readmissions.
This will allow organizations throughout the state to learn about successes that they can emulate, and it also will help to link health-care providers and social-service groups in need of each other’s services, officials said.
By December, officials hope to be able to measure the success of each program through eight metrics, such as emergency-room utilization or hospital readmissions per 1,000 persons, said Phil Kalin, CIVHC president/CEO.
Between the wide swath of participants offering services like transportation and financial help for needy residents and the measurable attributes, he believes the Healthy Transitions program will be precedent-setting.
“It’s almost like a social-network we’re trying to create, including crowd-sourcing,” Kalin said. “What we’re trying to do is illuminate where the connecting points are, see who can supply them and point to what’s working.”
The federal government already has taken steps to try to reduce readmissions, such as fining hospitals whose readmission rates are too high. That has led to a reduction in readmission rates for the first time in five years, but more has to be done — and programs like Healthy Transitions can provide the carrot to the federal government’s stick, said several officials at a public rollout of the program Monday.
“This is an incredibly exciting day for Colorado, for communities both rural and urban,” said U.S. Sen. Michael Bennet, D-Colo. “What’s exciting to me about today and the work you’re doing here is you’re embarking on a campaign no one told you that you had to do.”
CIVHC will work with four operating partners to run the initiative — CFMC, the hospital association, Colorado Rural Health Center and the Colorado Health Care Association.
Date: Jul 8, 2013