As many as one in five Medicare patients returns to the hospital within 30 days of being discharged, costing the program billions of dollars every year, and prompting providers, payers, patients, and health care stakeholders across the country to work to reduce avoidable readmissions. In Nevada, efforts including community-level engagement driven by HealthInsight, the Medicare Quality Improvement Organization (QIO) for the state, contributed to a 22 percent decline in hospitals readmissions between early 2011 and late 2012, amounting to 1,566 fewer people being readmitted within 30 days of discharge and saving the Medicare program about $15 million in averted hospitalization costs.
HealthInsight Nevada’s efforts to engage communities throughout the state and promote coordinated approaches to quality improvement activities included working with hospitals to conduct comprehensive risk assessments of patients upon admission and deploy resources identified in the assessments (i.e., medication management).
The QIO also worked with hospitals to address patients’ health care needs after discharge by:
- Providing in-home visits with a nurse to assess safety and social risks
- Calling patients every week during the first month after discharge
- Making follow-up appointments with patients’ primary care providers
- Providing referrals to Nevada's Aging & Disability Resource Center (ADRC) for help with long-term support options.
In Nevada, the work of HealthInsight and providers and stakeholders across the state between late 2010 and early 2013 reduced readmissions per 1,000 Medicare beneficiaries by 21percent, 1.5 times the national reduction of 14 percent. HealthInsight continues to work with community providers and partners to further drive down the state’s readmission rate.