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Reducing Avoidable Readmissions for the Rural Population. INDIANA RURAL HEALTH ASSOCIATION June 7, 2011 Nancy Meadows, RN, BS Project Director Robbin Lubbehusen, BA Project Manager Health Care Excel. Background.
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INDIANA RURAL HEALTH ASSOCIATION
June 7, 2011
Nancy Meadows, RN, BS
Robbin Lubbehusen, BA
Health Care Excel
Approximately 18% to 20% of Medicare beneficiaries who are discharged from a hospital are readmitted within 30 days (MedPAC, 2007; Jencks et al., 2009)
Readmission rates vary significantly across hospitals and states, as well as across diagnoses, even after adjusting for disease-specific and severity-related differences
The primary component of reducing readmissions in rural settings is the ability to coordinate care and ensure the patient has access to health care services and community support.
Developing high quality care transitions
Transmitting and communicating essential data elements to practitioners involved in a patient’s care across all settings
Structuring organizational and community delivery systems to promote seamless transitions across care settings
Reviewing coverage and limitations that affect access to care and services
Helping patients and caregivers understand what should expect at the next care setting(s)
Source: Improving Care Transitions. Jane Dorman. Care Management Institute, Kaiser Permanente. January 13, 2010.
Source: Health Care Advisory Board (2010). Playbook for Accountable Care, Road Map for the Transition to Total Cost Accountability. The Health Care Advisory Board: Washington, D.C.
Workforce and provider shortages (e.g., supply of physicians or places to go for medical care)
Limited access to specialty care
Limited financial capacity
Predominately older populations with multiple chronic conditions
Isolation and sometimes large geographical areas and travel distances
Lack of coordination and communication across information systems and between providers
Health care professionals are not necessarily trained in care coordination
History of becoming innovative to meet challenges
Absence of large, complex systems
Patients are less scattered among multiple delivery systems
Culture of community collaboration
Strong primary care physician infrastructure
Established multiple disciplinary teams and networks are often in place to ensure access and improve quality of care
Rural cultural norms contribute to a level of community engagement leading to a shared interest in accomplishment
Examine current state of readmissions and discharge processes
Assess and prioritize improvement opportunities
Develop an action plan of strategies to implement
Monitor and evaluate progress
Readmission rates by diagnoses
Readmission rate by practitioners
Readmission rates by readmission source
Readmission rates at different time frames
“We must close the gap between what health care professionals know and what the rest of America understands.”
Dr. Richard Carmona,
U.S. Surgeon General 2002-2006
Develop community connections to eliminate barriers to successful care transitions
Develop strategies and interventions to engage patients, families, and caregivers in addressing the issue
Patient empowerment and
self management skills
Plan of care
This material was prepared by Health Care Excel, the Medicare Quality Improvement Organization for Indiana, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 9SOW-IN-TRAN-10-008 02/23/2010