A Continuing Collaboration

Randall Krakauer, MD 

Five years ago there was considerably less attention paid to the issue of readmissions than is the case today. Mary Naylor, Mark Pauly and the University of Pennsylvania team had already demonstrated the potential to reduce 90 day readmissions through better management of the discharge process, including the period immediately after discharge. Our team at Aetna was busy building Medicare care management infrastructure to impact chronic illness and Advanced Illness at the intersection of quality and cost - and had already seen a reduction in avoidable admissions and readmissions through telephonic case management. We needed to know whether there was incremental opportunity with on-site and home care management. So began a very productive collaboration that continues. Our program began with collaboration with Mary, Mark, and their team on Aetna Medicare Advantage members in metropolitan Philadelphia, with a Transitional Care program, measured against a clinically matched group in another region. With the demonstration of a 20% reduction in 90-day readmissions (publication 1), and considerable cost savings (impact at the intersection of quality and cost) we began building Transitional Care programs that are now nationwide. With the increased importance of Star Rating measures for Medicare programs, this experience has served us well. Such programs are still being expanded, but they are part of comprehensive care management programs everywhere - it is no longer necessary to demonstrate their value.

My collaboration with Mary, Mark, and their team has also led me to another venture: my role on the National Advisory Committee (NAC) for the Interdisciplinary Nursing Quality Research Initiative (INQRI) program. Since joining the NAC in 2006, I have been pleased to review research proposals, advise funded grantees on their project plans, and offer advice and support to Mary and Mark as they lead this impressive program. Like Aetna’s work with the Penn team, INQRI teams have continually shown the value of nurse-led interventions.

Our work and collaboration on reducing readmissions has been very productive and valuable. But since we don't actually achieve Nirvana in this world, this work and collaboration will continue, and we expect to continue pushing the limits of our potential. Similarly, I look forward to seeing the continued impact that I know INQRI teams will have on improving healthcare quality.

Dr. Krakauer is the National Medical Director for Aetna Medicare and a member of INQRI’s National Advisory Committee. 

1) Naylor, M; Bowles, K; McCauley, K; Maislin, G; Pauly, M; Krakauer, R: "High Value Transitional Care: Translation of Research into Practice." J. Eval. Clin. Practice. 16 March 2011, 1-7.

This post is part of our week-long blog carnival focused on the Medical Care supplement.  Click here to access all posts in this carnival.

Care About Your Care Videos - Our Grantees Respond

Last month, we told you about an exciting event sponsored by the Robert Wood Johnson Foundation, "Care About Your Care," which focused on reducing hospital readmissions through improved transitions in care.

In addition to a live webcast, the event also featured the presentation of winners from a video contest featuring a series of videos submitted by care teams to demonstrate their successful strategies to improve transitions.

We continue to be impressed by this work and some of our INQRI grantees wanted to take the opportunity to comment on some of these fantastic contributions.

Northern Piedmont Community Care

"This approach to care makes so much sense to me that I have to ask myself why this isn't the prevailing model of healthcare delivery. Many chronic diseases can be managed and even prevented through a healthful lifestyle, but research shows that the majority of people do not know how to be healthy. Patient teaching and education is a core component of the nursing process, and the success of community clinics like the one featured in the video places nurses in the center of the healthcare reform and efforts to promote high-quality patient-centered cost-effective care." 
- INQRI Grantee Olga Yakusheva 

CARE Network - Transition to Better Care

"This video about care transitions tells the story so well. The patient's story is central in the video which says a lot about how the CARE Network hold their priories." 
 - INQRI Grantee Nancy Hanrahan 

U of U Health Care- Transitions Program

"A small investment in time at discharge can pay off in a big way. Ensuring that patients and their informal caregivers understand what is needed to be done upon discharge may well prevent a return to the hospital. Since hospital days are far more costly than is outpatient care, it behooves providers to devote a small amount of time and resources prior to release and just after discharge from the hospital to prevent an even greater investment due to an exacerbation of illness. This is an area where Ben Franklin's aphorism, 'Pennywise and pound foolish' is spot on." 
 - INQRI Grantee Phyllis Solomon

Webinar Next Week: Translation of a Transitional Care Nursing Intervention for People with Serious Mental Illness

The transition from a psychiatric hospitalization back into the community is a vulnerable period for individuals with serious mental illness. Cycling in and out of psychiatric hospitals and emergency services is harmful to this population and depletes scarce public resources. The Transitional Care Model for Persons with Serious Mental Illness (TCM-SMI) proposes to break this cycle by providing 90 days of intensive hospital-to-home services. An INQRI project led by Nancy Hanrahan and Phyllis Solomon was designed to translate the TCM intervention to meet the complex needs of SMI clients in public managed care.

Join us on Wednesday, March 27 from 12n-1pmET as Drs. Hanrahan and Solomon present the findings from this important study.

Register for this webinar.

Care About Your Care

The Robert Wood Johnson Foundation and dozens of organizations will convene February 13 for Care About Your Care, a national initiative that highlights what works to improve care transitions and reduce avoidable hospital readmissions.

Nancy Snyderman, MD, chief medical editor for NBC News, will lead experts and health care leaders from diverse communities in sharing how they bring together patients, care providers, and community services to foster better health care outcomes.

The live event will feature:

• Risa Lavizzo-Mourey, MD - Robert Wood Johnson Foundation president and CEO
• Mary Naylor, PhD, RN, INQRI Program Director - University of Pennsylvania School of Nursing
• Eric Coleman, MD - University of Colorado Anschutz Medical Campus
• Jonathan Blum, MA - Centers for Medicare & Medicaid Services

Representatives from care teams from across the nation who are working on innovative ways to improve care transitions.

When: Wednesday, Feb. 13, 2013 12:30–2:00 p.m. ET

To Register for the Live Webcast: Contact careaboutyourcare@rwjf.org

Join the Twitterverse: With the hashtag #yourcare 

RWJF Video Contest: Coordinating Care Transitions

Across the country, patients, their families, nurses, care coordinators, and other front-line health care providers are pioneering effective ways to reduce hospital readmissions. They are developing tools and practices to ensure that hospital staff, patients, and primary care providers are working together, especially when a patient’s care is transitioning, like when they leave the hospital for home or a nursing facility.

The Robert Wood Johnson Foundation (RWJF) is sponsoring a video contest to discover collaborative ways providers and patients are working to avoid readmissions and improve patients’ care and their health outcomes. Have you—as a patient, family member, caregiver, nurse, care coordinator, or other health care provider—developed an innovative approach to improve the way patients and their care teams communicate, especially when a patient is transitioning from the hospital?

Applying for the contest is simple. Just send a short video showing and/or telling what you are doing to improve transitions. Winners will then be professionally filmed, and they and their video will be featured during RWJF’s Care About Your Care effort early in 2013. Care About Your Care is a national effort to spark conversation and galvanize attention about what people can do to identify and receive better health care.

 Click here to learn more.