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Readmissions Network Successes


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  View this recording to learn more about the TMF QIN-QIO’s successes in reducing readmissions and building community coalitions.


Readmissions Network Successes Transcript

So the problem with readmissions, we've heard a lot about the data on readmissions. But we know that about 31% of hospitalizations are consuming about $2 trillion of the total health care expenditures in the United States. So as everyone is aware, rehospitalization has been a big focus area for CMS and other payers to try to curb some of the expenditures that go with it.

We recruited and engaged the hospitals, nursing homes, home health, dialysis and the physicians to come together to work on readmissions at the community level. Again, it's a community problem. Right now we know that the hospitals are the ones that are being penalized. But in our project, we truly did break those silos down.

We brought everyone to the table. This is not a hospital issue. This has to do with nursing  home health care. And so we pushed that accountability.

It goes from just being a hospital responsibility to being all of us because we are accountable for the care that we're providing our patients, our family members that are receiving care in our community. So again, not just the hospitals. Everyone in the community is responsible and has a stake in the problem.

We broke down the silos. We engaged the community, starting with the hospitals. We engaged the hospitals. We engaged them and asked them to conduct interviews with their staff, talk to them about readmissions.

What changes are they seeing? What things can we change? We analyzed a lot of data. CMS sourced data, there for the community as the hospitals would pull their information and their data.

The data, again, like I said, is based on fee-for-service patients. We're able to track that Medicare beneficiary across the continuum of care where, as most of you may know, the hospitals, they're only able to track beneficiaries if they come back to their own facility. So we were able to provide them additional data and information.

About 5% of the patients that are readmitted into the system are kind of lost to the hospitals. They are not aware that they've had a readmission, because they may go to the sister facility or the one other hospital in town in another channel. So our data was extremely valuable to actually gave them a true picture of what was happening to the that  patient and their true readmission rate.

For those of you that are interested in embarking in this work-- strongly encourage you to develop and foster internal and external team approach. You've got to take the work of readmissions outside your own facility and your own walls. This is a community problem.

You can only do so much within your own walls. You have to bring other providers to the table to talk to you about what areas they see for improvement and what things we need to do as a community. We're all in it together. 
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