Avoidable rehospitalizations can harm patients and place unnecessary strain on the providers and organizations that care for them. Looking to identify successful interventions for reducing avoidable rehospitalizations, the Centers for Medicare & Medicaid Services (CMS) selected CIMRO of Nebraska as one of 14 QIOs to participate in a 2008-2011 Care Transitions pilot project.
The results of the pilot show that interventions aimed at improving care transitions—when patients move from one care setting to another, such as from a hospital to their home—reduced rehospitalizations for Medicare patients by almost six percent in the communities participating. A less expected result was that Medicare beneficiaries in the communities also experienced a 5.74 percent reduction in hospitalizations over the two-year period. The project’s success was documented in the January 23/30, 2013 issue of the Journal of the American Medical Association.
Working with health care and community organizations in Omaha, CIMRO of Nebraska led efforts with in an Omaha community to improve care coordination and care transitions. In addition, several community learning groups were formed to improve communication among and between healthcare settings. An emphasis was placed on access to electronic health records, medication reconciliation, implementation of consistent communication tools and clinical education on disease-specific topics.
The results in Nebraska were even better than the national average. In Omaha, there was a 6.2 percent reduction in rehospitalizations of Medicare patients and a 6.6 percent reduction in hospitalizations. Communities of comparable size, demographics and hospitalization utilization—but where there were no concerted efforts to improve care transitions—averaged considerably more modest reductions, just a 2.05 percent drop in rehospitalizations and a 3.17 percent decline in hospitalizations.
Today, CIMRO of Nebraska is working with healthcare providers across the state and supports local collaborative efforts to improve care coordination.