Montefiore Medical Center in New York City's Bronx borough has a long history of taking risk with its patients. Anne Meara, RN, MBA, is associate vice president of network care management for CMO, Montefiore Care Management, a healthcare management company that works with a network of more than 3,400 physicians and ancillary providers who provide care to more than 225,000 individuals covered by a variety of government-sponsored and private sector health insurance programs. She says focusing on readmissions only is likely to be less effective than working to eliminate system breakdowns and improving chronic care management.
Hospitals, from a leadership standpoint, are often lured into focusing on the readmission and not the factors that led to it in the first place. So it's not that targeting can't work, but that it's very short-term and not sustainable. In fact, Meara says focusing on readmissions at all leaves out all the interventions that can be made to a patient's care along the way. The readmission represents the culmination of all that effort, or lack of it.
"Focusing on the readmissions is focusing on the far end of the continuum," she says. "Particularly with preventable readmissions, there are systems breakdowns along the way—some related to things in control of the healthcare provider and some not so much. We're focused on many stops along the way and moving preventive care and chronic care management further upstream in the continuum."
Meara says Montefiore's efforts to reduce readmissions critically involves partners outside the health system because patients in the area access many different healthcare providers that aren't necessarily owned or controlled by the health system. In partnerships with local payers and other healthcare providers, including other hospitals, Montefiore has implemented extensive interventions geared toward helping avoid readmissions in all stratifications, even among patients who may have psychosocial issues or transportation problems. They scale up interventions based on risk factors.
"These are not high-tech interventions, but they are resource-intensive," she says. "Many hospitals are engaged in post follow-up phone call programs. The difference with this is, we stayed involved."
Other hospitals may stop intervening after the postdischarge follow-up call, for example, and they often don't go beyond checking on prescription-filling and adherence. The care transition managers involved in the Bronx Collaborative—which includes three hospitals: Montefiore, St. Barnabas Hospital, Bronx-Lebanon, and two payers: EmblemHealth and Health First—not only search to identify challenges surrounding patients likely to be readmitted, but also are coached to intervene.
Results bear out the return on this increased level of intervention. Among 500 patients who received two or more "interventions" in the Bronx Collaborative to manage the transition between hospital and home, only 17.6% were readmitted to the hospital within 60 days of discharge versus 26.3% among a comparison group of 190 patients who received the current standard of care. When the other 85 patients who received only one intervention for a variety of reasons are included in the results, there was a higher readmission rate, at 22.8%, but still lower than the standard.