As part of ongoing efforts to help reduce avoidable hospital readmissions, IPRO, the QIO for New York, facilitates a community coalition involving providers from different settings of care. The initiative, which began in early 2011, involves three hospitals and eight nursing homes in Albany and Rensselaer counties in the Upper Capital region of New York State. Staff from the coalition member providers meets monthly to discuss opportunities and approaches to improve care transitions within the community, focusing on:
- Improving communication and coordination across settings during transfer,
- Targeting patients at risk for re-hospitalization,
- Developing root cause analyses and work plans on priority areas for improvement.
IPRO provided technical support to the coalition for implementation of a broad range of interventions, including:
- Cross-setting case conferencing on nursing home residents at risk for readmission,
- Community root-cause analysis through cross-setting case reviews to identify readmission drivers and opportunities for process improvement,
- Cross-setting medication discrepancy review and tracking,
- Implementation of verbal practitioner-to-practitioner report upon transfer to nursing home,
- Access to hospital electronic health records through remote nursing home portals,
- Identification of single “source of truth” document for transfer of discharge medication list,
- “Gold Standard” discharge summary and medication list developed for community adoption and implementation,
- Education of emergency department physicians on capabilities of nursing homes to manage complex medical conditions as an alternative to hospitalization.
The initiative resulted in a 15 percent relative improvement in community 30-day all cause readmission rates for discharges from partner hospitals to nursing homes between first quarter 2011 baseline rates (pre-intervention) and fourth quarter 2012 rates (post-intervention), representing the most current data available.