Innovative Care Transitions Program Reduces Patient Readmissions

Bronx Collaborative and Treo Solutions to Discuss Program Outcomes during American Hospital Association Leadership Summit

Innovative Care Transitions Program Reduces Patient Readmissions

<0> Treo SolutionsJolene Nicotina, 800-545-6567 </0>

A cohort of hospital patients who received the services of a unique care transitions program run by the Bronx Collaborative, a payer-provider coalition that includes three hospital systems and two large insurers serving Bronx, N.Y., had a 33% lower 60-day patient readmission rate than a comparison group.

The Collaborative’s study, which was funded by grants from the New York Community Trust and the New York State Health Foundation, included an innovative predictive model developed by Treo Solutions, a leading healthcare transformation company that uses data analytics to offer unique insights, strategy and tools to assess patients’ risk of readmission.

Among 500 patients who received the minimum of two or more interventions, in a special, multi-step program to manage the transition between hospital and home, only 17.6 percent were readmitted to the hospital within 60 days of discharge versus 26.3 percent among a comparison group of 190 patients who received the current standard of care, the data showed.

This year at the 21 Annual Health Forum – American Hospital Association Leadership Summit, key executives from Montefiore Medical Center, who led the design and implementation of the care transitions program, and Treo Solutions will share real-world experience in improving health and controlling costs, highlighting Treo’s predictive model as an essential tool in that process.

“The successful reduction of the 60-day readmission rate demonstrates that a region-wide organization of providers and payers can employ advanced analytic tools and work together to improve outcomes and lower costs for a diverse, economically-challenged, urban population,” said Stephen Rosenthal, Vice President, Montefiore Medical Center, and Executive Director of the Bronx Collaborative.

The AHA Leadership Summit is being held at the Manchester Grand Hyatt in San Diego, California on July 25 –27. Each year, the Leadership Summit attracts more than 1,400 healthcare executives and provides an opportunity to present creative solutions to some of the nation’s most pressing issues. This year, the Summit will focus on the coordination and management of care. “Treo has an established history of transitioning healthcare systems from volume to value and we are extremely pleased to work with the Bronx collaborative to deliver on this commitment,” said Herb Fillmore, Treo’s Vice President of Strategic Innovation.

The Bronx Collaborative includes three non-profit hospital systems – Bronx Lebanon Hospital Center, St. Barnabas Hospital and Montefiore Medical Center – and two payer organizations, EmblemHealth and Healthfirst. Together they developed a uniform Care Transitions Program (CTP) that was made available to Medicare, Medicaid and commercial members of the two health plans. Patients were selected using Treo’s predictive model that identified those most at-risk for a readmission based on their diagnoses and the number of readmissions within the preceding 12 months. All participants were Bronx residents age 50 and older and had a working telephone. The program included a series of inpatient and post-discharge interventions by nurse care transitions managers and an electronic care transitions record developed for the CTP by the Bronx Regional Health Information Organization.

Since 2002, Treo Solutions has been driving transformation in healthcare through alignment, collaboration, and transparency, leveraging enhanced data to deliver value. Treo’s highly scalable tools, optimized claims database of over 45-million covered lives, and expertise in collaborative care logistics empowers clients to make value-informed decisions to create new risk-sharing and total cost-of-care models. Treo’s focused experience and agility allows clients to anticipate—and rapidly react to—a constantly changing market.