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Quality Improvement in Care Transitions in Medicare Beneficiaries
Medicare beneficiaries often receive healthcare services from multiple clinicians in various healthcare settings, making improvements in the quality of transitions in care particularly important in this population. Previous models for improving care transition quality have been shown to reduce short-term rehospitalizations.
In 2006, the Centers for Medicare & Medicaid Services (CMS) announced various improvement strategies aimed at improving care and reducing costs. One such strategy was utilizing Quality Improvement Organizations (QIOs) to lead improvements in care transitions. The QIOs served every US state and territory and worked to improve the value of services.
The pilot stage of the program quickly resulted in substantial reductions in rehospitalizations and, in 2008, CMS initiated a quality improvement (QI) project to achieve whole-system enhancement within dynamic settings. Researchers recently conducted a study to evaluate whether QIO-facilitated community-wide QI could engage a variety of clinical and social service practitioners and organizations to improve care transitions for geographically defined community populations of Medicare beneficiaries and whether this work would correlate with reduced rehospitalizations. They reported study results in the JAMA [2013;309(4):381-391].
In the QI initiative for care transitions, the QIOs and their partners (hospitals, nursing facilities, home health care agencies, hospices, social service agencies, Area Agencies on Aging, and clinicians) were expected to implement evidence-based improvements, track progress, and modify approaches as needed. The primary outcome measure was all-cause 30-day rehospitalizations per 1000 Medicare fee-for-service (FFS) beneficiaries. All-cause hospitalizations per 1000 Medicare FFS beneficiaries and all-cause 30-day rehospitalizations as a percentage of hospital discharges were secondary outcome measures.
The initiative included monitoring by community-specific and aggregate control charts and evaluation with pre-post comparison of performance differences for 14 intervention communities and 50 comparison communities from before (2006-2008) and during (2009-2010) implementation. The intervention communities included Medicare FFS beneficiary populations ranging from 22,070 to 90,843; 6.8% to 29.5% of the dominant county population living below the federal poverty level; and a score of 0.53 to 1.83 on the Hospital Care Intensity Index (national score is 1.0).
In the 14 intervention communities, the mean rate of rehospitalizations per 1000 beneficiaries was 15.21/1000 per quarter in 2006-2008 and 14.43/1000 in 2009-2010, a decrease of 0.87/1000 (95% confidence interval [CI], 0.47-1.27 per 1000; P<.001 paired t test). There was a decrease in mean rehospitalization rate in the 50 comparison communities, but it was not statistically significant: 15.03/1000 per quarter in 2006-2008 and 14.72 in 2009-2010, a decrease of 0.31/1000 (95% CI, –0.03 to 0.65 per 1000; P=.08).
In 2006-2008, the mean rate of hospitalizations per 1000 beneficiaries per quarter was 82.27; in 2009-2010 the mean rate of hospitalizations was 77.54 in intervention communities. In the comparison communities, the 2006-2008 mean rate was 82.09 and the 2009-2010 mean rate was 79.48. The pre-post between-group difference showed larger reductions in hospitalizations in the intervention communities (2.12/1000 per quarter; 95% CI, 0.47-3.77; P=.01).
In the intervention communities, the mean community-wide rates of rehospitalizations as a percentage of hospital discharges were 18.97% (2006-2008) and 18.91% (2009-2010); rates in the comparison communities were 18.76% (2006-2008) and 18.91% (2009-2010). There were no significant differences in the pre-post between-group differences.
In conclusion, the researchers stated, “Among Medicare beneficiaries in intervention communities, compared with those in uninvolved communities, all-cause 30-day rehospitalizations and all-cause hospitalizations declined. However, there was no change in the rate of all-cause 30-day rehospitalizations as a percentage of hospital discharges.”
