Reducing Hospital Readmissions: It Takes a Village

The Arkansas Foundation for Medical Care’s SIP Care Transitions Team (L to R): Jamey Mantz, Amy Witherow, Faye Nipps, Jerry Wicker, Dr. Christi Quarles Smith, Ashley Gibson, Dr. Kristy Bondurant, Tonyia Haynes

The Arkansas Foundation for Medical Care’s SIP Care Transitions Team (L to R): Jamey Mantz, Amy Witherow, Faye Nipps, Jerry Wicker, Dr. Christi Quarles Smith, Ashley Gibson, Dr. Kristy Bondurant, Tonyia Haynes

In September 2012, the Arkansas Foundation for Medical Care (AFMC), which is the Medicare Quality Improvement Organization (QIO) for Arkansas, was awarded a Special Innovation Project (SIP) through the Centers for Medicare & Medicaid Services (CMS) to reduce hospital readmissions within the dually eligible (Medicare-Medicaid) population. AFMC focused its quality improvement efforts on a seven-county area in Arkansas’ Lower Mississippi Delta Region. According to AFMC’s Manager of Quality Programs, Dr. Christi Quarles Smith, “This region was selected due to its lack of resources, lack of access to medical facilities, poor transportation systems, low average household income, and most importantly, because it had the highest hospital readmission rates for dual-eligible beneficiaries, particularly for those discharged to the home health setting.”

To get the ball rolling, AFMC did a community-specific root cause analysis and reviewed Medicare Part A claims data. As a result of this analysis, the AFMC team noticed that the 30-day hospital readmission rate for dual-eligible beneficiaries from the home health setting was extremely high. This discovery led the QIO to focus on strategies to reverse this trend within the home health community.

The next step was to build partnerships with the hospitals in the region. AFMC reached out to an eight-hospital horizontal alliance in their seven-county area in the Delta and gained their support to advance the initiative. “This was a huge accomplishment because these hospitals usually function as competitors. However, they all saw the tremendous value in participating in this project and a real opportunity to improve health care,” said Smith.

AFMC then recruited nine home health agencies in the area to participate in the project. These agencies allowed AFMC to conduct in-depth chart reviews to determine the key issues leading to the elevated readmission rates. The reviews revealed two important issues:

  1. Poor communication between home health agencies and other providers
  2. Minimal community resource referrals leading to resources being underutilized

“We evaluated these two problems and did some brainstorming to figure out how to best resolve these issues,” shared Smith. As a result, the AFMC team constructed a three-pronged approach to combat the high dual-eligible hospital readmission rates in the Delta Region:

  1. Form a community-based coalition to serve as a neutral playground for agency staff and community leaders to gather, interact, and share
  2. Participate in the INTERACT (Intervention to Reduce Acute Care Transfers) Home Health Pilot Program
  3. Develop a Community Resource Guide

Community-Based Coalition

AFMC formed a community coalition in April 2013 before any interventions were implemented to strengthen support for its dual-eligible readmission rate reduction program. Meetings were held with key personnel – mostly in provider-neutral settings – to generate interest in the project and gain community buy-in. AFMC understood the importance of including all individuals who were on the front lines of patient care to not only ensure that they were truly invested in the initiative, but also to maintain a sense of community within the coalition.

The inaugural meeting was held to introduce the project and to share care transitions data in that particular area. “Time was also allotted for open discussion, allowing coalition members to share their insights on what they thought the initiative should look like, which allowed participants to take ownership of the coalition,” said Amy Witherow, AFMC Information Spread Advisor/Coalition Coordinator.

The following four coalition meetings focused on a variety of topics but always allowed time for coalition participants to share their own stories. Relying on the concepts of the “ReThink Health Model for Community Organizing,” a collaborative initiative of the Rippel Foundation that teaches the importance of learning why you do things, how to build coalitions to achieve success, as well as the importance of storytelling, the coalition grew stronger.

“It really hits home with health care providers to hear and share their stories; it encourages them to remember the true reasons why they are in health care and why patient care is important. Most have a personal story that led them to work in the health care industry. Storytelling allows us to get the “heart buy-in” – gaining the heart and then getting to the head,” explained Witherow.

The coalition meetings also included breakout sessions in which the providers discussed ideas for interventions and shared resources and tools. All participants were required to sign a coalition charter, which solidified their commitment to support the project and work to make it a success.

The coalition currently has 58 members which hail from within the seven-county area. Participants include hospital representatives from the horizontal hospital alliance, home health agencies, community organizations, civic and community leaders, and existing health care coalitions in each county. “The encouragement and support that home health providers receive from civic and community leaders who they may not interact with on a regular basis has really helped to empower our home health providers,” said Withrow. “Home health agencies often feel isolated in their work. This recognition is so appreciated.”

One final meeting is scheduled for July 2014 to discuss sustainability beyond the completion of the project.

INTERACT Home Health Pilot Program

Another successful effort that was initiated by AFMC to help address the issue of poor communication between home health agencies and other providers was working with nine home health agencies in southeast Arkansas to gain acceptance into the INTERACT Home Health Pilot Program, which ran from October 2013 to March 2014.

INTERACT was originally developed as a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital.

Based on the success of this program in the nursing home setting, INTERACT developers released a home health toolkit that includes many of the same tools as the nursing home version but has been modified for use in home health settings. AFMC felt that this program would provide home health agencies in their Mississippi Delta region with the resources they desperately needed to improve provider-to-provider communication, thereby resulting in reduced readmission rates.

At the onset of the intervention, AFMC offered face-to-face training sessions to provide agency staff with instruction on how to use the INTERACT tools. An example of one of these tools is the Stop & Watch Early Warning tool. “This tool can be used by any agency staff

member or by family/caregivers that routinely see a patient to track differences they might notice in the patient’s condition, such as changes in their personality, eating habits, sleeping habits, etc.”

AFMC also gathered the nine home health agencies to participate in three webinar training sessions on the INTERACT tools and provided hard copy notes of the trainings to distribute to those agency staffers who were not able to attend. The webinars provided instruction on how to use tools, what processes worked best, etc.

“We saw a lot of success from this program, achieving a 46% relative improvement rate for dual-eligible readmissions when compared to the same time frame the year prior,” said Smith. “This improvement had a lot to do with the INTERACT intervention and the improvements made in communication.”

Community Resource Guide

Another obstacle in combatting high dual-eligible readmission rates in the Mississippi Delta region was the underutilization and lack of provider-initiated referrals to available resources. In response to this issue, AFMC decided to develop a community resource guide.

“Over a two month period, we gathered and updated resources from existing guides and worked with providers to get their input on resources they use regularly to create our guide,” explained Smith. Once the guide was completed in December 2013, it was distributed throughout the seven-county area through providers and community resources in each county and at existing health fairs. There were three versions of the guide:

  1. Provider version – printed on heavy paper, 3-ring binder
  2. Beneficiary version – 8.5 x 5.5 booklet, soft cover – fits into purse, easy to carry
  3. Online version – offering greater accessibility and clickable links and can be updated in real time

To date, more than 200 hard copy guides have been distributed and the online version has garnered innumerable views and downloads. AFMC has plans to print additional copies. If you would like a copy of the provider or beneficiary version, please contact:

Christi Quarles Smith, PharmD
Manager, Quality Programs
Arkansas Foundation for Medical Care
Phone: (501) 212-8709

Download a PDF of this success story.

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