In New JAMA Study, New York Hospitals Show Reduced Readmission Rates

Jan 23, 2013, 10:00 ET from IPRO

Capital Region Hospitals, Nursing Homes, Home Health Agencies Worked with IPRO in National CMS "Care Transitions" Initiative

LAKE SUCCESS, N.Y., Jan. 23, 2013 /PRNewswire-USNewswire/ -- Hospitals, nursing homes and home health agencies in the Upper Capital Region of New York that worked collaboratively with IPRO, New York State's Medicare Quality Improvement Organization (QIO), on improving transitions of care showed reductions in 30-day rehospitalizations and all hospitalizations for Medicare beneficiaries.  Results of the new study are published in the January 23, 2013 Journal of the American Medical Association (JAMA).

The communities working with QIOs showed nearly twice the reduction in hospitalizations and rehospitalizations as those not working with QIOs.  QIOs are independent organizations that contract with the Centers for Medicare & Medicaid Services (CMS) to work collaboratively with health care providers and professionals in order to help improve care for Medicare beneficiaries.

"While many communities are working to reduce rehospitalization rates, the communities supported by QIO efforts experienced double the rate of reduction as others," said Jane Brock, MD, MSPH, lead study author and Chief Medical Officer, Colorado Foundation for Medical Care. "This study shows that a coordinated approach involving diverse stakeholders in a community—organized and spearheaded by a quality improvement expert—is a promising strategy."

The study looked at results from the 2009-2010 intervention period during the CMS 9th Scope of Work (SOW) Care Transitions initiative, which took place in 14 communities across the U.S.  Close to 50 health care providers in New York's Rensselaer, Saratoga, Schenectady, Warren and Washington counties took part. Care transitions take place when patients move from one setting to another, such as from hospital to home or nursing home.

According to study authors, New York's Upper Capital Region achieved 5.1% relative improvement for hospital readmissions for more than 68,000 Medicare beneficiaries, and reduced hospitalizations by 5.46%. Communities of comparable size, demographics and hospital utilization—but where there were no QIO-facilitated efforts to improve care transitions—averaged considerably more modest reductions, just a 2.05 percent drop in rehospitalizations and a 3.17 percent decline in hospitalizations.

 "We are gratified that this well-designed study has confirmed what we already knew:  that by working with IPRO in a concerted, collaborative effort, New York's health care community can significantly improve care for the state's residents," said Clare B. Bradley MD, MPH, Senior Vice President and Chief Medical Officer, IPRO. "We look forward to continued progress as we move forward with new care transitions initiatives."

Nationally, the 14 communities in the JAMA study averaged a 5.7 percent reduction in rehospitalizations. Medicare beneficiaries in these communities also experienced a 5.74 percent reduction in hospitalizations over the two-year period.

"It is gratifying to see that this peer reviewed study demonstrated the QIO Care Transitions program helped reduce hospital readmissions in the 14 participating communities," said Joseph Twardy, President/CEO, Visiting Nurse Service of Schenectady & Saratoga Counties. "Through working closely with IPRO, our agency and Ellis Medicine, were able to collaboratively develop effective and time-sensitive interventions to address heart failure readmissions.  This program is part of a series of population health initiatives we are leading called 'Care Central.'  Care Central is reinventing how our community approaches health and wellness.  This has been of tremendous benefit to our patients, and has helped keep many of them out of the hospital."

Ellis Medicine and the Visiting Nurse Association of Schenectady & Saratoga Counties partnered with the community to improve care coordination and patient outcomes for heart failure patients front and center in their care transitions initiatives. The effort has brought together providers including community-based cardiologists and primary care physicians, as well as the leadership of skilled nursing facilities and home health agencies, in an effort to address this issue.

"The QIOs' work in this project shows a reduction in hospitalization and rehospitalization rates, which are vitally important for keeping Medicare beneficiaries as healthy as possible for as long as possible," said Patrick Conway, MD, MSc, CMS Chief Medical Officer and Director of the Agency's Center for Clinical Standards & Quality. "Thanks to QIOs, these communities created networks of clinicians, facilities, families, social services agencies, and others that share a common language in coordinating care for patients—the community's sickest and most vulnerable people. These communities effectively prevented hospitalizations, resulting in people being more likely to stay home and healthy."

The U.S. Department of Health & Human Services has established a goal of 20% reduction in avoidable rehospitalizations.  Due to the success of the QIOs'9th SOW projects, CMS is now funding all QIOs across the U.S. to continue community-based readmission reduction efforts through July 2014.

Current Initiatives Take Aim at Care Transitions in New York

In their current Medicare work plan, which runs from August 2011 to July 2014, IPRO and other Quality Improvement Organizations across the U.S. are convening care transitions learning networks in multiple communities. A Learning and Action Network (LAN) is an improvement initiative that brings together health care professionals, patients and others around an evidence-based agenda to achieve rapid, wide-scale improvement. The LAN model includes collaborative projects, online interactions, and peer-to-peer education to facilitate shared commitment, energy, and knowledge that allows participants to learn from each other as well as from the QIO. The care transitions LANs focus on improving care for patients as they transition between healthcare settings within a specified community.  QIOs are driving this work forward through a combination of face-to-face and virtual events to encourage sharing of best practices and resource dissemination.

As part of its charge from CMS, IPRO continues to work collaboratively with hospitals in the Upper Capital Region to improve care transitions and reduce readmissions.  A number of  Hudson Valley hospitals are also participating in the current initiative (see "New York Care Transitions Hospitals" list below).

IPRO also worked collaboratively with 10 community partnerships across the state in applying for Federal funding through the Community Based Care Transition Program (CCTP).   The CCTP, created by Section 3026 of the Affordable Care Act, tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries. The goals of the CCTP are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high-risk beneficiaries, and to document measurable savings to the Medicare program.

IPRO is a national organization providing a full spectrum of healthcare assessment and improvement services that foster more efficient use of resources and enhance healthcare quality to achieve better patient outcomes. Founded in 1984, IPRO is highly regarded for the independence of its approach, the depth of its knowledge and experience, and the integrity of its programs. IPRO holds contracts with federal, state and local government agencies, as well as private-sector clients, in more than 33 states and the District of Columbia. A national not-for-profit organization, IPRO is headquartered in Lake Success, NY.  For more information, visit

This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-NY-AIM8-13-01


New York Care Transitions Hospitals

Albany Medical Center
Albany Memorial Hospital*
Ellis Medicine*
Glens Falls Hospital*
Northern Dutchess Hospital (Rhinebeck)
Putnam Hospital Center (Carmel)
Samaritan Hospital (Troy)*
Saratoga Hospital*
Seton St. Mary's Hospital (Troy)*
St. Francis Hospital (Poughkeepsie)
St. Peter's Hospital (Albany)
Vassar Brothers Medical Center (Poughkeepsie)

*Hospitals included in study.  Nearly 50 New York health care providers participated in the CMS 9th SOW Care Transitions initiative, including hospitals, nursing homes, home health agencies and private practices.

Community Based Care Transitions Program Communities (current)

Brooklyn Care Transition Coalition
Eddy Visiting Nurse Association (Albany)
Isabella Geriatric Center (Manhattan)
Mt. Sinai Hospital (Manhattan)
New York Methodist Hospital (Brooklyn)
North Country Community-based Care Transitions Program
P2 Collaborative of Western New York, Inc.
Queens Care Transition Collaborative
Tompkins County, New York Office for the Aging
Visiting Nurse Service of Schenectady & Saratoga Counties, Inc. (VNS)