The federal government has begun penalizing hospitals it determines to have excess patient readmission rates for certain conditions. An analysis of a program implemented in three states to reduce preventable readmissions statewide identified three key obstacles to success: 1) forming productive, collaborative relationships across care settings; 2) identifying effective interventions, especially across settings; and 3) addressing a lack of quality improvement capabilities among some health care providers. To see rapid, widespread reductions in readmission rates, public policy should help remove these barriers.
Each year, one of five Medicare beneficiaries returns to the hospital within 30 days of discharge, costing the program roughly $18 billion. Many such readmissions are thought to be preventable with better care. In an effort to reduce readmission rates, Medicare has begun financially penalizing hospitals deemed to have excess readmissions for heart attacks, congestive heart failure, or pneumonia. In this Commonwealth Fund–supported study, researchers examine the early experiences of participants in the State Action on Avoidable Rehospitalizations (STAAR) initiative, a four-year effort begun by the Institute for Healthcare Improvement in 2009 and supported by The Commonwealth Fund. The program, which was implemented in Massachusetts, Michigan, and Washington, set ambitious goals for improvement—20 percent to 30 percent reductions in readmission rates—and involved providers from across the health care continuum.
- STAAR leaders, advisers, and participants agreed that fostering relationships between providers across care settings is key to reducing readmissions. The creation of "cross-continuum" teams opens new lines of communication, helps participants acquire a realistic understanding of each other’s roles, and identifies practical opportunities to improve care. However, establishing genuinely collaborative relationships presents a significant challenge, since these kinds of relationships are not naturally occurring in most communities. In particular, hospitals have difficulty recruiting primary care physicians, nursing home frontline staff, and providers from beyond their networks or health systems.
- Participants noted that the lack of evidence on the effectiveness of various interventions for reducing readmissions, especially for care outside the hospital, hinders efforts. This problem is complicated by the lack of agreement on standard definitions for readmission rates and preventable readmissions.
- Some hospitals and other providers do not have the infrastructure or experience needed to implement rapid-cycle quality improvement techniques.
Addressing the Problem
Efforts to reduce hospital readmissions on a large scale will need to focus explicitly on promoting real collaboration across care settings, taking into account both economic and human factors, the authors say. The federal Community-Based Care Transitions Program, recently launched to support partnerships between hospitals and community organizations, should provide practical lessons to help guide these efforts. And given that hospitals with limited resources for quality improvement are especially at risk for incurring Medicare’s new penalties, policymakers should consider providing support for training in quality improvement methodologies, as well as incentives for achieving degrees of improvement.
About the Study
Researchers conducted 52 interviews in 2011, about two years after STAAR began, with national program leaders, state STAAR directors, improvement advisers, hospital participants, postacute care providers, members of professional associations, and health care policy leaders.
The Bottom Line
Changing economic incentives for hospitals may not be sufficient to encourage rapid, widespread reduction of readmission rates. Extensive efforts will be needed to identify effective interventions and encourage care coordination.