PDF  Print  E-mail Link Care Networks Smooth Transition from Hospital to Nursing Home Greg Pawlson MD, MPH Executive Vice President, NCQA and Chair, National Advisory Committee Member, Innovations Exchange Expert Panel A growing literature points to transfers from facility to facility or clinician to clinician as a critical juncture for improving quality and reducing waste. A recent study of the Medicare program demonstrates that nearly 20 percent of Medicare patients discharged from a hospital are readmitted within 30 days and nearly half of them have no documented (by claims data at least) contact with the health care system before readmission.1 Hospital readmission rates from nursing homes have received relatively little attention in the medical literature or in demonstration programs. The data that exists indicate that nursing home patients have very high hospital admission rates with an average of more than 1 hospital bed day per resident per year. Nursing home residents also have high readmission rates—in one study, nearly 50 percent of patients admitted to hospitals from nursing homes were readmitted within a year.2 Although not all readmissions are preventable, the high cost—both in terms of dollars and impact on the patient—suggests that even a small reduction in preventable admissions or readmissions would be a substantial contribution. Mary Naylor and her colleagues at the University of Pennsylvania have shown in multiple research demonstration projects that involving nurse care managers—beginning in the hospital and extending beyond discharge—can lower readmission rates.3 A similar successful model (Guided Care) was developed by Chad Boult at Johns Hopkins University to reduce hospital admissions from ambulatory care sites.4 The innovation, Cooperative Network Improves Patient Transitions Between Hospitals and Skilled Nursing Facilities, Reducing Readmissions and Length of Hospital Stays, is a feasible, effective, and replicable model. The set of interventions developed by Summa Health Care system's "Care Coordination Network" could be amplified further by tying it to other innovations such as the Naylor or Boult models. All of the multiple interventions used in this quality improvement project appear fairly easy to implement by a hospital, health plan, or even a large integrated medical group. An area not addressed by the innovation is reimbursement disincentives to reduce admissions and readmissions. Health plans including Medicare Advantage that cover both skilled care and nursing home care have some financial incentive to reduce readmissions. But, hospitals and nursing homes often benefit financially from having a high volume of hospital admissions and readmissions. Given the still-dominant Medicare fee-for-service sector, it is often difficult to support innovations of this type that clearly would benefit society and individual patients. Payment modifications involving bundled payments or nonpayment for avoidable readmissions might substantially increase the number of entities using innovations like this one. References 1Quality Matters: Hospital Readmissions, The Commonwealth Fund, Vol. 29, March/April 2008. 2Lewis MA, Leake B, Clark V, et al. Changes in case mix and outcomes of readmissions to nursing homes between 1980 and 1984. Health Serv Res. 1990;24(6):713-28. [PubMed] 3Naylor MD. Transitional care for older adults: a cost-effective model. LDI Issue Brief. 2004;9(6):1-4. [PubMed] 4Aliotta SL, Grieve K, Giddens JF, et al. Guided care: a new frontier for adults with chronic conditions. Prof Case Manag. 2008;13(3):151-8; quiz 159-60. [PubMed]

Original publication: October 17, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 20, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 10, 2012.
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