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Care Transitions Program reduces readmissions at three Bronx hospitals

July 26, 2013

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A collaboration among three hospitals and two health insurers in the Bronx, NY, has significantly lowered readmission rates at the hospitals by emphasizing personal contact with patients before and after their hospital discharge.

That is the finding of a study on the Care Transitions Program (CTP) that is being presented today, July 26, at the Health Forum/AHA Leadership Summit in San Diego.

The study by the Bronx Collaborative, found that among 500 patients who received two or more “interventions” in the CTP, only 17.6% were readmitted to the hospital within 60 days of discharge. That compares to 26.3% in a group of 190 patients who received the current standard of care. The Bronx Collaborative includes Bronx Lebanon Hospital Center, St. Barnabas Hospital and Montefiore Medical Center, and insurers, EmblemHealth and Healthfirst.

Another 85 patients in the study who received only one intervention – for a variety of reasons – had a higher readmission rate, raising to 22.8% the overall 60-day readmission rate for patients in the intervention group.

“These results underscore the value of personal contact with patients before and after their discharge from the hospital and follow-up appointments with their personal physicians to help prevent problems that frequently contribute to readmissions,” said Anne Meara, associate vice president for network care management at CMO, Montefiore Care Management, who led the project’s design team. CMO, Montefiore Care Management is a unit of Montefiore Medical Center, which comprises four hospitals with 1,491 beds and provides more than 2.6 million ambulatory visits through a network of nearly 100 locations.

The Bronx Collaborative designed the CTP using evidenced-based interventions and some customized methods to better connect with their patient population with the aim of reducing readmissions within 60 days following a discharge from the three hospitals. The hospitals are located in one of the most ethnically diverse and poor counties in the U.S., and the county also has a high disproportionate disease burden.

“We [Montefiore] have recognized over the course of time the importance of being able to manage a population regionally – that people don’t always access care in one place,” said Meara. “A big part of what we also wanted to test here was the ability of hospitals to collaborate at an operational level around an intervention
like care transitions.”

The CTP was made available to Medicare, Medicaid and commercial members of the two health plans, and patients were selected using a predictive model that identified those most at-risk for a readmission based on their diagnoses and the number of readmissions within the preceding year.

Nurse care transition managers used a number of interventions including intensive pre-discharge education and post-discharge telephone calls to review medications, identify concerns and verify the completion of the follow-up physician visit.

“Establishing the rapport and making sure the care transition manager had the right contact information post-discharge was a key component,” said Janet Kasoff, director of the Montefiore Care Management Center for Learning and Innovation and a member of the CTP’s design team.

In addition to receiving at least two interventions, patients received a follow-up physician visit within 14 days of discharge.

“It was very patient-centered and very patient-focused,” said Jitendra Barmecha, M.D., a physician at St. Barnabas Hospital and a member of the CTP’s design team. Barmecha also is vice president of medical informatics at St. Barnabas Hospital.

He says another critical component to the CTP’s success was the hospitals’ ability to share patient data. A care transitions analyst at each hospital entered data in a special program developed for the CTP by the Bronx Regional Health Information Organization, and a program pharmacist reviewed medication records and worked with patients who were having problems complying with the prescribed regimen.

The CTP was supported by a grant from the New York State Health Foundation and the New York Community Trust. The hospital systems contributed in-kind services and the health plans agreed to pay a fee for each patient who received at least two of the interventions in the program’s protocol.

“The program was designed to reflect the key concepts of accountable care – improving outcomes and patient satisfaction while lowering costs,” said Montefiore’s Meara. “We met those goals, and identified opportunities that could possibly be applied successfully at other hospitals.”

By Pete Davis