Reducing Avoidable Re-Hospitalizations:
Process Improvements, Policy Challenges
Amy Boutwell MD MPP
IHI-CMWF Reducing Re-hospitalizations Initiative
Institute for Healthcare Improvement

“The Billion Dollar U-Turn”
• 17.6% of Medicare admissions are readmissions within 30 days
– Accounting for $15 B in spending
• Not all re-hospitalizations are potentially preventable, not all avoidable,
but many are (accounting for $12B in Medicare spending)
– HF, Pna, COPD, AMI lead the medical conditions
– CABG, PTCA, other vascular lead surgical conditions
• Disparities exist along socio-economic, racial and “burden of illness” lines
• Individual delivery systems and health services researchers have
demonstrated dramatic (40-85%) reduction of 30-day readmission rates
for certain patient populations (esp. CHF)

Prevalence and Drivers of Re-hospitalizations
• Preliminary 2007 Medicare data analysis finds:
– 20% beneficiaries are re-hospitalized at 30 days
– 35% are re-hospitalized at 90 days
– 67% are re-hospitalized or deceased at 1 year
• Among medical patients re-hospitalized at 30 days:
– 50% no bill for MD service between discharge and re-hospitalization
• Among surgical patients re-hospitalized at 30 days:
– 70% were re-hospitalized with a medical DRG
Source: Jencks, Williams, Coleman preliminary data pending peer-review

IHI-CMWF Initiative to Reduce Re-Hospitalizations
IHI received a grant from The Commonwealth Fund to lead an
initiative to support a multi-state initiative to dramatically reduce
re-hospitalizations
Context:
• Reducing re-hospitalizations is seen by many as an opportunity to
simultaneously improve quality and decrease costs
• A win for patients, payers, purchasers
• Mixed reactions from providers, hospitals
Challenge:
• Requires working within and between sites of care
• Payment, regulatory, professional norms, data are all barriers
• Create “system-ness” in fragmented environment

Why Re-hospitalizations? Why Now?
• Increasing cost of health care is prompting many to focus on areas of high
cost and low quality, or other areas of significant savings
– States, purchasers, payers seeking savings
• MedPac June 2007 and 2008 reports highlight avoidable hospitalizations
as an area of high-cost, low-quality
– Some health care systems want to “get out ahead” on this issue
• Some commercial payers, integrated systems already track rates
• Number of states plan to publically report 30-day readmission rates
• CMS Care Transitions focus in the 9th SOW

What can be done, and how?
• There exist a wealth of approaches to reduce unnecessary
readmissions that have been locally successful
Which are high leverage? Which can go to scale?
• Success requires engaging clinicians, providers across
organizational and service delivery types, patients, payers,
and policy makers
How to align incentives? How to catalyze coordinated effort?

Key Strategies for Reducing Re-hospitalizations
Primary Drivers Secondary Drivers
Who ???
Aim: • Multi-stakeholder Coalitions
• Hospital Associations
To dramatically
• Integrated Health Care Systems
reduce re- • Payers and Purchasers
hospitalizations in • Communities
Will • Clinicians / Providers of Care
states / regions
How ???
• Aligned incentives, Policy Change and
Payment Reform
• Transparent State-wide Measurement
Outcome Measures:
• Optimizing the transitions in care after
1.Re-hospitalization
hospitalizations
rates (Target: reduce
• Providing enhancements / supplemental to
by 30%)
Ideas routine care for patient s at high risk for
re-hospitalization
2.Patient and family • Engaging consumers and their family
satisfaction with : caregivers in their own care (and
medication managment)
•transition out of the
hospital (Target:
• Micro-System Capability
50% increase)
• Customized Sequencing of Work
Execution
•coordination of care • Robust, timely, and actionable measurement
that can help to drive Improvement
in community (Target:
(provides feedback over time)
50% increase) • Learning System
o collaborative learning
o local support for improvement

Evidence: Reducing Re-hospitalizations
• Growing evidence of the effectiveness of following:
– High quality in-patient care
– Manage medical co-morbidities (in medical and surgical inpatients)
– Early assessment of discharge needs
– Enhanced patient and caregiver self-management engagement
– Early post-acute follow up with MD or RN (home visit, phone call)
– Hospital-based post-acute follow-up (phone calls, nurse visit)
– Appropriate referral for home care services
– Appropriate patient centered end of life/palliative care discussions
– Remote monitoring
– Improved transfer processes between acute hospitals and post-acute
facilities

Improve Existing Processes
• 81% of patients requiring assistance with basic functional
needs failed to have a home care referral
• 64% said no one at the hospital talked to them about
managing their care at home
Clark PA. Patient Satisfaction and the Discharge Process: Evidence-Based
Best Practices. Marblehead, MA: HCPro, Inc.; 2006.
9

Enhance Existing Care or Provide Supplemental Care
• Excellent research and experience of innovators highlight the
effectiveness of enhanced care delivery during transitions:
– Transition coaching (Coleman)
– Advanced NP coordination roles (Naylor)
– Guided care model (Bolt)
– Nurses that “wrap around” primary care for high –risk populations
(CMS demonstrations)
– Enhanced primary care coordination with home health (NYVNA)
– IHI Transforming Care at the Bedside (Ideal Transition Home for HF)

High-Leverage Opportunities for Action
1. Improved Transitions for All Patients
a) Transitions “out” of the hospital
b) Reception “in” to home (activated home health, office practice)
c) Reception “in” to skilled nursing (activated post-acute rehab, NH)
1. Proactively address the needs of “high risk” patients
a) Create inventory of evidence-based “wrap around” or enhanced services
b) State-specific assessment of plausibility of financing
1. Engage patients and families/caregivers
a) Web-based tool, AARP campaign (medications), Partnership for Healthcare
Excellence campaign (consumer activation),
b) Proactive role in care, especially at times of transitions

Improving the Transition Out of the Hospital
Key Recommendations:
1. Enhanced Assessment of Patients
2. Enhanced Teaching and Learning
3. Patient-Centered Communication Handoffs
4. Ensure Timely Post Acute Follow-up
12

HF Readmissions within 30 Days
35
30
29 Aug 06 = Implemented use
of new patient education
25
25 materials
Percentage
Jan 07 = Initiated
20
19 19 complimentary visits
18
16
16
15
14 12 14
12
11 11 9
10 10 8
10
9
9 9.0
8
7 7
5 5
5
4 4
0 0 0 0
0
Jan- 0 6
Jan- 0 7
M ay- 0 5
J u l- 0 5
S ep- 05
N o v- 0 5
M a r- 0 6
S ep- 06
N o v- 0 6
M a r- 0 7
S ep- 07
N o v- 0 7
M ay- 0 6
J u l- 0 6
M ay- 0 7
J u l- 0 7
Rate (%) Median

Reducing Readmissions

Creating Will: Reliable Data
35th

35th

MA rate: 29%
Best state: 18%
MA rank: 35
MA rate: 20%
Best state: 13%
MA rank: 41

Creating Will: Align Incentives for System-ness
• Create incentives to work across traditional settings of care and between
providers (standards, bundled payment, differential payment)
• Create incentives to communicate with patients/caregivers (HCAHPS)
• Improve outpatient care coordination (Medical Home, ACOs, bundling)
• Encourage efficiencies in coordination and communication (electronic
records, email and phone interactions, group mgt)
• Invest in enhanced services for high risk patients (payment, bundling)
 Decrease barriers to change (“carrot,” gain-sharing, reliable data)
 Implement catalyst to change (“stick,” data transparency, payment
reduction, “bundling”)

Creating Will: Develop Solutions to Policy Challenges
• IHI will facilitate targeted technical assistance to state
leadership entities working to reduce avoidable re-
hospitalization in the following domains:
– Financial implications of reducing re-hospitalizations
– Payment and other policy reforms
– Data and measurement strategies
– Collaborations across the continuum of care
– Engaging patients and families/caregivers
• By working as a multi-state collaborative, hope to facilitate and
accelerate adaptation of promising policy/ structural
approaches