A three-year pilot program in Whatcom County that took a wider, collaborative approach to caring for patients after they left the hospital reduced readmission rate by nearly 7 percent, according to a recent study published in the Journal of the American Medical Association.
The local effort, which occurred from 2008 to 2011, focused on Medicare patients.
It was one of 14 such pilots nationwide funded by the federal Centers for Medicare and Medicaid Services as part of Medicare's focus on reducing costs, in part by curbing avoidable returns to hospitals.
"Readmissions do cost the Medicare program billions," said Evan Stults, spokesman for Seattle-based Qualis Health. "One-in-five Medicare beneficiaries comes back to hospitals within 30 days of being discharged."
Qualis coordinated the Whatcom County pilot, which was called "Stepping Stones: Bridging Healthcare Gaps."
The heart of "Stepping Stones" included coaching for patients and their families, as well as standardized discharge orders to help patients understand warning signs, manage their medications and make sure they arrange for follow-up doctors' appointments, for example.
Qualis has a contract with Medicare to serve as the quality-improvement organization in Washington and Idaho. Such organizations coordinated the pilots in the 14 communities nationwide.
Researchers, whose findings were featured in the Jan. 23 JAMA article, studied the impact of the pilot programs, which sought to provide better care for patients as they transition between care settings, such as from the hospital to home.
That's when gaps in communication and coordination can increase the risk for patients and their return to the hospital.
"Transitions are the time when people fall through the cracks and things go wrong," said Victoria Doerper, executive director of Northwest Regional Council.
The council, which also serves as the Area Agency on Aging, was one of the medical and social service providers that worked together in the Whatcom County pilot, which also sought to involve patients and their families.
Other partners were St. Joseph hospital, Critical Junctures Institute, Family Care Network, and PeaceHealth Medical Group.
Going into the pilot, Whatcom County already had the lowest rehospitalization rate among the 14 communities nationwide, with Stults noting that people and providers here have a history of tackling health care as a community.
"This shows there is opportunity for improvement no matter where you start, even in a high-performing community like Whatcom County," he said of the results noted in the JAMA article.
A PeaceHealth official echoed those thoughts.
"We knew we could do better, which is why we participated in the study in the first place," said Chris Phillips, director for community affairs with PeaceHealth St. Joseph Medical Center. "We knew we were good, and what we wanted to become was excellent and world class."
Such community efforts led to a drop in hospital readmission rates for Medicare beneficiaries in all of the communities served by the pilot program, according to the JAMA article. Other communities in the project included Denver, Miami and Atlanta, as well as Providence, R.I., and Harlingen, Texas.
What's more, researchers found that such efforts also reduced hospitalization rates among Medicare patients, by nearly 6 percent in Whatcom County.
And while the pilot has ended in Whatcom County, efforts to reduce preventable returns to the hospital continue through a recently launched initiative called "Whatcom Impact Project: Improving Care Transitions."
Also funded by the Medicare program, the initiative focuses on coaching patients and their families. Partners in the effort include the Whatcom Alliance for Health Advancement and Northwest Regional Council.
"It's been very well received. We are seeing drastic drops in readmission rates among those who participate," said Elya Moore, development coordinator for Whatcom Alliance for Health Advancement. "We're taking what we learned in Stepping Stones and carrying it forward."
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