The document summarizes research on developing a primary care model to reduce hospital readmissions. It conducted an environmental scan of the literature, interviewed patients before and after discharge, and analyzed care processes at primary care sites. Preliminary findings show multi-component interventions tend to be more effective, and that improved communication between hospitals and primary care is needed. Next steps include further analyzing primary care workflows and identifying components of a Re-Engineered Visit model to reduce readmissions.

1. Re-engineering Visits (REV) in
Primary Care – Implementing
Strategies to Reduce
Readmissions
Michael Hochman MD, MPH
Albert Farias PhD, MPH
Sonali Saluja MD, MPH
April 4, 2018

2. Funding and Disclosures
• This project was funded the Agency for Healthcare Research and
Quality
• Drs. Hochman, Farias and Saluja have no conflicts of interest, financial
or otherwise, to report.

3. Agenda
• Project background
• Project objectives and study questions
• Environmental Scan
• Patient Interviews
• Primary care practice
• Summary and next steps
• Question and Answer

4. Background on Public Health Problem
• High rates of readmissions are a major patient safety problem
associated with medical errors
• Efforts to address readmissions have focused on the hospital setting
and much less on the primary care setting
• The primary care setting is well-suited to play a key role across the
health system in reducing unnecessary hospitalizations, improving
outcomes, and lowering costs

5. REV Project Objective
• Conduct exploratory research on how to develop a primary care
model to address hospital readmissions
• Identify a set of components that will serve as the foundation for
AHRQ research on development, testing, and implementation of the
Re-Engineered Visit (REV)

6. The Project Team
Jim Maxwell, PhD
Principal Investigator &
Project Director
John Snow, Inc.
Angel Bourgoin, PhD
Project Manager
John Snow, Inc.
Joanne Crandall
Project Associate
John Snow, Inc.
Jeffrey Greenwald, MD
Co-Investigator
Massachusetts General Hospital
Ted Palen, MD
Co-Investigator
Kaiser Permanente
Michael Hochman, MD, MPH
Co-Investigator
USC Gehr Family Center
Richard Balaban, MD
Co-Principal Investigator
Cambridge Health Alliance
Sonali Saluja, MD, MPH
Co-Investigator
USC Gehr Family Center
Albert Farias, PhD, MPH
Co-Investigator
USC Gehr Family Center

7. Project Activities
Writing (Apr ‘18 – Sep ‘18)
Manuscript Presentation Task Order Report
Analysis (Apr ‘18 – Jun ‘18)
Identification of REV Components
Field Research (Jun - Aug’16 & Oct ‘17 – Mar ‘18)
Pilot Analysis of Primary Care Processes
Foundational Research (Oct ‘15 – Oct ’17)
Environmental Scan Key Informant Interviews
There are four main activities in this project (Oct ‘15 – Sep ‘18):

8. Project Activities
Writing (Apr ‘18 – Sep ‘18)
Manuscript Presentation Task Order Report
Analysis (Apr ‘18 – Jun ‘18)
Identification of REV Components
Field Research (Jun - Aug’16 & Oct ‘17 – Mar ‘18)
Pilot Analysis of Primary Care Processes
Foundational Research (Oct ‘15 – Oct ’17)
Environmental Scan Key Informant Interviews

9. 1. Environmental Scan
• Purpose: To summarize major challenges and potential solutions related to readmissions from the
primary care perspective.
• Methods:
• Peer-reviewed literature search using PubMed, Ovid, and CINHAL for the terms primary care and
patient centered medical home in combination with the each of the terms readmission, care
transition, and hospital discharge.
• Excluded duplicates, international or pediatric focus, non-primary care focus and opinion articles
• A search was also conducted for gray literature (online) for case study and experiential knowledge from
AHRQ, HHS, and other initiatives on primary care and readmissions.
• We reviewed a total of 42 peer-reviewed articles and 15 gray literature items for the
environmental scan.

10. Challenges to care coordination described in the literature.
System  Lack of financial incentives for care coordination
 Regulatory barriers to information sharing
 Lack of reimbursement for non-medical services
Organizational  Inability for EHRs to communicate
 Lack of standardized process for improving care transitions
 Inadequate financial resources
 Inadequate workforce for care coordination such as care coordinators
 Insufficient communication across settings
 Inadequate coordination with patient centered medical home (PCMH) practices
Provider  Lack of time and competing priorities
 Lack of information on hospital experience and treatment
 Medication discrepancies
 Lack of communication between inpatient and outpatient providers
 Inadequate communication with providers from other setting (e.g. home care, community mental health, aging services)
Patient  Medication problems or errors
 Hospital complications
 Difficulty reconciling follow up care with patients’ life priorities
 Difficulty scheduling follow appointments with PCP and tests
 Confusion regarding translating knowledge into health promoting actions at home
 Lack of support for addressing nonmedical needs (e.g. nutrition, housing, transportation, safety)
 Financial barriers to receiving follow up care
 Lack of participation of caregivers in discharge planning and follow up care

11. Summary Table of the Research on Primary Care-Based Interventions to Reduce Readmissions
Intervention Outcomes
Primary Care notifications when
patients are hospitalized
Hospitalizations were reduced for some conditions in one study however another
showed no impact on timeliness of follow-up visits or readmissions.
Early identification of post-discharge
complications
Most of the studies did not demonstrate evidence of reduced 30-day readmissions
or emergency department visits (with the exception of a quasi-experimental
telemonitoring study), though many showed increased rates of primary care
follow-up appointments.
Medication Management
No improvement in 30-day readmission rates however a couple of studies
demonstrated cost savings
Bundled Care Coordination
Interventions Implemented in Primary
Care Practices Affiliated with Hospitals
The majority of studies demonstrated reduced 30-day readmissions. Among the
studies that did not demonstrate reduced readmissions (including a randomized
controlled trial), other benefits included reduced 30-day emergency department
visits and reduced readmissions for high-risk patients.
Primary Care-Based Care Transitions
Programs Led by Health Plans
All three studies demonstrated reduced hospital readmission rates.

12. 1. Environmental Scan
Summary
• Literature on primary care-based readmission reduction efforts much less developed
than hospital-based efforts
• Multicomponent interventions tended to be more effective than individual interventions,
particularly in the context of more general primary care transformation efforts (e.g.
PCMH)
• Most interventions were studied in large academic medical centers, which may not be
generalizable to smaller, independent practices
• Payer- and health plan-sponsored transitions programs demonstrate the feasibility of
implementing programs on a large scale in a financially sustainable way

13. Perspective Piece
• “Primary Care Can Lead the Path to Reducing Readmissions”
• Innovations in primary care require system wide reform
• Improved communication between hospitals and primary care clinics
• Adequate support and compensation for clinics to lead transitions care efforts
• Considering incentives and alternative payment strategies to promote innovation

14. 2. Patient Interviews: Methods

15. Pre-Discharge Interviews

16. Post-Discharge Interviews

17. Post-Discharge Interviews

18. 3. Primary Care Site: Objective
• Question: What do processes of care for recently discharged patients look like
in real primary care practices? To what extent are they desirable and feasible?
We collected data from:
• Primary care site staff to understand the workflow at 2 AltaMed primary care
sites (Pico Rivera and El Monte), 1 IPA site associated with White Memorial
Hospital
• We included all clinic staff including: Physicians, front and back office staff,
health information management team, and care gap coordinators.
• Also included AltaMed central staff: case managers, pharmacy technicians
and pharmacists

19. 3. Primary Care Site Perspective: Methods
1. Data collection, round 1: Work flow mapping preliminary interview
2. Analysis, round 1: Research team maps the transitional care activities
3. Data collection, round 2: Work flow mapping follow-up interview
4. Analysis, round 2: Research team revises the map and analyzes data
5. Presentation: Research team summarizes findings in a PPT to be shared with
primary care site staff

20. 3. Primary Care Site: Objective
To understand the facilitators and challenges to care processes across 4 phases of
care
• During hospitalization
• After discharge and before follow-up visit
• During follow-up visit
• After the follow-up visit

21. 3. Primary Care Site Perspective: Initial Findings
• There can be significant variation in transitional care workflow dependent on
patient type, individual staff, and individual clinics within systems
• Most challenges in delivering transitional care, or their root causes, occur before
the primary care visit
Not knowing that a patient was discharged;
Not reaching patients between discharge and the primary care visit;
Scheduling and assisting patients with a timely follow-up visit;
Unavailable/incomplete/inaccurate discharge summary;
Patient not engaged in discussing the hospitalization during visit; and
Medication reconciliation inconsistently delivered across the care transition process.
• Smaller, independent clinics may be able to handle transitional care well as long
as there are relationships and systems in place to address these challenges

22. 3. Primary Care Site Perspective: Initial
Findings
• Opportunities
• AltaMed policy to aim to have discharge visit within 72 hours
• Staff has some infrastructure to access hospital records
• Some coordination to get access to discharge information, however, limitation
is with hospital responsiveness
• Case managers assigned to high-risk patients (LACE SCORE) who belong to
AltaMed’s panel of patients have better coordination of services

23. 3. Primary Care Site Perspective
Primary Care Site Workflow Data Collection Status
Boston, MA
Cambridge Health Alliance Completed during pilot
Somerville Family Practice 1st round of interviews completed
Codman Square Project approved, starting to schedule
Denver, CO
Parker Clinic (Kaiser Permanente) 1st round of interviews completed
Westminster Clinic (Kaiser
Permanente)
1st round of interviews completed
Ken Caryl (Kaiser Permanente) TBD
Los Angeles, CA
El Monte Clinic (AltaMed) Completed
Pico Rivera Clinic (AltaMed) Completed
AltaMed IPA 1st round of interviews completed

24. Summary of Preliminary Findings
• Multi-component interventions tend to be more successful, especially in the
context of broader practice transformation (Environmental scan)
• Improving communication and alignment between hospitals and primary care,
providing adequate support and compensation for primary care to play an active
role, and fostering effective community partnerships (Environmental scan)
• Many patients in the inpatient setting have a PCP and plan to visit them after
discharge, but most would like assistance setting up a follow-up appointment and
expect PCP to know what happened in the hospital (Patient interviews)
• Challenges in delivering transitional care often occur prior to the hospital follow
up visit (Primary care process)

25. Next Steps
• Continuing field work at primary care sites
• Analyzing the second round of interviews with primary care staff
• Finalization of third site in Denver and Los Angeles
• Research team is meeting regularly to share findings and receive feedback from
different data collection activities
• Planning on in-person meeting in June 2018 in Boston to analyze REV
components
• End products: Manuscript, presentation, task order report to AHRQ

26. Questions?
Michael Hochman, MD, MPH, Director Gehr Family Center for Health
Systems Science, Keck SOM USC
michael.hochman@med.usc.edu
Albert Farias, PhD, MPH, Assistant Professor, Keck SOM USC
albertfa@usc.edu
Sonali Saluja, MD, MPH, Assistant Professor, Keck SOM USC
sonali.saluja@med.usc.edu

27. Discussion
• In what ways do the environmental scan, patient interviews, and primary care
processes resonate or differ from your experience?
• What about these findings are most interesting to you, and would be
relevant/helpful to your respective fields?
• Do you see particular value in bringing together the perspectives of primary care
staff, patients, and community agencies in the same research study? Are there
any other stakeholders you would consider?
• How can the REV be integrated with hospital-based approaches?