"The fundamental flaw in this model is that hospitals are the only entity eligible to be penalized for readmissions, yet hospitals are not eligible to directly receive any of the technical assistance funds available," she said.
It's a sea change in thinking. The CBOs that stand to receive funding are the same CBOs that now distribute food, run transportation, housing, or eldercare programs, and which already work with old, sick people in need and already have strong links to downstream providers, such as rehab facilities and nursing homes, or even Meals-on-Wheels.
Jane Brock, MD, Chief Medical Officer for the Colorado Foundation for Medical Care, the Medicare Quality Improvement Organization (QIO) for Colorado, has been working with care transitions project models for years and is enthused by the idea.
QIO programs that tested the concept with "transition coaches" prevented 30% to 50% of readmissions, not just those that happened in 30 days, but over longer periods as well, Brock says.
As you might imagine, the program has hospital leaders asking lots of questions. Will CBOs be bound by medical confidentiality rules? Can a CBO competently do this difficult work? Who will these CBOs select to hire and train? The CBO will also have to a perform root cause analysis when a readmission occurs, and keep track of whether its interventions actually work.