Study: NC cuts readmissions by 20% among sickest, poorest patients

North Carolina hospitals reduced readmissions by 20 percent among the sickest and poorest patients in the state, thanks to a transitional care program that required intensive follow-ups with Medicaid patients, according to a study published in Health Affairs.

The transitional care project, reportedly the largest of its kind in the nation, was launched in 2008 and conducted by Community Care of North Carolina (CCNC), a physician-led program that focuses on helping poor people get healthcare and avoid hospitalization, according to an announcement about the study in Health Affairs.

The research team looked at 13,476 Medicaid patients with complex chronic conditions who received a transitional care assessment or intervention by a program care manager following a hospital discharge July 2010 through June 2011. The study included patients discharged from 120 hospitals, patients enrolled in 1,325 primary care medical homes and residents of 99 of North Carolina's 100 counties.

The project involved 800 nurses and social workers doing intensive follow-ups with Medicaid patients, the Raleigh News & Observer reported. They sometimes shadowed patients for months to make sure they took their medications, kept their doctor's appointments and followed all instructions.

Transitional care services depended on the individual needs of patients and ranged from a brief assessment, a hospital bedside visit prior to discharge, service coordination, medication reconciliation, a home visit by a nurse care manager or a comprehensive medication review by a clinical pharmacist.

The research team found that those who received transitional care were 20 percent less likely to abe readmitted in the subsequent year, compared with clinically similar patients who received usual care. Benefits of the intervention were greatest among patients with the highest readmission risk, the abstract said. One readmission was averted for every six patients who received transitional care services and one for every three of the highest-risk patients.

"What was unique and gratifying was that we were able to replicate this all over the state of North Carolina," C. Annette DuBard, a senior vice president of informatics and evaluation at CCNC, one of the study authors, told the News & Observer. "It's not specific to any one hospital or any healthcare system."

Care managers typically talked to high-risk patients in the hospital and followed up with a home visit within 72 hours after discharge, DuBard said. At the patient's home, the care manager reviewed the patient's prescriptions with the patient and family and in some cases arranged transportation, even accompanying the patient to the doctor's office.

"In the absence of this kind of support, the majority of these highest-risk patients will be rehospitalized within three months," DuBard said. "We can be confident this is a positive return on investment because so many readmissions were averted."

Transitional care services are gaining momentum across the country. A similar study released in June showed transitional care services significantly decreased readmission rates at three nonprofit hospitals in the Bronx, N.Y. Of the 500 patients who received two or more personal contact interventions, only 17.6 percent bounced back to the hospital within 60 days of discharge, compared with 26.3 percent of 190 patients who received standard care.

And a collaborative initiative involving 83 hospitals and 93 community partners in Minnesota saw 4,570 fewer avoidable hospital readmissions between Jan. 1, 2011, and Dec. 31, 2012, saving more than $40 million. Participating hospitals and providers used a combination of comprehensive discharge planning, medication management, patient engagement, transition care support, and transition communications.

More hospitals might want to consider similar programs to avoid Medicare readmission penalties. According to data released last week by the Centers for Medicare & Medicaid Services, 2,225 hospitals will receive payment reductions totaling $227 million starting  Oct. 1. Of those hospitals, 18 hospitals will lose 2 percent of Medicare reimbursements, the top penalty, while 154 will lose 1 percent or more.

To learn more:
- read the study abstract
- here's the announcement
- check out the News & Observer article