The document summarizes findings from a study on the effect of care coaching on hospital readmission rates. It shows that patients who received care coaching had lower readmission rates at 14, 30, and 60 days compared to those who did not receive coaching. The document also lists locations where studies have been conducted on reducing hospital readmissions and shows trends in readmission rates over time in different regions. It discusses challenges in establishing community infrastructure and partnerships to effectively coordinate care transitions to reduce readmissions.

2. Jane Brock, MD, MSPH
Colorado Foundation for Medical Care

3. FFS (N = 155, 154, 153)
40
30
Rate (%)
20
10
0
14 Days 30 Days 60 Days
Time Elapsed Since Index Discharge
Coached Non-coached

4.  AL: Tuscaloosa
 CO: Northwest Denver
 FL: Miami
 GA: Metro Atlanta East
 IN: Evansville
 LA: Baton Rouge
 MI: Greater Lansing area
 NE: Omaha
 NJ: Southwestern NJ
 NY: Upper capital
 PA: Western PA
 RI: Providence
 TX: Harlingen HRR
 WA: Whatcom county

5. 30-day hospital readmissions per 1,000 eligible beneficiaries, semi-annual
(O-4)
Best-fit lines for observed rates
50.00 Lower is better. Statistically significant trends, per Cochrane-Armitage test, are indicated by bolded p-values.
45.00
11
1
40.00
11 (p<0.0001)
3 3 (p=0.8862)
13
35.00
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)
14
15.00 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 (†).

6. No Community
infrastructure for
achieving common goals

7. What’s he saying? I sure
hope my wife is getting
this..
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

8. What We Learned

10. SNA by Bill Mahoney, PhD

11.  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)

12.  No successful applications first 4 months
 Technical assistance available 8/1
 Frequent misunderstanding of the program
 ‘CBO’
 Few existing programs with data

14.  We know how to systematize
behavior change to avoid hospital
readmisisons
 We mostly know who can get paid to
do it
No Community infrastructure  We are getting more sophisticated
for achieving common goals about building collective impact
But we’re still not quite there..

18.  Policy is necessary but might be insufficient

19. “It’s clear that somebody has to do
something and it’s incredibly pathetic
that it has to be us.”
Jerry Garcia