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 TMF Health Quality Institute* as one of 14 QIOs to participate in a 2008-2011 Care Transitions pilot project.
The results of the national 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.
The community-based approach coordinated by TMF and other QIOs in the study was markedly different from commonly used hospital-based approaches to improve care transitions, which have often focused on interventions among patients with a specific disease or in a specific hospital unit. TMF quality improvement consultants worked with health care providers in the Rio Grande Valley to implement interventions to improve medication management, post-discharge follow-up, communication and coordination of care. In addition, TMF promoted increased self-management of chronic disease for patients and caregivers through education and support, including training on how to use a personal health record.
As a result, in the Rio Grande Valley community where TMF coordinated community-based efforts to reduce readmissions, there was an 11.6 percent reduction in rehospitalizations of Medicare patients and an 8.6 percent reduction in hospitalizations during the pilot project.
*In spring of 2014, CMS determined to separate the consumer type protection activities - case review, beneficiary complaint and appeals - from the quality improvement work for the QIO program going forward. As of August 1, Texas is represented by two Quality Improvement Organizations. TMF Health Quality Institute has formed the TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO) with subcontractors Arkansas Foundation for Medical Care, Primaris in Missouri and the Quality Improvement Professional Research Organization, Inc. in Puerto Rico to provide quality improvement work throughout Texas, Arkansas, Missouri, Oklahoma and Puerto Rico. Beneficiary and family centered care services are now provided by KEPRO.