Listen to the July 28 informational call, led by faculty, regarding IHI’s upcoming Collaboratives. Review the presentation slides. Please note due to technical difficulties, the first two minutes of the call were not recorded. At this time, a general program description was presented.
The Challenge
Poorly executed transitions in care negatively affect patients’ health and well-being and often result in avoidable and costly readmissions to the hospital. Maintaining continuity in patients’ medical care is especially critical following discharge from the hospital. Gaps in planning for the transition, failures in communication, and delays in scheduling post-discharge care all contribute to readmissions. A good transition out of the hospital can significantly impact a patient’s quality of life while allowing nurses, physicians, and other clinical caregivers to provide the kind of excellent care they desire.
A Medicare Payment Advisory Commission (MedPAC) Medicare data analysis found that 17.6 percent of all Medicare hospital admissions are readmissions, and that these account for $15 billion annually in expenditures. Of the $15 billion in readmission costs, it found that $12 billion were potentially preventable. In addition, there is evidence documenting the high rates of readmissions for patients with certain conditions such as congestive heart failure (CHF). Among the populations studied, CHF 30-day readmission rates are particularly high at approximately 20 to 24 percent.
The Solution
The Reducing Readmissions by Improving Transitions in Care Collaborative focuses on creating an ideal transition for patients from the hospital to home. The aim of this Collaborative is to reduce 30-day readmission rates by 30 percent and increase patient and family satisfaction with optimal transitions and coordination of care. During this Collaborative, participants will develop skills to design safe and reliable transition processes, more effectively engage patients and families to be better self-managers, and effectively coordinate care at discharge across settings. Team composition encourages participants to arrange handoffs in creative and innovative ways along with the opportunity to work across disciplines and care settings.
During this Collaborative, teams will focus on interventions, including enhanced assessment of post-discharge needs, enhanced teaching and learning, enhanced communication at discharge, and timely post-acute follow up. Many teams from medical and surgical units working on the IHI-Robert Wood Johnson Foundation (RWJF) Transforming Care at the Bedside (TCAB) project achieved very promising results by implementing these interventions for patients with CHF. There is tremendous opportunity for hospitals to prevent readmissions by focusing on specific patient populations and addressing the entire system of care.
