Homeless Navigator Feb. Issue

Volume 3, Number 2 February, 2014
Published by Health Policy Publishing, LLC ● 209-577-4888 ● www.ReadmissionsNews.com
Kaiser Permanente Program
Provides Hope and Resources to
Homeless Patients
By Michael Carter
omeless patients are getting the help they need to rebuild their lives
thanks to a unique program at Kaiser Permanente Woodland Hills
Medical Center. Led by staff member Jonathan Lopez, the Homeless
Navigator Pilot Program aims to find shelter and other vital community services
for homeless patients who seek care in their emergency department.
The program is the first of its kind for Kaiser Permanente in Southern California.
This unique program addresses the needs of homeless patients by using a
coordinated approach that involves a dedicated team of staff and community
resource providers. The team consists of physicians, nurses, social workers,
case manager, administrators, and the Homeless Navigator.
Since its inception in April, 2012, the program has placed more than 576
homeless patients into shelters, transitional housing, permanent housing, and
substance abuse treatment programs. That’s a dramatic increase from 2011,
when just 25 homeless patients were placed in shelters during the entire year.
continued on page 4
Reducing Readmissions Rates
through Telehealth Solutions
By Lee Barrett
n the January Issue of Readmission News I briefly addressed the question about the greatest challenges facing the
healthcare industry in the struggle to reduce hospital readmissions. As I noted, while there are various strategies, for
many healthcare providers the challenge remains squarely on the clinical basics and the automation
of post-discharge care and follow-up.
This month I want to focus on the potential of telehealth solutions to reduce readmissions and the specific related
challenges that policymakers, plans, providers and patients must tackle to give those solutions the best chance of
success.
What are “Telehealth” Solutions?
Telehealth is the use of electronic information and telecommunication technologies to support long-distance clinical health
care and more, like patient education.
1
Telehealth solutions can be simple and straightforward like sending a text
reminder to a patient about a follow up appointment or calling patients who were recently discharged to ask if they still
have any questions about follow up care instructions. Telehealth includes the use of a smart phone and tablet application
to manage medications and track appointments with various health professionals. There are also more comprehensive
telehealth solutions that offer real-time monitoring of the patient’s health status at home.
In This Issue
1 Kaiser Permanente
Program Provides
Hope and Resources to
Homeless Patients
1 Reducing Readmission
Rates through
Telehealth Solutions
2 The Editor’s Corner
3 Refining the Hospital
Readmissions Strategy
through Patient
Feedback
3 Subscriber’s Corner
7 Data from HIN Surveys
8 Thought Leader’s
Corner
10 Industry News
12 Catching up with …
Traci Archibald, OTR/L,
MBA
H
I
continued on page 5

2 Readmissions News February, 2014
Readmissions News
February 2014, Volume 3, Issue 2
ISSN 2166-255X (Electronic)
ISSN 2166-2568 (Print)
National Advisory Board
Amy Boutwell, MD, MPP
Founder and President, Collaborative
Healthcare Strategies, Lexington, MA
Molly Joel Coye, MD, MPH
Chief Innovation Officer, UCLA Health
System, Los Angeles, CA
Thomas R. Graf, MD
Chief Medical Officer, Population Health
and Longitudinal Care Service Lines
Geisinger Health System, Danville, PA
Brian Jack, MD
Professor of Family Medicine, Boston
University Medical Center, Boston, MA
Martin S. Kohn, MD, MS, FACEP, CPE,
FACPE, Chief Medical Scientist, Care
Delivery Systems, IBM Research,
Hawthorne, NY
Randall Krakauer, MD, FACP, FACR
National Medical Director, Aetna
Medicare, Princeton, New Jersey
Cheri Lattimer
Director, National Transitions of Care
Coalition (NTOCC), Little Rock, AR
Josh Luke, PhD, FACHE
Vice President, Post Acute Services,
Torrance Memorial Health System, and
Founder, National Readmission
Prevention Collaborative, Torrance, CA
Harold D. Miller
Executive Director, Center for Healthcare
Quality and Payment Reform; President
and CEO, Network for Regional
Healthcare Improvement, Pittsburgh, PA
Mary D. Naylor, PhD, RN, FAAN
Marian S. Ware Professor in Gerontology
and Director of the NewCourtland Center
for Transitions and Health, University of
Pennsylvania, School of Nursing,
Philadelphia, PA
Miles Snowden, MD, MPH, CEBS
Chief Medical Officer, Optum, Atlanta, GA
Bruce Spurlock, MD
President and Chief Executive Officer,
Cynosure Health Solutions, Roseville, CA
_____________________________
Publisher - Clive Riddle, President, MCOL
Senior Editor - Raymond Carter
Readmissions News is published by
Health Policy Publishing, LLC monthly
with administration provided by MCOL.
Readmissions News
1101 Standiford Avenue, Suite C-3
Modesto, CA 95350
Tel: 209.577.4888 -- Fax: 209.577.3557
info@readmissionsnews.com
www.ReadmissionsNews.com
Raymond Carter, Senior Editor, Readmissions News
This month we have a different transition to report.
Marty Kohn will be starting a new job as of February 18 with a
start-up company called Jointly Health, headquartered in San
Juan Capistrano, CA. There he will be the Chief Medical
Scientist. Jointly Health’s team of scientists, clinicians,
engineers, and mathematicians is developing a Remote
Analytics and Monitoring Platform (RAMP) to help scientists
and physicians navigate and integrate physiological data into
medical knowledge. Happily, Marty will be staying on the
Readmissions News advisory board. Best wishes! Ed.
At the last minute we lost the op-ed piece that was slated for this space, so this will
give me a chance to make a pitch for contributions to the Editor’s page in 2014. I
see this as a place for both short opinion pieces -- perhaps something not being
done or acknowledged or not being done well enough -- and brief commentaries
noting some lesson learned along the way as part of a hospital readmissions
reduction program. Here are some possible ideas:
• A proper metric for tracking and reporting readmission rates
• The influence of non-health factors on readmissions -- housing, nutrition,
income, race, culture, etc.
• Conditions inappropriate for readmissions metrics
• Possible effects of age, language, culture, education, and price, for
example, on the use of mobile apps and remote monitoring devices
• Use of non-clinical workers (nutritionists, Community Health Workers,
social workers, housing advocates, paralegals) in readmissions efforts
• Fairly distinguishing among different types of hospitals (teaching, safety,
community, and Critical Access Hospitals) when it comes to comparative
readmission rates
• Creative hospital partnerships with long-term care, home health, hospice,
AAA, and other community agencies
• Hospital leadership and culture
These are but a few. I hope the Readmissions News community will feel free to be
creative. Ed.
Editor’s Corner
ORDER FLASH DRIVES OR THE WEB ARCHIVE NOW!
The Fourth National Readmissions Summit
December 4-6, 2013 -- Washington, DC
Flash drives contain full video and synced Power Points
Web archive allows on demand access for six months
Combine the web archive with the Readmissions Certificate Program
at no extra cost
All options are only $595 or $59.95 for access to an individual
presentation
www.ReadmissionsSummit.com

February, 2014 Readmissions News 3
© 2013, Health Policy Publishing, LLC. All rights reserved. No reproduction or electronic forwarding without permission. page 3
The University of Utah is trying to
reduce dangerous and costly
hospital readmissions by asking
patients what they think could be
done better. Researchers are
embarking on nine months of study
on the matter, gathering information
from patients about problems they
might have experienced in
communication and care
coordination prior to and following
surgery.
Brooke and his research team
hope to enlist up to 250 patients
from rural and urban areas in
Utah and surrounding states who
have experienced surgical care at
University of Utah Health Care
hospitals and surgical centers. …
The study is funded with $15,000
by the Patient-Centered
Outcomes Research Institute, a
Washington, D.C.-based patient
advocacy group interested in
improving communication
between patients and providers.
Refining the Hospital Readmissions Strategy
through Patient Feedback
By Wendy Leonard
The University of Utah is trying to reduce dangerous and costly hospital readmissions by asking patients what they think could
be done better. Researchers are embarking on nine months of study on the matter, gathering information from patients about
problems they might have experienced in communication and care
coordination prior to and following surgery. The two issues are most often to
blame for patients requiring a return to a doctor's care prematurely.
"We'll use their experiences to explore where major problems exist in
surgical care coordination, including gaining access to surgical specialists
and maintaining effective follow-up care," said Dr. Benjamin Brooke, a
vascular surgeon and assistant professor of surgery at the U. who is leading
the study.
Brooke and his research team hope to enlist up to 250 patients from rural
and urban areas in Utah and surrounding states who have experienced
surgical care at University of Utah Health Care hospitals and surgical
centers. They are also looking to speak with medical providers who often
refer patients to the University facilities or see patients after surgery.
"We're trying to ensure that we're not creating gaps in care that arise from
miscommunication or lack of communication," Brooke said.
Patients often meet with a number of providers, case consultants and other health
care workers before, during and after surgery, increasing the potential for
miscommunication and potential preventable problems. It is even more
complicated when patients have multiple medical issues and/or take various
medications, Brooke said.
But mix-ups can happen with just about any surgery patient.
"These issues are affecting quality of care now, and this is something that applies
to all surgical areas," Brooke said. "We want to find patients who have a true
interest in this issue and will give us insightful information."
The study is funded with $15,000 by the Patient-Centered Outcomes Research
Institute, a Washington, D.C.-based patient advocacy group interested in
improving communication between patients and providers.
Anyone interested in participating in the study — people who have had surgery or
cared for someone who has — can visit the medical center web site to register at
medicine.utah.edu/surgery/patient-transitions.php or can call 801-581-8409 for more information.
"There is a big opportunity for quality improvement" in the way patients are handed off from one provider to another, Brooke
said.
Wendy Leonard is a reporter for Deseret News, published in Salt Lake City, UT. She may be reached at
wleonard@deseretnews.com. This article first appeared on February 5 and is reprinted with permission.
Subscribers’ Corner
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We encourage you to contact us any time with feedback of any kind regarding Readmissions News. We especially would
like to hear from you regarding what topics you'd like to see addressed in future issues.

The program has been so
successful in ending
homelessness for Kaiser
Permanente patients that it has
become a new model of care for
this vulnerable population. During
the past year, the program has
received many accolades,
including the 2013 Community
Impact Partner of the Year Award
from Hope of the Valley Rescue
Mission and the Community
Partnership Award from The
Salvation Army in March 2013.
The goal of the Homeless
Service Provider
partnerships is to facilitate
access to a continuum of
care and coordinated
services enabling them to
identify long-term solutions
to improve homeless clients’
living conditions and
ultimately end their state
homelessness through
permanent housing.
Kaiser Permanente…continued
“This program has transformed the dynamics at our hospital. When these patients leave our emergency department, they are
leaving homelessness behind, which is our goal,” said Lopez. “We offer an atmosphere of hope and caring to our homeless
clients and we are making a significant difference,” added Lopez.
The program has been so successful in ending homelessness for Kaiser
Permanente patients that it has become a new model of care for this vulnerable
population. During the past year, the program has received many accolades,
including the 2013 Community Impact Partner of the Year Award from Hope of the
Valley Rescue Mission and the Community Partnership Award from The Salvation
Army in March 2013.
“Kaiser Permanente is not only a leading provider in health care, but now they are
leading the way in health and human services through their Homeless Navigator
Program,” said Ken Craft, president and chief operating officer for Hope of the
Valley Rescue Mission. The Mission is a non-profit agency serving thousands of
men, women, children and their families in the San Fernando Valley.
“Through the leadership of Mr. Lopez, homeless people who come to the hospital
are treated with dignity and respect and they are connected to community
resources. The program links the homeless with service providers that assist the
homeless with accessing case management and wrap around resources.
This unique program has been a catalyst in transforming the landscape of homeless service providers. Now, thanks to Kaiser
Permanente and the San Fernando Valley Homeless Service Providers we are all working together to assist the most
vulnerable in our society,” added Craft.
At Kaiser Permanente the mission to provide high-quality, affordable health care to its members takes the organization beyond
the walls of its hospitals and medical office buildings and deep into their communities. Here’s how the program works:
Lopez serves as a liaison between Kaiser Permanente Woodland Hills Medical Center and nonprofit community partners that
offer a soup-to-nuts array of services, including shelter, food, clothing, job assistance and substance abuse treatment. That’s
in addition to permanent housing which is the main component to ending homelessness.
Working with emergency medicine physicians, nurses, case managers, social workers, and deputy administrators Lopez
connects homeless patients with the services they need to end their homelessness.
Tom Gray, 46, credits the Homeless Navigator Pilot Program with saving his life. Addicted to crystal methamphetamine, he
lost his home and job and had been living on the streets for many years. He came to the attention of homeless team after
seeking emergency treatment for an abscess on his leg.
With the team’s support, Gray is now rebuilding his life. He is living at the Cabrito House, a sober living home for men
overcoming alcohol addiction. He is also working as a sales representative for a heating and air conditioning company in
Canoga Park, where he has been the sales leader for three out of 11 months. In his spare time, Gray gives motivational
speeches to patients at the Tarzana Treatment Center, a behavioral health care organization that provides substance abuse
and mental health treatment to adults and teens.
“Without this Homeless Navigator Program, I wouldn’t be where I’m at today. I would have gone back to the streets,” said
Gray. “It’s a great program.” The homeless navigator team is committed to helping more people like Gray.
Last summer, Lopez expanded his scope of responsibilities, assisting homeless patients
that had not entered the emergency department and consulted with dozens of homeless
clients monthly after they were discharged from the ER. As the Homeless Navigator,
Lopez develops community partnerships, through which Kaiser Permanente’s
NavigationTeam is able to arrange for transportation and placement in local shelters,
transitional housing and substance abuse treatment programs, when needed.
The goal of the Homeless Service Provider partnerships is to facilitate access to a
continuum of care and coordinated services enabling them to identify long-term
solutions to improve homeless clients’ living conditions and ultimately end their state
homelessness through permanent housing.
Community Partners include the Hope of the Valley Rescue Mission, House of Hope,
LA Family Housing, Columbus and Corbin House, San Fernando Valley Rescue
Mission in North Hollywood, the Bell Access Center, Genesis House and The
Lighthouse, a shelter for women and children in Ventura County.
In addition the Homeless Navigator Pilot Program works closely with Tarzana Treatment Center, Northeast Valley Health
Corporation, and the San Fernando Valley Community Mental Health Center. The newest community partners include the
Frequent User System Engagement System (F.U.S.E) and SSG Alliance - Project 40.
continued on page 5

The Central Indiana Beacon
Community project reduced
hospital readmissions to
three percent for patients
with congestive heart failure
and chronic obstructive
pulmonary disease using
video-conferencing with
nurses.
3
The study’s
control group had a
readmission rate of 15
percent.
Kaiser…continued
Paul Read, president of the Cabrito
Foundation, which oversees the
operations of the Cabrito House, a
sober living house for recovering
alcoholic men, praised Lopez’ hands-
on role in assisting homeless
individuals.
“It is a great privilege to work with
someone as dedicated as Mr. Lopez.
He works tirelessly to find people just
the right place that will give them the
best chance to regain their status in
the community,” said Read. “We are
fortunate to be a part of his team."
The Homeless Navigator Pilot
Program benefits not only homeless
patients but the community partners
as well.
For the past 18 months, Kaiser
Permanente employees have
volunteered to prepare and serve
dinner at L.A. Family Housing, The
Lighthouse, and the San Fernando
Valley Rescue Mission.
The staff also helped paint the library
at The Salvation Army and partnered
with the agency on several events.
Joint activities include The United Way
5K Walk to End Homelessness, the
2013 Greater Los Angeles Homeless Count and tuberculosis screening for residents of the organization’s residential
substance abuse treatment program. “We’re developing an interactive, supportive resource-sharing partnership with our
homeless service providers,” said Lopez. “Our goal is to provide the highest quality of care for our homeless neighbors and to
be the best community partner possible.”
Michael Carter is the executive director at Kaiser Permanente Woodland Hills Medical Center in Southern California. He
may be reached at whpublicaffairs@kp.org.
Teleheath…continued
Can these solutions be effective?
There are several studies that indicate telehealth solutions have a promising future to reduce healthcare costs, especially in
terms of reducing readmissions. Here is a summary of two such studies that focus on some of the discharge diagnoses in the
CMS penalty program.
Geisinger Health Plan in Pennsylvania conducted a two-year study using a home
telemonitoring system for patients with congestive heart failure.
2
The program included
case management and an interactive voice response (IVR) system. When a
discharged patient submitted his or her weight, the system asked a series of questions
about the patient’s symptoms. Geisinger reported a 44 percent drop in its readmission
rate compared to a control group of patients who only received case management
services.
The Central Indiana Beacon Community project reduced hospital readmissions to three
percent for patients with congestive heart failure and chronic obstructive pulmonary
disease using video-conferencing with nurses.
3
The study’s control group had a
readmission rate of 15 percent. In addition to up to six nurse visits over the video-
conference system, the patients submitted daily vitals to the nurses using a Bluetooth
scale, a blood pressure cuff connected to the system, and a Bluetooth pulse oximeter.
The system also recommended different educational videos to the patients, depending on their answers to six questions each
day. continued on page 6

According to a 2011 Pew
Internet study, age (65 or
older) was cited as one of the
top strongest negative
predictors for internet use.
4
How will this population
adapt to using sensors,
Bluetooth devices, video
conference monitors, and
other telehealth technology?
Telehealth solutions have great
potential to reduce the cost of
healthcare and increase the
patients’ quality of life by
reducing readmissions.
Policymakers, plans, providers,
and patients must work together
to tackle the obstacles of helping
an aging population adapt to new
technologies while promoting
collaboration across medical
professionals and an efficient
and effective way to deliver test
results, consultations and
instructions to patients securely.
Teleheath…continued
What challenges do policymakers, plans, providers and patients still need to address?
While the Geisinger and Central Indiana Beacon Community projects show very promising results, neither study specifically
targeted the Medicare population. The aging Medicare population is the most likely group to be readmitted to a hospital, but
will this group adopt and adhere to using such new technologies?
According to a 2011 Pew Internet study, age (65 or older) was cited as one of the top
strongest negative predictors for internet use.
4
How will this population adapt to using
sensors, Bluetooth devices, video conference monitors, and other telehealth
technology?
There may be more to learn from the Pew Internet study which found that of all adults
age 18 and over who do not use the Internet, the top reasons had very little to do with
being “too old to learn” (4 percent) or being “physically unable.” Instead, the top
three reasons were related to a lack of interest (31 percent), lack of a computer (12
percent), and costs (11 percent).
While there are currently financial penalties for Medicare providers to encourage
lowering readmission rates, a total solution must include the patients’ role. Both of the cited studies provided the necessary
hardware to patients, eliminating the factors of cost and lack of equipment. Patients also received education about using the
devices. If the education program helps patients understand how the telehealth solution can keep them at home and out of
the hospital, it provides a powerful incentive that addresses any lack of interest in technology.
The ability to share medical information easily with a patient’s total care team across various specialties and facilities is also
critical to the success of telehealth solutions. Collecting large amounts of medical data through telehealth is not enough.
Healthcare providers need an efficient and effective way to share patient results
with other healthcare providers as well as to deliver test results, consultation
services, and instructions to patients securely. Telehealth solutions must support
data privacy and security without compromising care.
Healthcare providers and plans can mitigate the risk of using telehealth vendors
through third-party accreditation. Through this process, providers receive an
objective comprehensive review of policies, procedures, controls, business
practices, and technical performance related to data security and privacy. The
review provides an evaluation of strengths and challenges, and it helps target
recommendations for continuous improvement.
Telehealth solutions have great potential to reduce the cost of healthcare and
increase the patients’ quality of life by reducing readmissions. Policymakers,
plans, providers, and patients must work together to tackle the obstacles of helping
an aging population adapt to new technologies while promoting collaboration
across medical professionals and an efficient and effective way to deliver test
results, consultations, and instructions to patients securely.
Lee Barrett is Executive Director of EHNAC, a federally recognized, standards development organization designed to improve
transactional quality, operational efficiency and data security in healthcare. Founded in 1993, the Electronic Healthcare
Network Accreditation Commission (EHNAC) is an independent, federally recognized, standards development organization
and tax-exempt, 501(c)(6) non-profit accrediting body designed to improve transactional quality, operational efficiency and
data security in healthcare. Mr. Barrett may be reached at lbarrett@ehnac.org.
References
1. What is Telehealth? Retrieved February 7, 2014, from http://www.healthit.gov/providers-professionals/faqs/what-telehealth-how-telehealth-
different-telemedicine
2. Geisinger Plan Reduces Readmissions 44% with Telemonitoring. (2012) Retrieved February 3, 2014, from
http://www.fiercehealthit.com/story/geisinger-plan-reduces-readmissions-44-telemonitoring/2012-03-02
3. Beacon trial Reduced Readmissions of Heart Patients to 3% Using Home Video Conferences. (2012) Retrieved February 3, 2014, from
http://medcitynews.com/2012/09/beacon-trial-reduced-readmits-of-heart-patients-to-3-using-home-video-conferences/
4. Internet Adoption Over Time. (2012) Retrieved February 7, 2014, from http://pewinternet.org/Reports/2012/Digital-differences/Main-
Report/Internet-adoption-over-time.aspx
Copyright  2013 by Health Policy Publishing, LLC. All rights reserved.
No part of this publication may be reproduced or transmitted by any means, electronic or mechanical,
without the prior written permission of the publisher.

© Copyright 2014 Healthcare Intelligence Network. Reprinted with permission. Ed.
Excerpted from "2014 Healthcare Benchmarks: Reducing Hospital Readmissions,"
published by the Healthcare Intelligence Network, http://store.hin.com/product.asp?itemid=4786
Excerpted from "2013 Healthcare Benchmarks: Care Transitions Management," published
by the Healthcare Intelligence Network, http://store.hin.com/product.asp?itemid=4615
Data from Healthcare Intelligence Network Surveys

Each month, Readmissions News asks a panel of industry experts to discuss a topic of interest to the hospital community. To
suggest a topic, write to Editor@ReadmissionsNews.com.
Q. What are the benefits -- and the limits -- of the new
mobile apps when it comes to patient and family
engagement in a readmissions reduction strategy?
“Mobile apps will no doubt assist in engaging the patient and family. One of the biggest challenges will be getting the hospitals
and health systems to embrace the most effective mobile apps, as their embedded IT partners (whether it be Epic, Cerner,
etc.) or others will have competing initiatives and often times a partner brand they would prefer to implement than the brand
that may be most effective. In regard to limitations, many post acute providers, particularly bigger SNF chains, still have a
tendency to hide behind HIPAA as a means not to share data, and that will become extremely prohibitive if they do not adapt
soon. The other limitation is that many folks in their golden years have still not adapted to mobile technology and it does not
appear to be a priority for them in the near future as well.”
Josh Luke, PhD
Vice President, Post Acute Services
Torrance Memorial Health System
Founder, National Readmission Prevention Collaborative
Torrance, CA
"Mobile apps can be an important tool in a broader readmission reduction strategy, but just because it’s on an iPhone or Android
device, doesn’t make it valuable. The successful mobile apps in a readmissions strategy will have some or all of the following
features: (1) they must provide value-add evidence-based educational content; (2) the content must match the specific needs of
a patient and their caregiver; (3) it must be pre-populated with existing patient data to engage them right away; and (4) it must be
readily available and accessible on any platform for when the patient is ready for it. Just because patients are in a hospital bed,
it doesn’t necessary mean they are ready to watch an educational video. Patients need to be ready and motivated to engage
with the mobile app on their own time. While the mobile technology is here, we still have to remember that the high frequency
users of healthcare dollars are in the last years of their life. According to Pew research from September 2013, of those aged 76-
80, only 8.3% have a smart phone, 60.8% have a regular feature phone, and 30.9% have neither type."
Eric Heil
Co-founder, President and Chief Executive Officer
RightCare Solutions
Horsham, PA
“Patient engagement is essential for compliance with a care plan, especially when it comes to diverting the knee-jerk reflex that
patients and providers have to defer to the ED. App developers and providers should keep in mind that a care plan is not what
the provider wants to happen but rather what the patient is actually willing to do. So, apps that are developed in a patient-
centric way, and consequently require some level of buy-in from the consumer, are likely to better engage the patient in
adherence to the care plan than apps that require no buy-in from the patient. Validation of worth in the form of payment forces
app developers to create products that patients really want and need. So one effective approach to reducing readmissions
through patient and family engagement is confirming the worth of apps by requiring the patient to ‘pay’ with cash, time,
attention, or some other scarce resource.”
Andrey Ostrovsky, MD
Chief Executive Officer and Co-Founder
Care at Hand
Boston, MA
Thought Leaders’ Corner

“Engaging patients and family members is critical to managing risk between episodes of physician care to reduce hospital
readmissions. We are beginning to see exciting healthcare delivery models emerging that include care received in non-
traditional community settings as an adjunct to patient care received in the clinical setting. Evidence based population
health programs delivered in the community as well as home-based patient and family support play an important role in
health behavior changes.
Chronic disease self-management, medication compliance, and lifestyle changes can be supported by a plethora of
emerging mHealth apps. However, being able to capture critical health data from mobile health apps and feed that data
back to extended care teams and family members is an important aspect to managing readmissions. The data from
mHealth apps must be linked to meaningful, evidence based population health programs designed and proven to improve
patient outcomes. Data collected by these apps that remains in a silo is of little value to managing large patient panels for a
readmission reduction strategy.”
Brenda Schmidt, MS, MBA
CEO
Viridian Health Management
Phoenix, AZ
“While mobile apps will continue to develop and fine tune the value in patient/family engagement, I feel the biggest
limitation is the absolute endorsement from the physician. Unless safeguards for personal information and HIPAA
requirements are in place, we will continue to see only sporadic use. Moreover, most apps in this space provide limited
functionality.
PatientPoint has introduced PatientPoint 360°, a robust, mobile ready patient portal that gives patients access to
physicians and their personal health information. It meets Meaningful use Stage 2 Criteria and provide patients with a
personalized engagement experience that uses EMR information, payer information, and best-in-class education to close
gaps in care, drive adherence, and strengthen the physician/patient partnership. Ultimately this partnership will engage
patients to take a more active role in their care -- and thus positively impacting readmissions.”
Alan Heyman
Senior Territory Manager
PatientPoint®
Cincinnati. OH
“Digital technologies, including ubiquitous mobile devices, will play a key role in transforming health care into a more efficient,
patient-centered system of care in which individuals have on-demand and real-time access to their medical records and
powerful clinical decision support tools that empower them to participate actively in their treatment plans.
As mobile apps become more user-friendly and technologies expand their reach to remote populations, they will be
seamlessly integral to the provision and financing of health services. In addition, today’s providers are witnessing the value
of next-generation apps in the reduction of hospital readmissions by focusing on the management of chronic conditions,
patient data capture through self-monitoring devices, and health improvement applications from the parallel industries of
fitness and wellness.
However promising, the crucial issue for apps will always be one of consumer trust -- specifically in regards to the data
exchange between stakeholders. It is critical that the industry continue to provide the appropriate level of regulations around
privacy and security for protected health information so that the issue of trust can serve as a market ‘enabler’ rather than a
market ‘barrier’.”
Lee Barrett
Executive Director
Electronic Healthcare Network Accreditation Commission (EHNAC)
Farmington, CT
Thought Leaders’ Corner

Minnesota Program Wins Eisenberg Award
Minnesota hospitals and their community partners have
received national recognition for their work to reduce
avoidable readmissions.
The Reducing Avoidable Readmissions Effectively
(RARE) Campaign, a broad-based coalition of hospitals
and care providers working to improve discharge planning,
medication management and primary care post-hospital
visits, was named a recipient of the 2013 John M.
Eisenberg Patient Safety and Quality Award for Innovation
in Patient Safety and Quality, one of the most prestigious
quality and safety awards in the country.
The 82 Minnesota hospitals and 100 community partners
in the coalition have prevented 6,211 avoidable hospital
readmissions between January 1, 2011 and June 30,
2013.
It is estimated that the RARE Campaign has helped
patients spend 24,844 more nights sleeping comfortably in
their own beds instead of the hospital and has reduced
inpatient costs by an estimated $55 million.
The program was featured in the May 2012 issue of
Readmissions News.
Black Children Readmissions Twice That of Whites
Black children are twice as likely as white children to be
readmitted to the hospital for asthma -- a disparity due in
large part to a greater burden of financial and social
hardships.
That’s the conclusion of researchers at Cincinnati
Children’s Hospital Medical Center, who found that 23
percent of black children were readmitted within a year,
while 11 percent of other children in the study, most of
whom were white, were readmitted within a year. Nearly
19 percent of all children were readmitted to the hospital
within 12 months.
Financial and social hardships, such as lack of
employment and not owning a car, accounted for about 40
percent of the increased likelihood of asthma
readmissions among black children. The study was
published online in the eFirst pages of the journal
Pediatrics.
Telemedicine, Staff “Champion” Cut Readmissions
Researchers from the Harvard Medical School and the
Dartmouth Institute for Health Policy and Clinical
Practice at the Geisel School of Medicine, writing in the
February issue of Health Affairs, reported positive results
from a 2010-2011 telemedicine campaign aimed at
reducing hospital readmissions from long term care
facilities.
The team studied the implementation of a
videoconferencing service that replaced physician after-
hours consultations at 11 Massachusetts long term care
facilities where no other readmission intervention was
underway.
Those nursing homes that were heavily engaged in the
new service saw an 11% drop in readmissions, which
translates to 15 fewer hospitalizations and $151,000 in
savings to Medicare. Facilities with minimal usage of the
service saw no decrease.
The team recommended use of a staff “champion” and
frequent staff meetings, but also cautioned that current
reimbursement rules provide no incentive to invest in
such an intervention.
Robotic-Assisted Hysterectomy Cuts Readmissions
Women with benign disease undergoing robotic-assisted
hysterectomy are significantly less likely to be readmitted
to a hospital within 30 days of their procedure than
women receiving laparoscopic, abdominal (open), or
vaginal hysterectomy.
That’s the conclusion of a new study published online in
The Journal of Minimally Invasive Gynecology. The
research team from Lehigh Valley Health Network also
found that robotic-assisted surgeries resulted in
significantly lower estimated blood loss, shorter overall
hospital stays, and lower total readmission costs.
Reasons for readmission identified in this study included
fever/infection, wound complications, co-morbidities
(additional disorders), vaginal bleeding, uncontrolled
pain, and bowel issues.
Premier’s QUEST Hospitals Report Quality Results
The 350+ QUEST hospital collaborative of Premier, Inc.
has reported savings of $11.65 billion over the past five
and a half years and avoided 136,375 deaths. Since
2011 the group also prevented 40,808 hospital
readmissions.
Industry News

HHS OIG Urges New Metrics for LTC Readmissions
A new report from the HHS Office of Inspector General
(OIG) looked at FY 2011 hospitalization rates for all
Medicare- or Medicaid-certified nursing homes where
Medicare residents were transferred to a hospital for an
inpatient stay. The OIG found that 25% of such patients
were readmissions, but also with wide variation.
These types of homes had the highest rates: those in
Arkansas, Louisiana, Mississippi, or Oklahoma and homes
with one, two, or three stars in the CMS Five-Star Quality
Rating System. Based on the analysis the OIG
recommended that CMS develop a quality measure that
describes nursing home resident hospitalization rates and
instruct State survey agencies to review the proposed
quality measure as part of the survey and certification
process. CMS concurred om both recommendations.
Community Health Workers Key to Readmission Plan
Staff at the Perelman School of Medicine at the University
of Pennsylvania have devised an effective, replicable
program assigning trained lay Community Health Worker
(CHWs) to patients at high risk for poor post-hospital
outcomes.
In Penn's IMPaCT (Individualized Management for Patient-
Centered Targets) model, CHWs hired from within the local
community help patients navigate the health care system
and address key health barriers such as housing instability
or food insecurity.
The Penn team tested the model in a randomized trial with
446 hospitalized patients, either uninsured or on Medicaid
and residing in low-income communities in which more than
30 percent live below the Federal Poverty Level. A study of
the program published in JAMA Internal Medicine found that
the intervention group had a 52 percent greater chance of
seeing a PCP within two weeks of hospital discharge, better
discharge communication, and a lesser likelihood of
multiple readmissions
Bed Cuts Affecting New Zealand Readmissions?
The New Zealand Resident Doctors Association and a
government health monitor have expressed concerns that a
reduction of 50 hospital beds in the southern district is
causing hospitals to discharge patients too quickly, resulting
in readmissions.
The rate for December was 11.7%, slightly higher than
November and higher than the “target” rate of 9.5%.
Nursing Homes are the Solution to Readmissions
That’s the title and central theme of this piece in Health
Affairs by David Gifford, MD, MPH, Senior Vice
President of Quality and Regulatory Affairs at the
American Health Care Association (AHCA), the largest
association in the U.S. representing long term and post-
acute care facilities. In it he endorses the OIG report on
tracking nursing home hospitalization rates and goes a
step further by arguing that payment should be linked to
those rates.
AHCA and PointRight, a data analytics company, have
developed a risk-adjusted measure, already submitted to
the National Quality Forum, which allows skilled nursing
providers to see rehospitalization data within four to six
months of submitting claims to CMS. ACHA has also
drafted readmissions reduction legislation specific to
nursing homes that guarantees $2B in Medicare savings
over 10 years by requiring homes to take rate cuts if they
do not meet specific readmissions savings targets.
Readmission Rates from Inpatient Rehab Facilities
A new study in the Journal of the American Medical
Association by a research team at the University of
Texas Medical Branch at Galveston notes that more than
one in 10 Medicare patients are readmitted within 30
days after discharge from inpatient rehabilitation facilities
(IRFs). The rate is the lowest (6 percent) for those who
had joints replaced in their lower extremities and highest
(20 percent) for those treated for debility (weakness or
feebleness). The other conditions included were
strokes, lower extremity fracture, brain dysfunction, and
neurological disorders. Together, all of the categories
account for about 75 percent of Medicare fee-for-service
patients receiving inpatient rehabilitation.
Hospital to Home Initiative Update
The Hospital to Home Quality Improvement Initiative, led
by the American College of Cardiology and the Institute
for Healthcare Improvement, continues to show positive
results according to a new update from Dr. Elizabeth
Bradley of the Yale School of Public Health. Her study
included 437 hospitals that completed a web-based
survey at baseline in 2012 and 12 to 18 months later.
Significantly more initiative hospitals reported partnering
with other local hospitals to reduce readmissions,
discharging patients with a follow-up appointment
scheduled, using electronic forms to reconcile
medications and “teach back” techniques, and tracking
patient follow-up appointments.
Industry News

12
Readmissions News: The Integrating Care for Populations and Communities Aim (ICPCA) had an ambitious goal of
reducing 30-day readmissions by 20% over a three-year period ending in 2013. Can you give us a sense of the milestones
and outcomes to date?
Traci Archibald: QIOs are currently working with over 400 communities across the country. Community stakeholders and
providers share the goal of improving the quality of care transitions for the individuals they serve and to reduce 30-day
readmissions. Since work began in August 2011, there has been a 13.2 % relative improvement in reduction of 30-day
readmissions per 1000 for Medicare fee for service (FFS) beneficiaries residing in communities where QIOs are engaged,
when comparing the data over a two year time period.
There has also been an 8.4 % relative improvement for admissions per 1000 Medicare FFS over the same time period in QIO
engaged communities. QIOs are providing technical assistance to communities to measure the effectiveness of interventions
implemented at the community level and have currently collected 336 measures that have shown improvement.
Readmissions News: The various Quality Improvement Organizations (QIOs) have been working with hospitals and what for
hospitals might be a new set of community partners (long term care, home health, hospice, aging) to develop seamless
transitions of care. How do you think the QIOs and hospitals have done?
Traci Archibald: QIOs have used community organizing tactics to help bring all community partners together and align forces
to achieve the common goal of improving the quality of care transitions. QIOs have worked to develop leaders in the
community and to foster collaboration between partners that have an equal stake in the process.
Hospitals and post-acute care providers as well as community based organizations all bring valuable resources to the effort.
Communities have learned that local Area Agencies on Aging can connect individuals to long term supports and services such
as meals and transportation that help keep them safely living at home. Hospitals understanding the needs of Home Health
Agencies and Skilled Nursing Facilities at the point of transition and vice versa has helped create improved communications
and more efficient and effective processes.
In many cases, spending a short time shadowing with other community partners has helped the community come together to
better understand the challenges and implement interventions to solve them.
Readmissions News: What kind of metrics should hospitals be collecting and benchmarking to assess their performance in
improving transitions and reducing readmissions?
Traci Archibald: Hospitals should look at the trends over time for admissions, readmissions (7-day, 30-day, 90-day),
observation stays, and Emergency Department visits. They should also collect data to measure the effectiveness of
interventions that are being implemented. For example, if a hospital implements a process to have patients teach back what
they have learned from discharge instructions, it is important to measure whether or not patients were able to teach back the
information. Population level measures, such as 30-day readmissions and admissions per 1000 FFS beneficiaries, are useful
measures to more fully understand what is happening at the community level, instead of focusing on individual providers or
settings.
Readmissions News: Finally, tell us something about yourself that few people would know.
Traci Archibald: I really enjoy doing jigsaw puzzles with my family.
Catching Up With …
Traci Archibald, OTR/L, MBA is the Aim Lead for the QIO (Quality Improvement Organization)
10th SOW (Scope of Work) Integrate Care for Populations and Communities (ICPA) Aim at the Centers
for Medicare and Medicaid Services (CMS) in the U.S. Department of Health and Human Services. This
is a three-year project funded by CMS which aims to improve the quality of care transitions and to reduce
30-day readmissions. Ms. Archibald has led national care transitions work in her role at CMS for the last
six years. Here she talks about the goal of the ICPA and its progress to date, how QIOs are helping
hospitals partner with other entities in the community to improve care transitions, what kind of metrics
hospitals should be collecting, and herself.
Traci Archibald, OTR/L, MBA
• Aim Lead, QIO 10th SOW Integrate Care for Populations and Communities Aim, Centers for Medicare and
Medicaid Services, Baltimore, MD
• Lead for other national care transitions work, CMS, Baltimore, MD
• Occupational Therapist in a variety of practice settings for 17 years
• Clinical Specialist for Quality and Accreditation for a rehabilitation department in Baltimore
• BS in Occupational Therapy from Boston University’s, Sargent College of Allied Health Professions; MBA from
the University of Baltimore

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