Amy E. Boutwell, M.D., Marian Bihrle Johnson, M.P.H., Patricia Rutherford, R.N., M.S., Sam R. Watson, M.S., Nancy Vecchioni, R.N., M.S.N., Bruce S. Auerbach, M.D., Paula Griswold, M.S., Patricia Noga, M.B.A., R.N., and Carol Wagner, R.N., M.B.A.
The State Action on Avoidable Rehospitalizations (STAAR) initiative fosters partnerships among hospitals and their community-based partners to improve provider communication at critical transitions in patients' care. It also has engaged payers, providers, and employers in statewide efforts to identify and mitigate barriers to well-coordinated care.
Avoidable rehospitalizations are a marker of poor-quality care and a leading source of costs in health care. To address this problem, the Affordable Care Act will impose a financial penalty on hospitals with higher-than-expected rates of rehospitalization. Reducing rehospitalization rates, however, also requires significant coordination among the physicians, hospitals, and nursing homes that share in the care of patients but often lack incentives to coordinate that care. Supported by grants from The Commonwealth Fund, the STAAR initiative seeks to reduce 30-day rehospitalization rates statewide in Massachusetts, Michigan, Ohio, and Washington. Writing in Health Affairs, the program leaders reported the results of the statewide mobilization strategy at the mid-point of the four year initiative.
Efforts to reduce rehospitalizations, the authors say, must extend beyond the walls of the hospital. Hospitals that face future financial penalties under the Affordable Care Act will find greater success in efforts to reduce rehospitalizations if they meaningfully partner with community providers. Of all the recommendations in the STAAR initiative, the most widely accepted and useful—acccording to participants and leaders—is the concept of the "cross continuum team."
Collaboration among hospitals and community-based providers is essential for improving transitions between care settings and keeping discharged patients out of the hospital. Fostering partnerships among providers, payers, and health plans can help identify causes of avoidable rehospitalizations and align programs and resources to address them.