30-day hospital readmissions per 1,000 eligible beneficiaries, semi-annual (O-4) Best-fit lines for observed rates50.00 Lower is better. Statistically significant trends, per Cochrane-Armitage test, are indicated by bolded p-values.45.00 11 140.00 11 (p<0.0001) 3 3 (p=0.8862) 1335.00 1 (p<0.0001) 7 13 (p<0.0001) 12 9 9 (p=0.6007)30.00 86 10 12 (p=0.0010) 5 7 (p<0.0001) 10 (p<0.0001) 8 (p<0.0001)25.00 6 (p<0.0001) 5 (p=0.0003) 4 4 (p=0.0526)20.00 2 2 (p<0.0001) 1415.00 14 (p=0.1434)10.00 Oct07-Mar08* Jan08-Jun08 Apr08-Sep08 Jul08-Dec08 Oct08-Mar09 Jan09-Jun09 Apr09-Sep09 Jul09-Dec09 Oct09-Mar10† Jan10-Jun10 Apr10-Sep10 Jul10-Dec10 Evaluation Period Baseline measurement is indicated by an asterisk (*). Follow-up evaluation is indicated by a dagger (†).
No Communityinfrastructure forachieving common goals
What’s he saying? I surehope my wife is gettingthis.. No I’m good to go. Whatever Blah blah you say is what blah, blah blah. we’ll do Doctor Any questions? Patient activation trumps all What We Learned
Community-Based Care Transitions Program Partnership between hospitals and CBOs To pay for transitional care activities not currently paid Intended to pay for existing successful programs Services to focus on geographically located population Paid by roster bill from the CBO The PAM is a required measure (paid for by TA contract)
No successful applications first 4 months Technical assistance available 8/1 Frequent misunderstanding of the program ‘CBO’ Few existing programs with data
We know how to systematize behavior change to avoid hospital readmisisons We mostly know who can get paid to do itNo Community infrastructure We are getting more sophisticatedfor achieving common goals about building collective impact But we’re still not quite there..
Policy is necessary but might be insufficient
“It’s clear that somebody has to dosomething and it’s incredibly patheticthat it has to be us.” Jerry Garcia