Readmissions News - Thought Leaders Corner

Q. How big an impact will the continuing growth in medical homes and ACOs have on the reduction in preventable readmissions? 

“If we recognize that avoidable readmissions are the ultimate stamp of a fragmented health care system, then the continued growth of medical homes and ACOs hold significant promise. The medical home team must continue to play a critical role as the ‘hub’ for all of a patient’s health needs, particularly vulnerable populations, including those with behavioral, mental health, substance abuse, and chronic conditions. In response, primary care providers and clinicians are increasingly accountable for a patient's health status, knowing where they are in the health care system, and providing necessary support and follow-up.

While this is a huge undertaking, strong, real-time communication between primary care and other provider organizations can be transformative. For example, many clinicians and organizations are increasingly using health information technology and population health management strategies to track populations at high risk for readmission, while others have developed strong partnerships and referral processes to ensure a smooth transition between care settings. However, a major barrier to widespread adoption of these strategies is putting the necessary payment mechanisms in place to reward reductions and savings. We’ve already seen success from the Medicare readmission reduction program and the ACO program, but we have a very long way to go. The PCPCC believes that the medical home’s emphasis on patient-centered, coordinated care should continue to play a foundational role in health system delivery reform, by ‘breaking down the walls,’ and having a lasting impact on the patient experience, quality of care, and costs.”

Michelle Shaljian, Chief Strategy Officer, Patient-Centered Primary Care Collaborative (PCPCC)

“At Geisinger, ProvenHealth Navigator® our advanced medical home model that started in 2006 is a primary strategy for care in an era of accountability and underpins our sustained success in reducing readmissions across the entire Medicare-Aged population by 35-40%. Accountable Care Organizations either with CMS, i.e., the MSSP program, or with private insurers create a financial model to allow clinical teams to realize financial success while improving the care of patients. Our strategy of focusing on improving quality and experience, and realizing the concomitant total cost of care reduction as a by-product, has been very successful. The readmission reduction is a great example of this. In addition to ACO and Medical Home, Bundled Payment also creates the appropriate incentive environment to allow folks to get paid for providing better care and not just more care. While removing the financial barrier is an important first step, it needs to be combined with significant delivery system quality improvement and redesign to accomplish durable improvements in care that result in readmission reductions.”

Tom Graf, Chief Medical Officer, Population Health and Longitudinal Care Service Lines Geisinger Health System, Danville, PA

"The $25 billion spent on preventable hospital readmissions has focused the need for successful strategies to reduce them. We can already see a significant impact of patient-centered medical homes in driving down preventable readmissions. For example, Horizon BCBS of New Jersey reported 25 percent fewer hospital readmissions among its PCMH program participants. HealthPartners in Minnesota demonstrated 40 percent lower readmission rates from its PCMH initiative. To benefit from shared savings and avoid penalties under the CMS Hospital Readmission Reduction Program, ACOs must prioritize readmissions as a focus. One key to success of an ACO is to build it on an infrastructure of PCMH practices. Blue Shield of California reported 15 percent fewer hospital readmissions through its PCMH-based ACO demonstration. As care models evolve, PCMH-based ACOs and ACO contract programs that emphasize patient-centered, high quality, coordinated care are most likely to see significant reductions in preventable readmissions. To this end, the American Academy of Family Physicians continues to educate its members about ACOs and support them in their efforts toward PCMH adoption."

Reid Blackwelder, MD, President, American Academy of Family Physicians Leawood, KS 

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